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Recommendations for Managing Stinging Insect Reactions

Recommendations for Managing Stinging Insect Reactions

The Stinging Insect Hypersensitivity Practice Parameter Update 2016 workgroup was commissioned by the JTF to develop practice parameters that address insect stings to develop a Practice Parameter that provides a comprehensive approach for insect hypersensitivity based on the current state of the science.Stings by insects of the Hymenoptera order (i.e., hornets, wasps, yellow jackets, honeybees, and fire ants) cause systemic reactions in about 3% of U.S. adults. At least 40 patients die annually in the U.S. from these stings, and they account for 20% of all anaphylaxis-related deaths. In patients with severe systemic reactions, 50% will experience anaphylaxis to future stings; with venom immunotherapy (VIT), this risk is <5%.


The primary focus of the stinging insect practice parameter over the years has been to provide a working framework for the management of stinging insect hypersensitivity and salient features of recommendations are :


  • More than 20% of adults are sensitized to insect venom but are not at substantially elevated risk for anaphylaxis, so screening asymptomatic patients is discouraged.
  • About 10% of the general population experience large local reactions from insect stings and can be treated symptomatically, possibly with short-course oral corticosteroids for severe swelling; risk for anaphylaxis in these patients is <5%, so VIT is not generally indicated.
  • Children and adults with cutaneous systemic reactions only (e.g., urticaria, peripheral angioedema) are at low risk for anaphylaxis and typically do not need VIT.
  • Measuring baseline serum tryptase can identify patients at high risk for anaphylaxis and those with mastocytosis.
  • All patients with severe systemic reactions should be referred for testing and, if positive, should receive VIT for 5 years. Patients should carry self-injectable epinephrine and medical identification and should be instructed on insect avoidance.
  • Consensus is lacking on whether low-risk patients (i.e., those with large local or cutaneous reactions, those receiving maintenance VIT, and those who have completed 5 years of VIT) should carry epinephrine, and the decision is left to physicians and patients.
  • Because β-blockers and angiotensin-converting–enzyme inhibitors might heighten risk for serious adverse events from stings or VIT, they should be used concomitantly with VIT only if absolutely necessary.


VIT greatly reduces the risk of systemic reactions in stinging insect–sensitive patients with an efficacy of up to 98%.The goal of VIT is primarily to prevent life-threatening reactions. Most important change from the previous version of this guideline (J Allergy Clin Immunol 2011; 127:852) includes the recommendation not to offer VIT to patients with cutaneous systemic reactions and the emphasis on checking tryptase levels.

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Source: NEJM Guideline

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