Specific immunotherapy using Hymenoptera venom
systematic review
Keywords:
Hymenoptera, Insects, Immunotherapy, Meta-analysis [publication type], Review [publication type]Abstract
CONTEXT AND OBJECTIVE: The only effective treatment for patients who have severe reactions after Hymenoptera stings is venom immunotherapy. The aim of this study was to review the literature to assess the effects of venom immunotherapy among patients presenting severe reactions after Hymenoptera stings. DESIGN AND SETTING: Randomized controlled trials in the worldwide literature were reviewed. The manuscript was produced in the Discipline of Allergy and Clinical Immunology, Universidade de São Paulo (USP). METHODS: Randomized controlled trials involving venom immunotherapy versus placebo or only patient follow-up were evaluated. The risk of systemic reactions after specific immunotherapy was evaluated by calculating odds ratios (OR) and their 95% confidence intervals. RESULTS: 2,273 abstracts were identified by the keywords search. Only four studies were included in this review. The chi-square test for heterogeneity showed that two studies were homogeneous and could be included in a meta-analysis. By combining the two studies, the odds ratio became significant: 0.29 (0.10-0.87). However, analysis on the severity of the reactions after immunotherapy showed that the benefits may not be so significant because the reactions were mostly similar to or milder than the original reaction. CONCLUSIONS: Specific immunotherapy should be recommended for adults and children with moderate to severe reactions, but there is no need to prescribe it for children with skin reactions alone, especially if the exposure is very sporadic. On the other hand, the risk-benefit relation should always be assessed in each case.
Downloads
References
Helbling A, Hurni T, Mueller UR, Pitchler WJ. Incidence of anaphylaxis with circulatory symp- toms: a study over a 3-year period comprising 940,000 inhabitants of the Swiss Canton Bern. Clin Exp Allergy. 2004;34(2):285-90.
Golden DB, Marsh DG, Kagey-Sobotka A, et al. Epidemiology of insect venom sensitivity. JAMA. 1989;262(2):240-4.
Golden DB. Insect sting allergy and venom immunotherapy: a model and a mystery. J Allergy Clin Immunol. 2005;115(3):439-47; quiz 448.
Incorvaia C, Pucci S, Pastorello EA. Clinical aspects of Hymenoptera venom allergy. Allergy. 1999;54 Suppl 58:50-2.
The discontinuation of Hymenoptera venom immunotherapy. Report from the Committee on Insects. J Allergy Clin Immunol. 1998;101(5):573-5.
Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17(1):1-12.
Hunt KJ, Valentine MD, Sobotka AK, Benton AW, Amodio FJ, Lichtenstein LM. A controlled trial of immunotherapy in insect hypersensitivity. N Engl J Med. 1978;299(4):157-61.
Schuberth KC, Lichtenstein LM, Kagey-Sobotka A, Szklo M, Kwiterovich KA, Valentine MD. Epidemiologic study of insect allergy in children. II. Effect of accidental stings in allergic children. J Pediatr. 1983;102(3):361-5.
Valentine MD, Schuberth KC, Kagey-Sobotka A, et al. The value of immunotherapy with ve- nom in children with allergy to insect stings. N Engl J Med. 1990;323(23):1601-3.
Brown SG, Wiese MD, Blackman KE, Heddle RJ. Ant venom immunotherapy: a double-blind, placebo-controlled, crossover trial. Lancet. 2003;361(9362):1001-6.
Ross RN, Nelson HS, Finegold I. Effectiveness of specific immunotherapy in the treatment of hymenoptera venom hypersensitivity: a meta-analysis. Clin Ther. 2000;22(3):351-8.
Golden DB, Kagey-Sobotka A, Norman PS, Hamilton RG, Lichtenstein LM. Outcomes of al- lergy to insect stings in children, with and without venom immunotherapy. N Engl J Med. 2004;351(7):668-74.
Blaauw PJ, Smithuis OL, Elbers AR. The value of an in-hospital insect sting challenge as a criterion for application or omission of venom immunotherapy. J Allergy Clin Immunol. 1996;98(1):39-47.
Kipper DJ, Saldanha MO, Tessaro L, Lança EA, Garcia PCR. Reações anafiláticas a picadas de formigas [Anaphylatic reactions to ant stings]. J Pediatr (Rio J) 1998;74(3):243-6.
Tracy JM, Demain JG, Quinn JM, Hoffman DR, Goetz DW, Freeman TM. The natural his- tory of exposure to the imported fire ant (Solenopsis invicta). J Allergy Clin Immunol. 1995;95(4):824-8.
Rhoades RB, Stafford CT, James FK Jr. Survey of fatal anaphylactic reactions to imported fire ant stings. Report of the Fire Ant Subcommittee of the American Academy of Allergy and Immunology. J Allergy Clin Immunol. 1989;84(2):159-62.
Moffitt JE, Barker JR, Stafford CT. Management of imported fire ant allergy: results of a survey. Ann Allergy Asthma Immunol. 1997;79(2):125-30.
Hoffman DR, Jacobson RS, Schmidt M, Smith AM. Allergens in Hymenoptera venoms.
XXIII. Venom content of imported fire ant whole body extracts. Ann Allergy. 1991;66(1): 29-31.
Freeman TM, Hylander R, Ortiz A, Martin ME. Imported fire ant immunotherapy: effectiveness of whole body extracts. J Allergy Clin Immunol. 1992;90(2):210-5.
Triplett RF. Sensitivity to the imported fire ant: successful treatment with immunotherapy. South Med J. 1973;66(4):477-80.
Tankersley MS, Walker RL, Butler WK, Hagan LL, Napoli DC, Freeman TM. Safety and efficacy of an imported fire ant rush immunotherapy protocol with and without prophylactic treat- ment. J Allergy Clin Immunol. 2002;109(3):556-62.
Lerch E, Müller UR. Long-term protection after stopping venom immunotherapy: results of re-stings in 200 patients. J Allergy Clin Immunol. 1998;101(5):606-12.
Lui CL, Heddle RJ, Kupa A, Coates T, Roberts-Thomson PJ. Bee venom hypersensitivity and its management: patients perception of venom desensitisation. Asian Pac J Allergy Immunol. 1995;13(2):95-100.
Keating MU, Kagey-Sobotka A, Hamilton RG, Yunginger JW. Clinical and immunologic follow-up of patients who stop venom immunotherapy. J Allergy Clin Immunol. 1991;88(3 Pt 1):339-48.
Golden DB, Schwartz HJ. Guidelines for venom immunotherapy. J Allergy Clin Immunol. 1986;77(5):727-8.
Moffitt JE, Golden DB, Reisman RE, et al. Stinging insect hypersensitivity: a practice parame- ter update. J Allergy Clin Immunol. 2004;114(4):869-86.
Reisman RE. Natural history of insect sting allergy: relationship of severity of symptoms of initial sting anaphylaxis to re-sting reactions. J Allergy Clin Immunol. 1992;90(3 Pt 1):335-9.
Charpin D, Birnbaum J, Vervloet D. Epidemiology of hymenoptera allergy. Clin Exp Allergy. 1994;24(11):1010-5.
Antonicelli L, Bilò MB, Bonifazi F. Epidemiology of Hymenoptera allergy. Curr Opin Allergy Clin Immunol. 2002;2(4):341-6.
Oude Elberink JN, De Monchy JG, Van Der Heide S, Guyatt GH, Dubois AE. Venom immuno- therapy improves health-related quality of life in patients allergic to yellow jacket venom. J Allergy Clin Immunol. 2002;110(1):174-82.
