Selection of Individuals

All individuals who have severe symptoms of anaphylaxis and have positive venom skin tests should receive VIT (Table 1). Children who have had very mild reactions with dermal symptoms only do not require therapy. Their families should be advised to keep epinephrine and antihistamines available. Adults who have had similar mild anaphylaxis can probably be treated in a similar fashion, but there is less evidence to support this practice in adults than in children. Currently VIT is still recommended for these adults. Those individuals who have had reactions of moderate intensity such as mild asthma, nausea, and urticaria, without serious life-threatening reactions, might also be treated without immunotherapy and with the availability of emergency medication. They are likely to have similar moderate reactions to subsequent stings. This decision is influenced by other factors such as risk of exposure, other disease processes, such as cardiac disease, and medication use.

Following serum sickness reactions, individuals usually have positive skin tests and are then at risk for subsequent anaphylaxis. These observations are similar to the classic horse-serum-induced serum sickness. If skin tests are positive, these individuals should then receive immunotherapy. Because venom is a highly sensitizing agent, individuals who have had toxic reactions may develop IgE antibody and then are at potential risk for anaphylaxis. In that situation, immunotherapy is indicated. As already noted, individuals with large local reactions usually are not candidates for VIT.

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