Venom Selection

The product brochure, which has not changed since the availability of commercial venoms in 1979, recommends VIT with each venom that elicits a positive skin-test reaction. Studies of venom antigenic crossreactivity explain the common observation of multiple positive venom skin tests despite only one insect sting reaction. For example, an individual who has had an allergic reaction following a yellow jacket sting will almost always have positive skin tests to both yellow jacket and hornet venoms and possibly to wasp venom. Awareness of this crossreactivity allows for more selective venom treatment. The selection of venom for therapy is based on a history of the culprit insect responsible for the reaction and the degree of skin-test reactivity. This approach utilizing

Table 1

Indications for Venom Immunotherapy in Patients With Positive Venom Skin

Tests a

Insect sting reaction

Venom immunotherapy

"Normal" — transient pain, swelling Extensive local swelling Anaphylaxis Severe Moderate Mild; dermal only Children

Adults

Serum sickness Toxic

No No

Yes Yes6

Yes6

Yes aVenom immunotherapy is not indicated for individuals with negative venom skin tests. ^Patients in these groups might be managed without immunotherapy (see text).

Table 2

General Venom Immunotherapy Dosing

Initial dose Incremental doses

Maintenance dose Maintenance interval

Duration of therapy

0.01-0.1 |g, depending on degree of skin test reaction

Schedules vary from "rush" therapy administering multiple venom injections over several days to traditional once weekly injections

50-100 |g of single venoms

300 |g of mixed vespid venom.

4 wk year 1

6 wk year 2 8 wk year 3 Stop if skin test becomes negative Finite time; 3- 5 yr (see text)

single venoms despite multiple positive skin tests is less expensive, requires fewer injections, and is therapeutically as very effective.

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