Bee Venom Immunotherapy

Dr Aarn HuissoonConsultant Immunologist

Birmingham Heartlands Hospital

I reacted to a sting – do I need VIT?Large Local reaction• Swelling at the sting• Develops over ~24 hours• Settles over several days

• Antihistamines and steroids• Not usually a reason for VIT

Systemic reaction

• Symptoms in minutes• May include any of:

– Itch, rash, flushing– Swelling (e.g. skin, throat)– Tight chest / wheeze / can’t

breathe– Dizzy, faint, collapse– “Feeling of impending doom”– Stomach cramps / diarrhoea

• Antihistamines and adrenaline

• YES - assessment for VIT

What does VIT assessment involve?

• Detailed history of the reaction– Timings, treatments, blood tests etc..

• Allergy testing– Skin prick test– Intradermal test– Blood test; bee venom IgE

• Breathing tests and ECG (some people)• Blood test; Tryptase

Immunotherapy Clinic

• Hospital-based• Run by doctors / nurses• Facilities for treating reactions• Well on the day• Pre-injection check• Wait for 1 hour after injection• Another check before home

What happens in VIT?

Build-up 12 weekly injections Increasing from 0.01 to 100 g / injn

Top-ups every 4-6 weeks for 3 yrs

100 g is ~3 stingsMay be 5 yrs or more

Risks of VIT

• Local or large local reactions in 50%

• Systemic reactions (SR)– 2 to 20 % of patients have SR– Risks for SRs:• Female• Bee allergy 14% (wasp 3%)

• Raised baseline tryptase

Outcomes of VIT• Protection– 80% prevention of severe reactions

• Quality of life improved• May also reduce large local reaction

Boyle RJ Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD008838

Outcomes of VIT

No VIT VIT

ANY systemic reaction to an insect

sting

(Bee or Wasp)

Low-risk population

83 per 1000 8 per 1000(2 to 23)

Medium-risk population

398 per 1000 40 per 1000(12 to 111)

High-risk population

724 per 1000 72 per 1000(22 to 203)

Boyle RJ Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD008838

How does VIT work?

• Type of immune response depends on how antigen is presented– Dose– Route (mouth, IV, ID SC…)

• Subcutaneous injections steer the immune response away from allergy

VIT for Bee sting allergy

• You should be able to have VIT if:– you have had a severe reaction to a bee sting

or– you have had a moderate reaction to a bee sting and you have• a high risk of stings• anxiety about stings• high levels of a protein called ‘tryptase’

Adapted from: www.nice.org.uk/guidance/ta246

Can anyone have VIT?

• Exclusions:– Severe asthma– Pregnancy– Not able to consent / attend reliably– Certain medications:• -blocker (e.g propranolol)• ACE inhibitor (e.g. ramapril)• Some antidepressants

– Some immune system disorders and cancers

Where can I go for VIT?

www.bsaci.org