Venom Immunotherapy in High-Risk Patients: The Advantage of the Rush Build-Up Protocol

Abstract

Background: Venom immunotherapy (VIT) is considered to be the gold standard treatment for patients with hymenoptera venom allergy. This treatment induces systemic reactions (SR) in a significant number of patients. Objective: To evaluate the outcome of VIT in patients with known risk factors for VIT-induced SR and to compare rush VIT (RVIT) and conventional VIT (CVIT). Methods: All of the patients who received VIT and had at least one of the following risk factors were included: current cardiovascular disease, uncontrolled asthma, high basal serum tryptase, current treatment with β-blockers or angiotensin-converting enzyme inhibitors, and age >70 or <5 years. Results: Sixty-four patients were included, and most of them (52; 81.5%) were allergic exclusively to bee venom. Thirty-five (54.7%) patients underwent RVIT and 29 CVIT. The incidence of patients who developed SR during the build-up phase was similar for RVIT and CVIT (25.7 and 27.5%, respectively; p = 1). However, the incidence of SR per injection was significantly higher in CVIT than in RVIT (5.6 and 2.75%, respectively; p = 0.01). Most reactions (79.1%) were mild, limited to the skin. Most of the patients (92.1%) reached the full maintenance dose of 100 μg. This dose was reached by a significantly larger number of patients receiving RVIT compared to CVIT (100 and 82.7%, respectively; p = 0.01). None of the patients experienced exacerbation of their concurrent chronic disease during VIT. Conclusion: VIT can be performed safely and efficiently in patients with risk factors for immunotherapy. In these patients RVIT appears to be safer and more efficient than CVIT.

Hymenoptera Venom Allergy: Management of Children and Adults in Clinical Practice

“…Conventional and "clustered" protocols do not significantly differ from one another as far as safety is concerned [172]. Ultrarush induction protocols have proved effective [173][174][175], inducing early changes in immunological parameters associated with the efficacy of VIT (IgE, IgG4) [176]. To increase adherence to VIT, management of immunotherapy protocols can be flexible, for example, by switching from an aqueous extract to a depot extract by the same manufacturer, with no impact on efficacy or safety [177].…”

Comparison of the Safety Profiles of 3 Different Hymenoptera Venom Immunotherapy Protocols: A Retrospective 2-Center Study of 143 Patients

“…Existing study data investigating whether certain treatment schedules are associated with a higher frequency of SR are highly conflicting [11,13,14,[22][23][24]. Large-scale studies ascribed accelerated protocols to a higher incidence of SR [13,14].…”

“…Large-scale studies ascribed accelerated protocols to a higher incidence of SR [13,14]. By contrast, a considerable number of other, though smaller, studies reported lower rates of SR when the VIT induction phase was shortened [11,[22][23][24]. In general, cluster protocols for Hymenoptera VIT were less studied and rarely compared to other VIT protocols in the past.…”

“…In general, cluster protocols for Hymenoptera VIT were less studied and rarely compared to other VIT protocols in the past. In most reports, rapid protocols (ultrarush/rush) were compared to a conventional protocol [23][24][25][26]. The only larger study which comprised rush, ultra-rush, as well as cluster VIT protocols was the European Academy of Allergy and Clinical Immunology multicenter study of Mosbech and Müller [14].…”