Review and Feature Article
Hymenoptera Venom Extracts in Clinical Practice

https://doi.org/10.1016/j.jaip.2018.08.015Get rights and content

Venom immunotherapy is the only treatment for the prevention of anaphylaxis and remains the prototypical model for its diagnosis and management. Unlike other causes of anaphylaxis, such as foods and drugs, preventative treatment using venom immunotherapy is highly effective with well-established protocols, and is widely available. Hymenoptera venoms are also unique in that the primary allergens are directly measurable in terms of micrograms, rather than labeled on the basis of potency. As such, venoms were the first truly standardized extracts. However, Hymenoptera venom presents unique challenges in collection, processing, and stabilization of the venom extract product. Historically, there have been minor variations in insect composition in venom extract content. These differences were in part based on variation in insect availability and venom collection and have created minor challenges. However, it is a recognized need that venom extracts contain an optimal and complete repertoire of relevant venoms so as to be assured of appropriate diagnosis and treatment. As such, insect availability and collection, as well as storage, stability, and sterility of venom extracts, have remained critical components to appropriate diagnosis and prevention of venom-induced anaphylaxis. In recent years there has been concerns about adequate supplies of venom for appropriate diagnosis and treatment of venom allergy, but these concerns seem to have stabilized, with the movement to a single venom supplier. This movement to a single supplier may provide its own challenges.

Section snippets

Background

Among the allergenic extracts in clinical use, Hymenoptera venoms (HVs) are unique in many ways. First, the primary allergens are measurable. Aeroallergen extracts are marketed with labeled potency represented as various defined units such as weight to volume (w/v), allergy units, or bioequivalent allergy units (all of which are American), or standardized quality (SQ) units, index of reactivity (IR) units, and others (in Europe). Venom extracts are the only allergen extracts whose potency is

Part 1: Clinical history

While gardening, a 26-year-old gravida 1, para 0, female at 26 weeks estimated gestational age was stung by a ground-dwelling bee. Within 3 to 5 minutes she experienced a general feeling of anxiety, throat fullness, and some mild hives. After taking diphenhydramine and not improving she went to the emergency room where she was given additional diphenhydramine and observed for a period of 90 minutes. She continued to do well and was discharged with no follow-up or other specific treatment. After

Additional considerations

This case illustrates several additional relevant situations in which the characteristics of HV may affect diagnosis and treatment. First, that the role of mast cell disease and its association with venom-allergic individuals have assumed new prominence in recent years. The relationship is discussed in more detailed elsewhere.28 However, renewed understanding was sufficient to prompt a change in clinical recommendation regarding the measurement of serum tryptase in venom-allergic individuals.12

Summary

Venom allergy is the prototypic model for the diagnosis and management of anaphylaxis. The initial exposure is generally obvious, the progress of reactions predictable, and diagnostic methods reliable and readily available. Unlike other causes of anaphylaxis, preventative treatment is highly effective and available. Treatment with VIT provides an important window into our understanding of the management strategy of immunotherapy. HVs are the prototypic standardized allergens and their

Acknowledgments

We thank Derek Constable, PhD (Technical Director, Jubilant HollisterStier Allergy Products Division), for providing details and guidance on the technical aspects of venom production. Additional background information on venom collection and production was provided by Greg Plunkett, PhD (ALK-Abello Inc).

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    Conflicts of interest: J. M. Tracy declares receiving honorarium from UptoDate. D. B. K. Golden declares Speaker Bureau honoraria from Genentech and Stallergenes; research support for clinical trials from Genentech and Stallergenes; and receiving royalties as an Editor for UptoDate.

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