Bee Venom Immunotherapy Dr Aarn Huissoon Consultant Immunologist Birmingham Heartlands Hospital

I reacted to a sting – do I need VIT? Large Local reaction Systemic reaction Swelling at the sting Develops over ~24 hours Settles over several days Antihistamines and steroids Not usually a reason for VIT 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 Top-ups every Increasing from 0.01 to 100 mg / injn Top-ups every 4-6 weeks for 3 yrs 100 mg is ~3 stings May 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 Quality of life improved 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

ANY systemic reaction to an insect sting 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: b-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