Safety Practices During Hymenoptera Venom Immunotherapy: Single-centre Experience with Protocolised Intravenous Cannulation and Adrenaline UsageTo the Editor,Anaphylaxis during venom immunotherapy (VIT) is potentially life-threatening and highly distressing for patients and clinical staff alike. Although reactions are typically mild,1 this risk has historically prompted conservative initiation protocols, including mandatory inpatient admission2 and routine peripheral intravenous cannula (PIVC) insertion. These measures facilitate rapid escalation of care, particularly when IV access may be difficult due to hypotension or high stress. Reflecting this cautious approach, clinicians also may have a relatively low threshold for administering rescue IM adrenaline early in systemic reactions (SRs) to prevent progression to severe anaphylaxis.We report a nine-year single-centre experience examining VIT-associated SRs and assess the impact of evolving safety practices, specifically protocolised PIVC insertion and adrenaline administration. Our findings support a shift away from routine PIVC, and towards more selective adrenaline administration in most patients.All Hymenoptera VIT initiations at our centre (Monash Health, Clayton, Australia) between May 2016 and February 2025, were retrospectively reviewed (detailed methods in supplementary material) In total, 456 patients commenced VIT including 16 Vespid (3.5%), 136 Honeybee (29.8%), 304 Jack Jumper Ant (JJA; 66.7%), comprising 2,388 visits and 5,520 injections. Patients ranged from 4 to 86 years (median 51), 54.6% were male, and ten (2.2%) had mastocytosis. All honeybee and vespid patients received Ultrarush initiation, while JJA patients were initiated via Semirush (58.2%) and Ultrarush (41.8%).Overall, 54.6% of patients experienced one or more SRs during up-dosing (Brown’s grading; Table 1). Twenty patients (4.4%) developed severe reactions, and 38 (8.3%) required adrenaline administration. JJA VIT was associated with significantly more SRs than honeybee VIT (64.5% vs 33.8%, p<0.001) and more frequent adrenaline use (10.5% vs 4.4%, p=0.042) . However, there was no statistically significant difference in the number of severe reactions based on venom type (p=0.14). Notably, both severe reactions (30% vs 3.8%, p=0.01) and adrenaline requirement (40% vs 7.6%, p=0.006) were more frequent in those with mastocytosis.To our knowledge, this is the first data suggesting that JJA venom may be more reactive than Honeybee venom. Previously, the use of honeybee venom has been regarded as the only well-established risk factor for SRs,3 largely relative to vespid venom.

Background Insect Stings with the venoms of Hymenoptera species are well recognized as leading directly to allergic reactions in sensitised individuals. As with other hymenoptera venoms – Venom specific allergen Immunotherapy (VIT) to Jack Jumper Ants (JJA) Myrmecia pilosula has demonstrated efficacy in preventing the direct morbidity associated with severe venom-associated allergic reactions. Despite this, the indirect morbidity of severe allergy on associated background health related quality of life (HR-QoL) has not previously been assessed in patients with JJA venom allergy. Materials and methods M pilosula venom-allergic patients referred for treatment in a specialized quaternary venom treatment centre were surveyed with a venom specific HR-QoL questionnaire before and after receiving 12 months of allergen-specific venom-immunotherapy (VIT) according to JJA. A smaller subgroup also repeated this questionnaire after receiving JJA sting-challenge. Results 53 patients completed both pre-VIT and post-VIT QoL questionnaires. 83% of these patients achieved a minimal important difference (MID) of increased change in QoL of >0.5. Mean HR-QoL improved by 1.85, NNT = 1.2. There was no statistically significant difference when stratified by index-reaction grade, but appeared to be greater impairment, and subsequent improvement, Female vs Male. In the subgroup of 22 patients surveyed after VIT & re-surveyed after supervised sting challenge, Mean HR-QoL improvement 0.7, and 50% achieved a MID >0.5; therefore giving a ‘Number needed to sting’ = 2.0. Patients with the largest impairment in HR-QoL appeared to benefit the most from sting-challenge. Conclusion In JJA venom allergy the magnitude of indirect allergic morbidity, measured by HR-QoL, appears to be a separate phenomenon to that of the direct morbidity of clinical allergic sensitivity [as measured by index reaction grade.] Patient factors including gender may be important considerations for this indirect morbidity. As with direct allergic sensitivity, improvements in indirect morbidity can also be obtained by VIT treatment. In addition, formal supervised exposure with sting-challenge in patients may provide additional improvements in those with significant persistent allergy-related QoL impairment.

Insect venom allergy is the most frequent cause of anaphylaxis in Europe and possibly worldwide. The majority of systemic allergic reactions after insect stings are caused by Hymenoptera and among these, vespid genera induce most of the systemic sting reactions (SSR). Honey bees are the second leading cause of SSR. Depending on the global region, other Hymenoptera such as different ant genera are responsible for SSR. Widely distributed hornets and bumblebees or local vespid or bee genera rarely induce SSR. Hematophagous insects such as mosquitoes and horse flies usually cause (large) local reactions while SSR occasionally occur. This position paper aims to identify either rare or locally important insects causing SSR as well as rarely occurring SSR after stings or bites of widely distributed insects. We summarized relevant venom or saliva allergens and intended to identify possible cross-reactivities between the insect allergens. Moreover, we aimed to locate diagnostic tests for research and routine diagnosis, which are sometimes only regionally available. Finally, we gathered information on disposable immunotherapies. Major allergens of most insects were identified, and cross-reactivity between insects was frequently observed. While some diagnostics and immunotherapies are locally available, standardized skin tests and immunotherapies are generally lacking in rare insect allergy.