What is the evaluation and treatment plan for a patient with a suspected bee sting allergy?

From the Guidelines

The evaluation and treatment plan for a suspected bee sting allergy should prioritize immediate assessment and management of anaphylaxis, with administration of epinephrine as the first line of treatment, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The approach to managing a suspected bee sting allergy involves several key steps, including:

• Removing the stinger by scraping rather than squeezing, washing the area with soap and water, and applying cold compresses for mild local reactions
• Using oral antihistamines like diphenhydramine or cetirizine to reduce itching and swelling, and ibuprofen or acetaminophen to manage pain
• Considering a short course of oral corticosteroids like prednisone for moderate reactions
• Carrying an epinephrine auto-injector and using it immediately if symptoms of anaphylaxis develop, followed by seeking emergency care, as emphasized in the 2011 practice parameter update on stinging insect hypersensitivity 1 Some key considerations in the management of bee sting allergies include:
• The importance of prompt administration of epinephrine in cases of anaphylaxis, as delayed use can be ineffective and even fatal 1
• The role of venom immunotherapy in reducing the risk of future severe reactions by gradually desensitizing the immune system, as highlighted in the 2005 practice parameter on the diagnosis and management of anaphylaxis 1
• The need for patient education on insect avoidance, emergency treatment, and the use of epinephrine auto-injectors, as recommended in the 2011 practice parameter update on stinging insect hypersensitivity 1
• The management of acute reactions to stings, including symptomatic treatment and consideration of antihistamines, cold compresses, and oral corticosteroids, as outlined in the 2011 practice parameter update on stinging insect hypersensitivity 1

From the FDA Drug Label

1 INDICATIONS & USAGE Adrenalin® is available as a single-use 1 mL vial and a multiple-use 30 mL vial for intramuscular and subcutaneous use. Emergency treatment of allergic reactions (Type I), including anaphylaxis, which may result from allergic reactions to insect stings, biting insects, foods, drugs, sera, diagnostic testing substances and other allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis.

The evaluation and treatment plan for a patient with a suspected bee sting allergy includes:

• Identifying signs and symptoms associated with anaphylaxis, such as flushing, apprehension, syncope, tachycardia, and airway swelling
• Administering epinephrine (IM) as an emergency treatment for allergic reactions (Type I), including anaphylaxis caused by insect stings 2
• Monitoring the patient for hypotension, convulsions, vomiting, diarrhea, and abdominal cramps
• Providing additional treatment as needed to manage anaphylaxis and prevent future reactions

From the Research

Evaluation of Bee Sting Allergy

• The evaluation of a patient with a suspected bee sting allergy involves a thorough medical history and physical examination, as well as diagnostic tests such as skin tests and measurements of IgE antibodies 3, 4.
• The severity of the allergic reaction is an important factor in determining the risk of future reactions, with more severe reactions indicating a higher risk 3, 4.
• Patients with a history of insect sting anaphylaxis and positive venom skin tests should have epinephrine available and are candidates for subsequent venom immunotherapy 3.

Treatment Plan

• Venom immunotherapy is a highly effective treatment for preventing future allergic reactions to bee stings, with a success rate of 80-100% in patients treated for 3-5 years 3, 4.
• The treatment involves regular injections of venom, starting with small doses and gradually increasing to a maintenance dose 5.
• Patients with severe systemic symptoms, such as hypertension or disturbances in consciousness, should be tested for mastocytosis and may require a higher maintenance dose of venom immunotherapy 4.
• The use of angiotensin-converting enzyme inhibitors (ACEIs) and β-blockers may increase the risk of a venom immunotherapy failure, and patients with these conditions should be closely monitored 4.

Special Considerations

• Beekeepers and their family members are at an increased risk of severe sting anaphylaxis due to their frequent exposure to bee stings, and require careful instruction on avoidance of re-exposure, emergency treatment, and specific immunotherapy with bee venom 6.
• Patients with a history of bee sting allergy should carry an epinephrine auto-injector with them at all times, and should know how to use it in case of an emergency 3, 4.