Box 18. Recommendations on the management of repeated systemic allergic adverse events in Hymenoptera VIT.

	Strength of consensus
39. Possible risk factors of systemic side effects of VIT shall be identified and eliminated as appropriate.	Majority
40. Concomitant therapy with an H1-blocking antihistamine should be performed. The last tolerated dose should be continued for 3 months and, subsequently, a new updosing should be attempted.	Consensus
41. If risk factors for systemic side effects are present and cannot be eliminated, and if concomitant therapy with an H1-blocking antihistamine is not effective, concomitant treatment with an anti-IgE antibody (omalizumab; off-label use) should be performed.	Majority
42. If side effects continue to occur, the last maximum dose that was tolerated should be administered every 4 weeks for 5 years.	Consensus