Table 3.

Patient selection for VIT – discrepancies between guidelines

	EAACI8	AAAAI17,58	NICE70,*	BSACI4
Indications	Respiratory and cardiovascular symptoms with positive skin test and/or IgE Urticaria if risk factors or quality of life impairment present with positive skin tests and/or IgE	Systemic reaction (especially respiratory symptoms, cardiovascular symptoms, or both)to an insect sting with specific IgEto venom allergens Previous near-fatal anaphylactic reaction to a sting Patients with mastocytosis or andincreased baseline serum tryptase	Severe systemic reaction to bee or wasp venom Moderate systemic reactions with one of the following: • Raised baseline serum tryptase • High risk of future stings • Anxiety about future stings	Systemic reaction with hypotension ± laryngeal edema ± asthma Must have positive venom-specific IgE
Relative indications		Adults who experience only cutaneous manifestations to an insect sting and positive specific IgE are generally considered candidates for VIT, although the need for VIT in this group is controversial Large local reaction to stings but have frequent unavoidable exposure		Mild asthma, moderate angioedema, abdominal pain, vomiting, diarrhea, mild hypotensive symptoms (light headedness, dizziness) in those at risk of further stings, eg, bee keeper/proximity to bees; occupational exposure, eg, fruit farmers, gardeners, etc Other factors, eg, proximity to medical help, patients’ preference, effect on quality of life
Contraindications	Large local reactions only Unusual reactions Negative skin tests or IgE regardless of reaction	Patients who have experienced only large local reactions to stings VIT is generally not necessary in children 16 years old and younger who have experienced cutaneous systemic reactions without other systemic manifestations after an insect stings		Not usually in cutaneous systemic reaction, eg, urticaria ±angioedema Local reaction Toxic reaction Any systemic reaction, independent of severity if negative specific IgE
Risk factors	Beta blocker use is a relative contraindication based on risk	Discontinue ACE inhibitors if possible		Comorbid conditions including asthma or other respiratory disease, cardiac conditions, and raised baseline tryptase/mastocytosis should be carefully considered before making a decision for VIT

Notes:

^*NICE guidance refers to one specific VIT product – Pharmalgen bee and wasp venom immunotherapy (ALK-Abelló, Horsholm, Denmark) – other guidance refers to all VIT products.

Abbreviations: AAAAI, American Academy of Allergy, Asthma and Immunology; ACE inhibitor, angiotensin-converting-enzyme inhibitor; BSACI, British Society of Allergy and Clinical Immunology; EAACI, European Academy of Allergy and Clinical Immunology; IgE, Immunoglobulin E; NICE, National Institute for Health and Care Excellence; VIT, venom immunotherapy.