Safety of hymenoptera venom immunotherapy: a systematic review

Introduction: The efficacy of venom immunotherapy (VIT) in patients with insect sting allergy is not questioned. However, its safety, especially when honeybee is used, is a matter of concern.

Areas covered: A systematic review of the literature on VIT was done, with both aqueous and depot extracts, to compare the frequency of systemic reactions to honeybee and vespid venoms. A Medline search was performed using the keywords ‘venom immunotherapy’, ‘safety’ and ‘tolerability’. The articles obtained were analyzed regarding the total number of patients treated with either honeybee or vespid VIT, the number and severity of systemic reactions during therapy, the type of extract used (aqueous or depot) and the administration regimen.

Expert opinion: The incidence of systemic reactions to VIT was 25.1% for honeybee venom and 5.8% for vespid venom (p < 0.0001), while it was similar with aqueous and depot extracts in the whole population of patients. This confirms that during VIT systemic reactions are significantly more frequent with honeybee venom compared with vespid venom, while there are no significant overall differences in systemic reactions between aqueous and depot extracts.     

Hypersensitivity to Hymenoptera venom: advances in diagnosis and implications for treatment

Diagnosis and treatment of hypersensitivity to Hymenoptera venom took a landmark step forward in the late 1970s with the introduction of venom as an adequate material instead of whole body extracts. Since then, venom immunotherapy (VIT) has provided allergic subjects with a complete protection from fatal anaphylaxis and prevented about 90% of all reactions to stings. The cross-reactivity among some venom components, particularly important in the case of cross-reacting carbohydrate determinants, has often made it difficult to recognize the true causative venom to be used in VIT. Recently, the introduction of purified and recombinant allergens, such as Api m 1 from honeybee venom, Ves v 5 from yellow jacket venom, and Pol d 5 from wasp venom, have allowed a more precise diagnosis with identification of the causative venom component. This paves the way for a patient-tailored VIT in the near future. Another issue which needs to be addressed is the improvement in the safety of VIT with honeybee venom, which is significantly less favourable in comparison to vespid venom. A number of molecular approaches are under investigation in order to achieve this objective. Alternative routes of administration, such as the sublingual and the intralymphatic, have also been proposed, but there are not yet sufficient data available to demonstrate their feasibility. This review also presents patents on new trends in therapies for the management of hypersensitivity to hymenoptera venom.     

Catecholamines in honey bee (Apis mellifera L.) and various vespid (Hymenoptera) venoms

—Liquid chromatography with electrochemical detection was used to separate, identify and quantitate the levels of dopamine (DA) and noradrenaline (NA) present in the venoms of honey bees of known ages and of DA and 5-hydroxytryptamine (5-HT) in various species of vespid wasps. Fluorescence histochemistry corroborated the presence of amines in honey bee venom glands and reservoirs and supported the quantitative results. The results show: (i) There is an age dependent variation in DA and NA levels in honey bee venom and there may be a similar variation in DA and 5-HT in the venom of queen Dolichovespula arenaria. (ii) There appears to be a seasonal variation in the quantities of DA and NA present in honey bee venom. Such a seasonal variation may be one of the factors involved in the variation in the levels of amine components present in the various vespid wasp venom samples. (iii) 5-HT is present in much greater quantities than DA in vespid venoms. Low levels of NA and DOPA are present in vespid venoms.     

PLGA microspheres containing bee venom proteins for preventive immunotherapy

Bee venom (BV) allergy is potentially dangerous for allergic individuals because a single bee sting may induce an anaphylactic reaction, eventually leading to death. Currently, venom immunotherapy (VIT) is the only treatment with long-lasting effect for this kind of allergy and its efficiency has been recognized worldwide. This therapy consists of subcutaneous injections of gradually increasing doses of the allergen. This causes patient lack of compliance due to a long time of treatment with a total of 30-80 injections administered over years. In this article we deal with the characterization of different MS-PLGA formulations containing BV proteins for VIT. The PLGA microspheres containing BV represent a strategy to replace the multiple injections, because they can control the solute release. Physical and biochemical methods were used to analyze and characterize their preparation. Microspheres with encapsulation efficiencies of 49-75% were obtained with a BV triphasic release profile. Among them, the MS-PLGA 34 kDa-COOH showed to be best for VIT because they presented a low initial burst (20%) and a slow BV release during lag phase. Furthermore, few conformational changes were observed in the released BV. Above all, the BV remained immunologically recognizable, which means that they could continuously stimulate the immune system. Those microspheres containing BV could replace sequential injections of traditional VIT with the remarkable advantage of reduced number of injections.     

Venom Immunotherapy: From Proteins to Product to Patient Protection

In this review, we outline and reflect on the important differences between allergen-specific immunotherapy for inhalant allergies (i.e., aeroallergens) and venom-specific immunotherapy (VIT), with a special focus on Venomil^® Bee and Wasp. Venomil^® is provided as a freeze-dried extract and a diluent to prepare a solution for injection for the treatment of patients with IgE-mediated allergies to bee and/or wasp venom and for evaluating the degree of sensitivity in a skin test. While the materials that make up the product have not changed, the suppliers of raw materials have changed over the years. Here, we consolidate relevant historical safety and efficacy studies that used products from shared manufacture supply profiles, i.e., products from Bayer or Hollister–Stier. We also consider the characterization and standardization of venom marker allergens, providing insights into manufacturing controls that have produced stable and consistent quality profiles over many years. Quality differences between products and their impacts on treatment outcomes have been a current topic of discussion and further research. Finally, we review the considerations surrounding the choice of depot adjuvant most suitable to augmenting VIT.     

Honeybee Venom Proteome Profile of Queens and Winter Bees as Determined by a Mass Spectrometric Approach

Venoms of invertebrates contain an enormous diversity of proteins, peptides, and other classes of substances. Insect venoms are characterized by a large interspecific variation resulting in extended lists of venom compounds. The venom composition of several hymenopterans also shows different intraspecific variation. For instance, venom from different honeybee castes, more specifically queens and workers, shows quantitative and qualitative variation, while the environment, like seasonal changes, also proves to be an important factor. The present study aimed at an in-depth analysis of the intraspecific variation in the honeybee venom proteome. In summer workers, the recent list of venom proteins resulted from merging combinatorial peptide ligand library sample pretreatment and targeted tandem mass spectrometry realized with a Fourier transform ion cyclotron resonance mass spectrometer (FT-ICR MS/MS). Now, the same technique was used to determine the venom proteome of queens and winter bees, enabling us to compare it with that of summer bees. In total, 34 putative venom toxins were found, of which two were never described in honeybee venoms before. Venom from winter workers did not contain toxins that were not present in queens or summer workers, while winter worker venom lacked the allergen Api m 12, also known as vitellogenin. Venom from queen bees, on the other hand, was lacking six of the 34 venom toxins compared to worker bees, while it contained two new venom toxins, in particularly serine proteinase stubble and antithrombin-III. Although people are hardly stung by honeybees during winter or by queen bees, these newly identified toxins should be taken into account in the characterization of a putative allergic response against Apis mellifera stings.     

Allergen Content of Therapeutic Preparations for Allergen-Specific Immunotherapy of European Paper Wasp Venom Allergy

Allergy to Polistes dominula (European paper wasp) venom is of particular relevance in Southern Europe, potentially becoming a threat in other regions in the near future, and can be effectively cured by venom immunotherapy (VIT). As allergen content in extracts may vary and have an impact on diagnostic and therapeutic approaches, the aim was to compare five therapeutic preparations for VIT of P. dominula venom allergy available in Spain. Products from five different suppliers were analyzed by SDS-PAGE and LC-MS/MS and compared with a reference venom sample. Three products with P. dominula venom and one product with a venom mixture of American Polistes species showed a comparable band pattern in SDS-PAGE as the reference sample and the bands of the major allergens phospholipase A1 and antigen 5 were assignable. The other product, which consists of a mixture of American Polistes species, exhibited the typical band pattern in one, but not in another sample from a second batch. All annotated P. dominula allergens were detected at comparable levels in LC-MS/MS analysis of products containing P. dominula venom. Due to a lack of genomic information on the American Polistes species, the remaining products were not analyzed by this method. The major Polistes allergens were present in comparable amounts in the majority, but not in all investigated samples of venom preparations for VIT of P. dominula venom allergy.     

Sublingual desensitization in patients with wasp venom allergy: preliminary results

The aim of this paper is to assess in an open prospective pilot case-control study the tolerability, safety and efficacy of an ultra-rush sublingual immunotherapy (SLIT) protocol with Vespula venom in wasp allergic patients compared to subcutaneous immunotherapy (SCIT). Forty-one wasp allergic patients were treated with sublingual (SLIT group) or subcutaneous (SCIT group) ultrarush immunotherapy with Vespula venom extract. All patients underwent skin tests and serum specific IgE and IgG4 detection before enrollment and after 6, 12 and 24 months of immunotherapy. The SLIT group consisted of 21 (6 females and 15 males) patients who received increasing doses of Vespula venom (Aquagen, ALK-Abellò) until the final dose of 30 drops of extract in 3 hours, containing 100,000 SQ-U/ml. The maintenance dose was of 10 drops of pure venom extract 3 times a week, for a total dose of 100,000 SQ-U weekly (corresponding to 100 microgram of venom extract). The SCIT group consisted of 20 patients (16 males and 4 females) who were treated with subcutaneous ultrarush immunotherapy with Vespula venom extract (Pharmalgen, Alk-Abellò). Patients received 101.1 microgram of Vespula venom in 3 hours and were treated with 100 microgram of wasp venom monthly. During the ultrarush sublingual treatment 2 patients (9.5%) experienced mild side-effects. Specific IgE and specific IgG to wasp venom did not show any significant modification. Four patients were field-stung by a wasp during the treatment (for a total of 6 stings). Two patients (3 stings), with a previous clinical history of a grade III and IV reaction, did not experience any reaction. One patient, with a previous grade II reaction, showed a large local reaction. The fourth patient, with a previous grade III reaction, was re-stung twice (after 12 and 24 months) with two systemic reactions (SR) (mild throat constriction). During the ultrarush SCIT phase, 3 (15%) patients experienced side-effects: 2 of them showed a large local reaction and 1 had headache and stomach ache. Specific IgE showed a significant (P = 0.001) increase after 6 months of treatment and then returned to baseline levels while specific IgG showed a significant (P = 0.001) increase after 6, 12 and 24 months in comparison with baseline. Nine patients were field-stung during the treatment: 8 of them experienced large local reactions; one patient (11%) experienced an SR (dizziness). Our results, even if in a small number of patients, suggest that in patients with Hymenoptera sting allergy SLIT could be efficacious with a good tolerability profile when compared to SCIT. Larger studies are needed to assess efficacy, safety and tolerability profile of wasp venom SLIT.     

Hymenoptera venom proteins and peptides for diagnosis and treatment of venom allergic patients

Stings by insects of the order Hymenoptera cause systemic, sometimes life threatening allergic reactions in 1 - 5% of the population in Europe and North America. Responsible for these reactions is an IgE mediated sensitization to proteins of the venoms injected during the stings of social Hymenoptera species, mainly the honey bee (Apis mellifera), vespids like Vespula sp., Polistes sp. and ants, in southern US and central America Solenopsis invicta and in Australia Myrmecia pilosula. The venoms of these insects are composed of low molecular weight substances like biogenic amines, cytotoxic and neurotoxic peptides like melittin, apamin, MCD-peptide and mastoparan, and proteins, mostly enzymes like phospholipase A and hyaluronidase, which are major venom allergens. Immunotherapy with Hymenoptera venoms has been shown to protect 80 to over 95% of patients with a history of systemic allergic sting reaction from further systemic reactions after re-stings. The procedure, safety and efficacy of this treatment and the immune mechanisms involved are discussed. Since ancient times honey bee venom has been used for the treatment of chronic inflammatory disease, especially arthritis. Anti-inflammatory effects of bee venom have been documented in animal experiments. Most clinical studies suggest an antiinflammatory effect as well, but are uncontrolled. The only few controlled studies could not confirm efficacy of treatment with bee venom so far.     

Acute polyradiculoneuropathy occurring after hymenoptera stings: a clinical case study

Hymenoptera stings may be responsible for both local and systemic reactions; these can be immediate or delayed, depending on the time between the sting and the development of signs or symptoms. Delayed clinical reactions have been reported, although unusual, due to serum sickness and/or affecting organs or systems generally not involved in the immediate reaction, such as heart, kidneys, central and peripheral nervous systems. This paper describes the clinical and immunological findings in a 51-year-old subject, who, after two stings of paper wasps, the second one after the third venom immunotherapy (VIT) injection, presented immediate large local and systemic allergic reactions which quickly improved after e.v. methylprednisolone administration. About 40 hours later, he developed acute polyradiculoneuropathy with muscle weakness, paresthesia, difficulties in standing up and walking. Skin tests and specific IgE determination showed allergy to paper wasp. The activation, by wasp venom, of peripheral blood mononuclear cells in primary culture, evaluated by tritiated thymidine incorporation proliferation assay, showed an important hypersensitivity to wasp venom. Therefore our results suggest the hypothesis that the polyradiculoneuritis causative etiopathogenetic mechanism might be a delayed immunological response to wasp antigens followed by an allergy-triggered autoimmune reaction, as previously suggested by other authors; they found lymphocytic infiltrates in demyelinization areas and at perivascular levels, by histologic examination of autoptical and bioptical material of patients with nervous system lesions after hymenoptera stings.     

Purification, sequencing and structural characterization of the phospholipase A1 from the venom of the social wasp Polybia paulista (Hymenoptera, Vespidae).

The biochemical and functional characterization of wasp venom toxins is an important prerequisite for the development of new tools both for the therapy of the toxic reactions due to envenomation caused by multiple stinging accidents and also for the diagnosis and therapy of allergic reactions caused by this type of venom. PLA(1) was purified from the venom of the neotropical social wasp Polybia paulista by using molecular exclusion and cation exchange chromatographies; its amino acid sequence was determined by using automated Edman degradation and compared to the sequences of other vespid venom PLA(1)'s. The enzyme exists as a 33,961.40 Da protein, which was identified as a lipase of the GX class, liprotein lipase superfamily, pancreatic lipases (ab20.3) homologous family and RP2 sub-group of phospholipase. P. paulista PLA(1) is 53-82% identical to the phospholipases from wasp species from Northern Hemisphere. The use restrained-based modeling permitted to describe the 3-D structure of the enzyme, revealing that its molecule presents 23% alpha-helix, 28% beta-sheet and 49% coil. The protein structure has the alpha/beta fold common to many lipases; the core consists of a tightly packed beta-sheet constituted of six-stranded parallel and one anti-parallel beta-strand, surrounded by four alpha-helices. P. paulista PLA(1) exhibits direct hemolytic action against washed red blood cells with activity similar to the Cobra cardiotoxin from Naja naja atra. In addition to this, PLA(1) was immunoreactive to specific IgE from the sera of P. paulista-sensitive patients.     

Cosmetic Applications of Bee Venom

Bee venom (BV) is a typical toxin secreted by stingers of honeybee workers. BV and BV therapy have long been attractive to different cultures, with extensive studies during recent decades. Nowadays, BV is applied to combat several skin diseases, such as atopic dermatitis, acne vulgaris, alopecia, vitiligo, and psoriasis. BV is used extensively in topical preparations as cosmetics and used as dressing for wound healing, as well as in facemasks. Nevertheless, the safety of BV as a therapeutic choice has always been a concern due to the immune system reaction in some people due to BV use. The documented unfavorable impact is explained by the fact that the skin reactions to BV might expand to excessive immunological responses, including anaphylaxis, that typically resolve over numerous days. This review aims to address bee venom therapeutic uses in skin cosmetics.     

Two-dimensional polyacrylamide gel electrophoresis of hymenoptera venom and venom sac extracts

Hymenoptera venom and venom sac extracts were studied by two-dimensional polyacrylamide gel electrophoresis using non-equilibrium pH gradient electrophoresis in the first dimension and sodium dodecyl sulfate electrophoresis in the second dimension. Pure Apis mellifera (honeybee) venom collected by electrical stimulation was resolved into five major and more than 20 minor components. Polistes (paper wasp), Vespula (yellow jacket), Dolichovespula (aerial hornet) and Vespa (old world hornet) venom sac extracts contained more than 40 components each. These results illustrate the complexity of the mixtures in current use for immunotherapy for stinging insect hypersensitivity. The degrees of similarity observed between the various species of Polistes and Vespula studied correlate with the phylogenetic classifications of these species.     

注射用蛇毒类血凝酶制剂的不良反应文献分析

目的:分析注射用蛇毒类血凝酶制剂不良反应的特点,为临床安全合理用药提供参考。方法:对1998-2015年中国生物医学文献数据库、中国期刊全文数据库及万方医学网中报道的注射用蛇毒类血凝酶制剂的不良反应病例进行统计分析。结果:共收集到69例患者的不良反应报告,以呼吸系统(25.00%)、全身性损害(24.28%)和心血管系统(22.83%)表现为主,大部分发生在注射后1~5 min。另外有5例报告给药途径为静脉滴注,归类为用药错误导致的不良事件,其表现和发生时间与不良反应类似。结论:严格掌握使用注射用蛇毒类血凝酶制剂的给药途径,了解药物剂量单位的意义,使用时密切观察,监测患者凝血功能等。     

Antigenic cross-reactivity of nerve growth factors from diverse source: activity versus toxicity of NGF

NGF used in these studies was from various sources: cobra venom (V-NGF), mouse submaxillary glands (M-NGF), honeybee venom (B-NGF), human serum (H-NGF), and cobra serum (CS-NGF). This investigation reports the antigenic cross-reactivity of NGFs from the above mentioned diverse sources. Antigenic cross-reactivity of NGFs was determined by immunological test, using anti-NGFs against V-NGF, M-NGF, B-NGF, and H-NGF. Results revealed that NGF was a conserved protein showing antigenic cross-reactivity among the NGFs from diverse source, except for NGFs from cobra and bee venoms. Anti B-NGF reacted poorly with cobra venom V-NGF and vice versa. Anti M-NGF showed higher antigenic reactivity with human serum H-NGF than with honeybee B-NGF and cobra serum CS-NGF. This research also reports that the toxicity of NGF is directly related to the biological activity of producing neurite outgrowth on PC12 cells. Cobra venom NGF produced neurites at 1-5 ng, and it was toxic at 10-20 ng on PC12 cells. After reducing the activity of NGF, it was found to be non-toxic to PC12 cells at 50 X concentration.     

Characterization of honeybee venom by MALDI-TOF and nanoESI-QqTOF mass spectrometry

The aim of the study was to comprehensively characterize different honeybee venom samples applying two complementary mass spectrometry methods. 41 honeybee venom samples of different bee strains, country of origin (Poland, Georgia, and Estonia), year and season of the venom collection were analyzed using MALDI-TOF and nanoESI-QqTOF-MS.     

Acute physiopathological effects of honeybee (Apis mellifera) envenoming by subcutaneous route in a mouse model

Bee stings are a health concern in the Americas, where fatal envenomings due to massive attacks by Africanized honeybees have been documented in the last decades. Most studies on the toxic effects of honeybee venom in experimental animals have been performed using the intravenous or intraperitoneal injection routes. The aim of this study was to develop a mouse model that would better resemble a massive honeybee attack by using the subcutaneous (s.c.) route to induce a severe, sublethal systemic envenoming. An array of acute venom effects were characterized, including biochemical, hematological, histological, and inflammatory alterations, after the s.c. injection of 0.5 median lethal dose of venom. Rapid increases in serum alanine (ALT) and aspartate (AST) transaminases, creatinine, urea nitrogen, uric acid, sodium and chloride electrolytes, and creatine kinase (CK) were recorded, indicating damage to liver, kidneys, and skeletal muscle. Also, coagulation disturbances (fibrinogen decrease, and moderate delay in prothrombin and partial thromboplastin times) were demonstrated. Circulating platelet and leukocyte numbers remained unaltered, but a hemoconcentration effect (hematocrit and hemoglobin increase) was observed. This effect might be related to the marked edema induced by the venom. In addition, this inflammatory response included a systemic increase in cytokines (IL-1β, IL-6, TNF-α), together with an elevation of serum malondialdehyde and nitric oxide. The myotoxic effects of venom, melittin, and phospholipase A₂ were demonstrated after injection by s.c. route. No synergistic myotoxicity between melittin and PLA₂ was observed. Moreover, these two components, when injected at equivalent concentrations to those present in venom, induced a lower increase in serum CK than venom, suggesting that other components also contribute to its strong systemic toxicity towards skeletal muscle. The model here presented may be useful in preclinical studies to assess therapeutic antivenoms developed to cope with the problem of massive bee attacks.     

Management of Double Sensitization to Vespids in Europe

Wasp allergy with a diagnostic profile of double sensitizations to vespid venom is a frequent clinical problem in areas where different genera of wasps are present. Identification of the insect responsible for serious reactions poses a diagnostic challenge as the only effective treatment to date is immunotherapy based on the specific venom. In southern Europe, the double sensitization to Vespula and Polistes venoms is highly frequent. It has been shown that the major allergenic proteins (Phospholipase A1 and Antigen 5) share sequences across the different genera and species, which would be the cause of cross-reactivity. Additionally, the minor allergens (Dipeptidyl-peptidases, Vitellogenins) have been found to share partial sequence identity. Furthermore, venom contains other homologous proteins whose allergenic nature still remains to be clarified. The traditional diagnostic tools available are insufficient to discriminate between allergy to Vespula and Polistes in a high number of cases. IgE inhibition is the technique that best identifies the cross-reactivity. When a double sensitization has indeed been shown to exist or great uncertainty surrounds the primary sensitization, therapy with two venoms is advisable to guarantee the safety of the patient. In this case, a strategy involving alternate administration that combines effectiveness with efficiency is possible.     

Comparison of treatment discontinuation and hospitalization among nonadherent patients initiating depot or oral typical antipsychotic medications

This analysis compared the effectiveness (treatment discontinuation and hospitalization) of depot and oral typical antipsychotics in nonadherent outpatients with schizophrenia. Data from the 3-year, prospective, observational Schizophrenia Outpatient Health Outcome study were used. Time to treatment discontinuation, percentage of patients hospitalized and the mean numbers of hospitalizations were compared for previously nonadherent patients initiating depot typical or oral typical monotherapy. Cox proportional hazards, linear and logistic regression models were used to adjust for differences between the treatment groups at the index visit. Of 1642 nonadherent patients, 431 (26%) started an oral typical (n=169) or depot typical (n=262) antipsychotic and were included in the analysis. After adjusting for index variables, treatment discontinuation was significantly lower in the depot typical cohort (hazard ratio: 0.72, 95% confidence interval: 0.54-0.97, P<0.05). Younger age and more severe positive symptoms were also associated with higher discontinuation. The frequency of hospitalization and the mean number of hospitalizations were both significantly lower for the depot typical cohort at 6 months (P<0.05) compared with oral typicals. In the usual care of outpatients with schizophrenia, treatment continuation among nonadherent patients is longer for depot typicals compared with oral typicals and is accompanied by less hospitalization in the short term.     

Crotalidae polyvalent immune Fab: a guide to its use in North American crotaline envenomation

Intravenous crotalidae polyvalent immune Fab (CroFab(?)) is effective in patients with minimal, moderate or severe crotaline envenomation, halting the progression of local venom effects and ameliorating haematological and other systemic abnormalities of envenomation. Despite treatment, patients may experience delayed-onset or recurrent venom effects (e.g. coagulopathy). Intravenous crotalidae polyvalent immune Fab is generally well tolerated, with acute hypersensitivity reactions being the most commonly occurring adverse event.