Hymenoptera Venom Products (Insect Venom) - Drug Interactions, Contraindications, Overdosage, etc

DRUG INTERACTIONS

3. DRUG INTERACTIONS

Patients with cardiovascular diseases and/or pulmonary diseases such as symptomatic unstable, steroid-dependent asthma, and/or those who are receiving cardiovascular drugs such as beta blockers, may be at higher risk for severe adverse reactions. These patients may also be more refractory to the normal allergy treatment regimen. Patients should be treated only if the benefit of treatment outweighs the risks. (1)
Patients on beta blockers may be more reactive to allergens given for testing or treatment and may be unresponsive to the usual doses of epinephrine used to treat allergic reactions.
See WARNINGS section regarding concurrent treatment with ACE inhibitors.
Certain medications may lessen the skin test wheal and erythema responses elicited by allergens and histamine for varying time periods. Conventional antihistamines should be discontinued at least 5 days before skin testing. Long acting antihistamines should be discontinued for at least 3 weeks prior to skin testing. (17) Topical steroids should be discontinued at the skin test site for at least 2-3 weeks before skin testing. (17, 18)
Tricyclic antidepressants such as doxepin, should be withheld for at least 7 days before skin testing. (19) Topical local anesthetics may suppress the flare responses and should be avoided on skin test sites.(20)
When using other drugs in patients receiving allergenic extracts, always consult the product labeling of the other drugs to determine any possible interaction with use of allergenic extracts, and specifically with stinging insect (Hymenoptera) venom extracts.

OVERDOSAGE

See ADVERSE REACTIONS Section.

CONTRAINDICATIONS

There are no known absolute contraindications to immunotherapy using Hymenoptera Venom Products. See also PRECAUTIONS and WARNINGS.
Patients showing negative intradermal skin tests to specific venoms at 1 μg/mL are not recommended for venom treatment.
Any injections, including immunotherapy, should be avoided in patients with a bleeding tendency. Patients with cardiovascular diseases and/or pulmonary diseases such as symptomatic unstable, steroid-dependent asthma, and/or those who are receiving cardiovascular drugs such as beta blockers, may be at higher risk for severe adverse reactions. These patients may also be more refractory to the normal allergy treatment regimen. Patients should be treated only if the benefit of treatment outweighs the risks. (1)
Patients on beta blockers may be more reactive to allergens given for testing or treatment and maybe unresponsive to the usual doses of epinephrine used to treat systemic reactions.(2)
Since there are differences of opinion concerning the possibility of routine immunizations exacerbating autoimmune diseases, immunotherapy should be given cautiously to patients with other immunologic diseases and only if the risk from insect stings is greater than the risk of exacerbating the underlying disorder.

REFERENCES

1. Lockey, Richard F., Linda M. Benedict, Paul C. Turkeltaub, Samuel C. Bukantz. Fatalities from immunotherapy (IT) and skin testing (ST). J. Allergy Clin. Immunol. 79 (4): 660-677, 1987.

2. Jacobs, Robert L., Goeffrey W. Rake, Jr., et. al.; Potentiated anaphylaxis in patients with drug-induced betaadrenergic blockade. J. Allergy Clin. Immunol., 68 (2): 125-127, August 1981.

3. Hunt, K. J., M. D. Valentine, A. K. Sobotka, A. W. Benton, F. J. Amodio, and L. M. Lichtenstein. A controlled trial of immunotherapy in insect hypersensitivity; New Eng. J. Med.; 299: 157-161; July 27, 1978

4. Summary of data from BB-IND 1292 clinical studies, 1978-79, on Hollister-Stier products.

5. Amodio, F., L. Markley, M. D. Valentine, A. K. Sobotka, L. M. Lichtenstein; Maintenance immunotherapy for Hymenoptera sensitivity; J. Allergy Clin. Immunol.; 61 (3): 134, 1978.

6. Reisman, R. E., Allergy Principles and Practice; E. Middleton, C. E. Reed, and E. F. Ellis, editors; C. V. Mosby Co., 1978.

7. Sobotka, A. K., N. F. Adkinson, Jr., M. D. Valentine, and L. M. Lichtenstein; Allergy to insect stings. IV. Diagnosis by R.A.S.T.; J. Immunol.; 121 (6): 2477-2484, 1978.

8. Hunt, K. J., M. D. Valentine, A. K. Sobotka, L. M. Lichtenstein; Diagnosis of allergy to stinging insects by skin testing with Hymenoptera venoms; Annals Int. Med.; 85: 56-59, 1976.

9. Annals of Allergy, Asthma and Immunology. Inhibitors of angiotensin II: potential hazards for patients at risk for anaphylaxis. Editorial. 78: 527-529, June 1997.

10. Pharm. Ind.(Germany). Anaphylactoid reactions in patients treated with ACE inhibitor treatment in combination with desensitization treatment or after insect bites. 56(9): IX226-227, 1994.

11. Tunon-De-Lara, J.M., et al. ACE inhibitors and anaphylactoid reactions during venom immunotherapy. The Lancet (United Kingdom). 340(8824): 908, Oct. 10, 1992.

12. Weinstien, A.M., B.D. Dubin, W.K. Podleski, S.L. Spector, R.S. Farr. Asthma and pregnancy. JAMA. 124 (11): 1161-1165, 1979.

13. Reid, M. J., R. F. Lockey, P. C. Turkletaub, T.A.E. Platts-Mills. Survey of fatalities from skin testing and immunotherapy. J. Allergy Clin. Immunol. 92 (1): 6-15, July 1993.

14. Reid, M. J., G. Gurka. Deaths associated with skin testing and immunotherapy. J. Allergy Clin. Immunol. 97 (1) Part 3:231, Abstract 195, January 1996.

15. Thompson, R. A. et al, report of a WHO/IUIS working group. The current status of allergen immunotherapy (hyposensitization). Allergy. 44: 369-379, 1989.

16. Malling, H.-J., B. Weeke, et al, The European Academy of Allergology and Clinical Immunology. Position Papers. Allergy. 48 (Supplement 14): 9-82, 1993.

17. Pipkorn, Ulf. Pharmacological influence of anti-allergic medication on In Vivo allergen testing. Allergy. 43: 81-86, 1988.

18. Andersson, M. and U. Pipkorn. Inhibition of the dermal immediate allergic reaction through prolonged treatment with topical glucocorticosteroids. J. Allergy Clin. Immunol. 79 (2): 345-349, February 1987.

19. Rao, Kamineni S., et al. Duration of suppressive effect of tricyclic anti-depressants on histamine induced wheal and flare reactions on human skin. J. Allergy Clin. Immunol. 82: 752-757, November 1988.

20. Pipkorn, Ulf, and M. Andersson. Topical dermal anesthesia inhibits the flare but not the wheal response to allergen and histamine in the skin prick test. Clinical Allergy. 17: 307-311, 1987.

21. DuBuske, L.M., C.J. Ling and A.L. Sheffer. Special problems regarding allergy immunotherapy. Immunol. Allergy Clin. North Am. (USA). 12 (1): 145-175, 1992.

22. Graft, D., K. Schuberth, A. Kagey-Sobotka, K. Kwiterovich, Y. Niv, L. Lichtenstein, M. Valentine. Assessment of prolonged venom immunotherapy in children. J. Allergy Clin. Immunol. 80 (2): 162-169, August 1987.

23. Peebles, Ray Stokes, Jr., B. Bochner, Howard J. Zeitz, ed. Anaphylaxis in the elderly. Immunol. Allergy Clin. of North Am. 13 (3): 627-646, August 1993.