Recommendations for Managing Stinging Insect Reactions

February 2, 2017

Recommendations for Managing Stinging Insect Reactions

  1. David J. Amrol, MD

Patients with severe systemic reactions should be referred for testing and immunotherapy.

  1. David J. Amrol, MD

Sponsoring Organizations: American Academy of Allergy, Asthma & Immunology; American College of Allergy, Asthma & Immunology

Target Audience: Primary care providers, emergency department physicians, allergists


Stings by insects of the Hymenoptera order (i.e., hornets, wasps, yellow jackets, honeybees, and fire ants) cause systemic reactions in about 3% of U.S. adults. At least 40 patients die annually in the U.S. from these stings, and they account for 20% of all anaphylaxis-related deaths. In patients with severe systemic reactions, 50% will experience anaphylaxis to future stings; with venom immunotherapy (VIT), this risk is <5%.

Key Points

  • More than 20% of adults are sensitized to insect venom but are not at substantially elevated risk for anaphylaxis, so screening asymptomatic patients is discouraged.

  • About 10% of the general population experience large local reactions from insect stings and can be treated symptomatically, possibly with short-course oral corticosteroids for severe swelling; risk for anaphylaxis in these patients is <5%, so VIT generally is not indicated.

  • Children and adults with only cutaneous systemic reactions (e.g., urticaria, peripheral angioedema) are at low risk for anaphylaxis and typically do not need VIT.

  • Measuring baseline serum tryptase can identify patients at high risk for anaphylaxis and those with mastocytosis.

  • All patients with severe systemic reactions should be referred for testing and, if positive, should receive VIT for 5 years. Patients should carry self-injectable epinephrine and medical identification and should be instructed on insect avoidance.

  • Consensus is lacking on whether low-risk patients (i.e., those with large local or cutaneous reactions, those receiving maintenance VIT, and those who have completed 5 years of VIT) should carry epinephrine, and the decision is left to physicians and patients.

  • Because β-blockers and angiotensin-converting–enzyme inhibitors might heighten risk for serious adverse events from stings or VIT, they should be used concomitantly with VIT only if absolutely necessary.

What's Changed

Major changes from the previous version of this guideline (J Allergy Clin Immunol 2011; 127:852) include the recommendation not to offer VIT to patients with cutaneous systemic reactions and the emphasis on checking tryptase levels.


This update reaffirms that all patients with severe systemic reactions to insect stings should undergo venom testing and, if positive, should complete 5 years of VIT.

Editor Disclosures at Time of Publication

  • Disclosures for David J. Amrol, MD at time of publication Equity Abbott; AbbieVie; Express Scripts; Johnson and Johnson; Novartis; Pfizer; United Health Leadership positions in professional societies Allergy Society of South Carolina (Past President)


Reader Comments (1)

Fritz Foulke, M.D. Physician, Family Medicine/General Practice, Salem, Oregon

This is anecdotal and I think applies more to local reactions, I and my family have noted that a brief, quick soak in an alkaline cleanser (PBW or powdered beer wash, ~ 1/4 tsp in 6-8 oz lukewarm water) completely relieves pain in about 30 seconds and is followed by no development of inflammation over next 24 hours. Presumably this solution denatures venom protein thereby stopping reaction?

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