Wasp Stings Medication
- Author: Carl A Mealie, MD, FACEP, FAAEM; Chief Editor: Joe Alcock, MD, MS more...
Medication use varies depending on the severity of the wasp sting. Antihistamines are used to treat mild urticarial symptoms. Catecholamines are needed in extreme cases (eg, anaphylaxis).
H1-receptor antagonists block the effects of histamine. Diphenhydramine and hydroxyzine are two of the most widely used H1 blockers for oral and parenteral use in wasp stings.
Diphenhydramine is used for symptomatic relief of symptoms caused by release of histamine in allergic reactions.
Hydroxyzine antagonizes H1 receptors in the periphery and may suppress histamine activity in the subcortical region of the CNS.
These agents modulate and decrease the inflammatory response to the sting. Onset of action is delayed for several hours; therefore, glucocorticoids have very little effect in the acute setting. Early administration continues to stabilize the patient.
Steroids ameliorate the delayed effects of anaphylactoid reactions and may limit biphasic anaphylaxis. In severe cases of serum sickness, parenteral steroids may be beneficial to reduce the inflammatory effects of this immune complex–mediated disease.
Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Epinephrine and the inhaled beta agonist albuterol reverse the effect of histamine (rather than blocking the effect).
Epinephrine is the drug of choice for treating anaphylactoid reactions. It has alpha-agonist effects that include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Beta-agonist effects of epinephrine include bronchodilatation, chronotropic cardiac activity, and positive inotropic effects.
Epinephrine can be administered subcutaneously for mild-to-moderate reactions and intravenously and via an endotracheal tube.
Albuterol is a beta-agonist for bronchospasm refractory to epinephrine. It relaxes bronchial smooth muscle by action on beta2 receptors, with little effect on cardiac muscle contractility.
Glucagon is the drug of choice for severe anaphylaxis in patients who take beta-blockers (should be used in addition to epinephrine, not as a substitute).
Pancreatic alpha cells of the islets of Langerhans produce glucagon, a polypeptide hormone. It exerts opposite effects of insulin on blood glucose. Glucagon elevates blood glucose levels by inhibiting glycogen synthesis and enhancing formation of glucose from noncarbohydrate sources, such as proteins and fats (gluconeogenesis). It increases the hydrolysis of glycogen to glucose (glycogenolysis) in the liver in addition to accelerating hepatic glycogenolysis and lipolysis in adipose tissue. Glucagon also increases the force of contractions in the heart and has a relaxant effect on the GI tract.
The dose used for anaphylaxis is higher than the usual dose of 1 mg (1 U) IV/IM/SC used to treat hypoglycemia.
Antihistamine, H2 Blocker
The combination of H1 and H2 antagonists may be useful in chronic idiopathic urticaria not responding to H1 antagonists alone. It may also be useful for itching and flushing in anaphylaxis, pruritus, urticaria, and contact dermatitis.
Famotidine is an H2 antagonist that, when combined with an H1 type, may be useful in treating allergic reactions that do not respond to H1 antagonists alone.
Starr CK. A simple pain scale for field comparison of Hymenoptera stings. J Entomol Sci. 1985 April. 20:225-31.
Pumphrey RS, Roberts IS. Postmortem findings after fatal anaphylactic reactions. J Clin Pathol. 2000 Apr. 53(4):273-6. [Medline].
Nittner-Marszalska M, Cichocka-Jarosz E. Insect sting allergy in adults: key messages for clinicians. Pol Arch Med Wewn. 2015 Sep 3. pii: AOP_15_083:[Medline].
Forrester JA, Holstege CP, Forrester JD. Fatalities from venomous and nonvenomous animals in the United States (1999-2007). Wilderness Environ Med. 2012 Jun. 23(2):146-52. [Medline].
Guenova E, Volz T, Eichner M, Hoetzenecker W, et al. Basal serum tryptase as risk assessment for severe Hymenoptera sting reactions in elderly. Allergy. 2010 Jul. 65(7):919-23. [Medline].
Diaz JH. The impact of hurricanes and flooding disasters on hymenopterid-inflicted injuries. Am J Disaster Med. 2007 Sep-Oct. 2(5):257-69. [Medline].
Sun Z, Yang X, Ye H, Zhou G, Jiang H. Delayed encephalopathy with movement disorder and catatonia: A rare combination after wasp stings. Clin Neurol Neurosurg. 2012 Dec 21. [Medline].
Nandi M, Sarkar S. Acute kidney injury following multiple wasp stings. Pediatr Nephrol. 2012 Dec. 27(12):2315-7. [Medline].
Barach EM, Nowak RM, Lee TG, et al. Epinephrine for treatment of anaphylactic shock. JAMA. 1984 Apr 27. 251(16):2118-22. [Medline].
Brown SA, Seifert SA, Rayburn WF. Management of envenomations during pregnancy. Clin Toxicol (Phila). 2013 Jan. 51(1):3-15. [Medline].
EpiPen EpiPen JR [package insert]. NAPA California: Dey. 2009.
Ruëff F, Przybilla B. Venom immunotherapy. Side effects and efficacy of treatment. Hautarzt. Mar 2008. 59(3):200-5. [Medline].
Ludman SW, Boyle RJ. Stinging insect allergy: current perspectives on venom immunotherapy. J Asthma Allergy. 2015. 8:75-86. [Medline].
Vachvanichsanong P, Dissaneewate P. Acute renal failure following wasp sting in children. Eur J Pediatr. 2009 Aug. 168(8):991-4. [Medline].
Rekik S, Andrieu S, Aboukhoudir F, Barnay P, Quaino G, Pansieri M, et al. ST Elevation Myocardial Infarction with No Structural Lesions after a Wasp Sting. J Emerg Med. 2009 Mar 26. [Medline].
Jairam A, Kumar RS, Ghosh AK, Hasija PK, Singh JI, Mahapatra D, et al. Delayed Kounis syndrome and acute renal failure after wasp sting. Int J Cardiol. 2008 Aug 13. [Medline].
Andrewes CH. The lives of Wasps and Bees. New York, NY: American Elsevier Publishing Co; 1969.
Austen KF. Diseases of immediate sensitivity. Fauci AS, ed. Harrison's Principles of Internal Medicine. New York, NY: McGraw Hill; 1998. 1860-1869.
Bohlke K, Davis RL, DeStefano F, Marcy SM, Braun MM, Thompson RS. Epidemiology of anaphylaxis among children and adolescents enrolled in a health maintenance organization. J Allergy Clin Immunol. 2004 Mar. 113(3):536-42. [Medline].
Boxer MB, Greenberger PA, Patterson R. The impact of prednisone in life-threatening idiopathic anaphylaxis: reduction in acute episodes and medical costs. Ann Allergy. 1989 Mar. 62(3):201-4. [Medline].
Fadal RG. IgE-mediated hypersensitivity reactions. Otolaryngol Head Neck Surg. 1993 Sep. 109(3 Pt 2):565-78. [Medline].
Golden DK. Immunology Allergy Clinics of North America. 2000. 20(3):553-570. [Full Text].
Hauk P, Friedl K, Kaufmehl K, et al. Subsequent insect stings in children with hypersensitivity to Hymenoptera. J Pediatr. 1995 Feb. 126(2):185-90. [Medline].
Li JT, Yunginger JW. Management of insect sting hypersensitivity. Mayo Clin Proc. 1992 Feb. 67(2):188-94. [Medline].
Muellman RL, Lindzon RD, Silvers NS. Allergy, hypersensitivity and anaphylaxis. Rosen P, ed. Emergency Medicine, Concepts and Clinical Practice. 4th ed. St. Louis, Mo: Mosby Year Book; 1998. 2759-2776.
Sampson HA, Munoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report--second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Ann Emerg Med. 2006 Apr. 47(4):373-80. [Medline].
Settipane GA, Boyd GK. Anaphylaxis from insect stings. Myths, controversy, and reality. Postgrad Med. 1989 Aug. 86(2):273-6, 278, 280-1. [Medline].
Thomas M, Crawford I. Best evidence topic report. Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers. Emerg Med J. 2005 Apr. 22(4):272-3. [Medline].