Use of B-Blockers during immunotherapy for Hymenoptera venom allergy

Medical Department, Spital Bern Ziegler, Switzerland.
Journal of Allergy and Clinical Immunology (Impact Factor: 11.48). 03/2005; 115(3):606-610. DOI: 10.1016/j.jaci.2004.11.012


Beta-blockers may aggravate anaphylactic reactions and interfere with treatment. There is therefore concern about their use in patients who have a history of anaphylaxis or are on allergen immunotherapy. Immunotherapy is the best available treatment for prevention of life-threatening anaphylaxis to Hymenoptera stings, which is often observed in elderly patients who have cardiovascular disease and therefore are on beta-blocker treatment.
To analyze the risk of beta-blocker treatment during venom immunotherapy.
We screened all 1682 patients with Hymenoptera venom allergy seen during a period of 34 months for immunotherapy, cardiovascular disease, and treatment with beta-blockers.
Of the 1389 patients in whom immunotherapy was recommended, 11.2% had cardiovascular disease, and 44 of these were on beta-blockers before immunotherapy. In 31 of those, the drug was replaced before starting treatment. In 3 with coronary heart disease and 1 with severe ventricular arrhythmia, the drug was continued throughout immunotherapy. In 9, it was reintroduced after reaching the maintenance dose. In an additional 12 patients, beta-blockers were newly started during immunotherapy. Of 25 patients on beta-blockers during immunotherapy, 3 (12%) developed allergic side effects, compared with 23 (16.7%) of 117 with cardiovascular disease but without beta-blockers. Systemic allergic symptoms after re-exposure by sting challenge or field sting were observed in 1 of 7 (14.3%) with and 4 of 29 (13.8%) without beta-blockade. No severe reactions to treatment or sting reexposure were observed in patients with beta-blockade.
Combination of beta-blockers with venom immunotherapy may be indicated in heavily exposed patients with severe cardiovascular disease.

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    • "The issue of patients treated with immunotherapy and simultaneously receiving a β-adrenergic blocker is one that is commonly encountered and one that has generated intense interest as well as some controversy.18,19 This controversy has been generated in part because of the difficulties that are presented to the clinician when substitutions for β-blockers need to be made before the initiation of immunotherapy and because in some instances immunotherapy can be carefully performed even in patients who are receiving venom while on β-adrenergic blockers.20 In addition, it has been shown that β-adrenergic blockers may not increase the risk of anaphylactic events to radiocontrast material.21 "
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    • "In a recent report [16], it was shown that more than 10% of patients with allergic reactions to hymenoptera stings have cardiovascular disease and about a third of them are receiving β-blockers. The authors of this study suggested that, in populations with high degree of exposure to hymenoptera stings such as beekeepers or gardeners who are suffering from coronary artery disease, heart failure or severe cardiac arrhythmias, immunotherapy should be applied under βblockade but with special precautions. "
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