When to Test and How to Treat Insect Sting Allergies, with David Golden, MD

At the 2025 American Academy of Allergy, Asthma, & Immunology (AAAAI) annual meeting in San Diego from February 28 – March 3, HCPLive sat down with David Golden, MD, from Johns Hopkins to discuss when to test for insect sting allergies and how to treat it.1

Generally, Golden recommends only testing patients for insect sting allergies if they have an anaphylactic reaction, not simply uncomfortable swelling. Of course, Golden considers how an insect sting impairs quality of life, giving the example of a beekeeper frequently getting stung by bees, and how they may need epinephrine to improve their overall wellbeing. In this case, Golden recommends the beekeeper be tested for an insect sting allergy.

Golden also recommends testing for insect sting allergies in individuals with suspected mast cell conditions. However, people may not know they have a mast cell condition, and it is often discovered when they have an allergic reaction.

“We worry a lot about those people because we know that they're like a gun ready to go off. Their mast cells are primed and ready to go, and that's potentially dangerous,” Golden said. “If we knew someone had mast cell condition and they had a sting reaction, we would be…pushing the idea that they need to be tested.”

Unlike mast cell conditions, having other allergic conditions—such as asthma or severe allergies to something non-insect related—is not something that can increase the likelihood of a more severe insect sting allergy. Golden does not recommend testing for an insect allergy simply because the patient has asthma or severe allergies.

Golden said there are no emerging treatments for managing insect sting allergies. However, patients can undergo venom immunotherapy.

“One of the biggest problems is that outside of the field of allergy, nobody knows about it,” Golden said. “It's amazing to me that, and I'll be willing to bet that 90 to 95% of healthcare practitioners don't know that venom immunotherapy exists.”

Many patients with insect sting allergies do not tell their doctor about their previous reaction since they do not believe a reaction like that will happen in the future. And for those who do tell their doctor, many practitioners will give them an epinephrine injector and say there is no need for them to visit an allergist. However, 80% of patients with an epinephrine injector do not use it when they experience anaphylaxis.2

“Let's face it, people don't like needles, but we can get around that now by prescribing an epinephrine nasal spray that we not only hope people will actually use, but they'll use early,” Golden said.

He said people often delay the use of an epinephrine injector, saying something along the lines of, “Oh, well, I'll just wait and see if I get worse.”

“That's a terrible idea because if you wait too long, it doesn't even work,” Golden said. “So having a [nasal] spray, we hope [that] will mean people will use it as soon as they notice that they're having a reaction, and that's going to prevent a lot of severe reactions in hospital visits. So that is new, and it's an exciting addition to our ability to help protect people and treat reactions.”

A relevant disclosure for Golden includes Genentech USA, Inc.

References

1. Golden, D, and Adams, K. Dilemmas in Insect Allergy. Presented at AAAAI 2025 in San Diego on March 1.

2. Dribin TE, Waserman S, Turner PJ. Who Needs Epinephrine? Anaphylaxis, Autoinjectors, and Parachutes. J Allergy Clin Immunol Pract. 2023 Apr;11(4):1036-1046. doi: 10.1016/j.jaip.2023.02.002. Epub 2023 Feb 14. PMID: 36796511; PMCID: PMC10259181.