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Hymenoptera stinging insects are common culprits for allergic reactions. Anaphylaxis to insect stings can be life threatening and is associated with a significant risk of recurrence. Insect allergy requires referral to an allergist/immunologist for education and for diagnostic evaluation that will direct further management and treatment. Venom immunotherapy is safe and effective; it prevents sting anaphylaxis in up to 98% of patients. Potential risk factors for side effects during testing and treatment should be assessed for every patient to mitigate risk and to guide treatment recommendations and the duration of immunotherapy., Competing Interests: Disclosure K.E. Adams has nothing to disclose. J.M. Tracy serves on the advisory boards for Pharming, Biocrist, and Thermo-Fischer; Honoraria: UptoDate. D.B.K. Golden serves on the speaker bureau for Genentech; as a consultant to ALK, Stallergenes, Allergy Therapeutics, Kaleo, and Aquestive; as a section editor for UpToDate and receives clinical trials support from Genentech, Novartis, and Allergy Therapeutics., (Published by Elsevier Inc.)

Questions and controversies regarding venom immunotherapy (VIT) remain. It is important to recognize risk factors for severe sting anaphylaxis that guide the recommendation for testing, epinephrine injectors, and VIT. Premedication, rush VIT, and omalizumab are successful in overcoming recurrent systemic reactions to VIT. A maintenance dose is adequate in children, but higher doses are needed in high-risk patients. The consensus on risk of β-blockers and angiotensin-converting enzyme inhibitors in patients on VIT has shifted to the belief that risk is small. The decision to stop VIT after 5 years rests on known risk factors rather than any diagnostic tests., (Copyright © 2019 Elsevier Inc. All rights reserved.)