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Insect bites and stings - Management
How do I manage systemic reactions to an insect bite or sting?

  • If a severe systemic reaction occurs, such as wheezing or other signs of respiratory distress or hypotension:
    • Treat urgently as for anaphylaxis and admit to hospital.
  • If there are symptoms of systemic toxicity that suggest impending anaphylaxis (e.g. abdominal pain, vomiting, rhinitis and conjunctivitis, or a sense of impending doom):
    • Treat as for anaphylaxis and admit to hospital.
  • If generalized urticaria occurs, but the person is otherwise well:
    • Give an oral antihistamine and an oral corticosteroid.
      • Offer a non-sedating antihistamine to control daytime symptoms.
      • Consider giving an additional sedating antihistamine at night if the itch is interfering with sleep.
      • In adults, give prednisolone 40 mg once a day, and in children give 1–2 mg/kg body weight once a day.
      • Continue prednisolone for 3–5 days, depending on the severity of the reaction.
    • Advise the person to seek urgent medical help if the rash worsens, swelling develops which involves the mouth or throat, or wheeze or breathing difficulties occur.
Clarification / Additional information
  • Some drugs, such as beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, alpha-blockers, monoamine oxidase inhibitors, or tricyclic antidepressants, may increase the severity of the reaction.
  • Anyone with a history of chronic lymphoid leukaemia may exhibit severe or delayed bite reactions.
Basis for recommendation
  • The basis for this recommendation is expert opinion from the published literature [Spickett, Personal Communication, 2003; Burns, 2004; Moffitt et al, 2004].
  • Oral antihistamines:
    • No published randomized controlled trials have assessed the efficacy of oral antihistamines in the treatment of acute urticaria, although they are widely recognized as the mainstay of treatment.
    • In chronic urticaria, second-generation antihistamines have been shown to be more effective than placebo in controlling itch and the appearance of weals, whilst reducing sleeplessness and lessening interference with daily activities.
    • Sedating antihistamines are not recommended for daytime use because the drowsiness they cause can affect a person's ability to drive or perform other skilled tasks [Grattan et al, 2001; Zuberbier et al, 2006]. However, the addition of a sedating antihistamine at night to a non-sedating (daytime) antihistamine may help people unable to sleep due to itching, and is considered to be safe [Grattan et al, 2001].
  • Oral corticosteroids:
    • For people with severe acute urticaria, experts recommend a short course of high-dose oral corticosteroids [Reisman, 1994; Moffitt et al, 2004; Steen et al, 2005].
    • In view of the lack of studies of oral corticosteroids for systemic reactions or large local reactions to insect bites or stings, CKS recommends that a 3–5 day course of oral prednisolone is used, in the doses used for an acute exacerbation of asthma [SIGN and BTS, 2005].

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