The Effect of Antihypertensive Drugs on Severity of Anaphylaxis and Side-effects During Venom Immunotherapy
Conditions: Hymenoptera Venom Allergy, Antihypertensive Treatment
Sponsor: Medical University of Graz

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EAACI Interest Group on Insect Venom Hypersensitivity 
 
 
STUDY PROTOCOL 
 
EADOAS-Study 
 
The effect of antihypertensive drugs on severity of 
anaphylaxis and side –effects during venom immunotherapy 
EAACI multicenter study 
 
NCT04269629 
 
Study coordinator: 
Gunter J. Sturm, MD, PhD 
Department of Dermatology 
Medical University of Graz 
Auenbruggerplatz 8 
8036 Graz, Austria 
Telephone: +43-650-5142129 
Telefax: +43-316-385-12466 
E-mail: gunter.sturm@medunigraz.at 
 

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Table of Contents 
 
1. 
Study synopsis ................................................................................................................................. 4 
2. 
Indication and objectives ................................................................................................................ 6 
3.1 
Beta-blockers .......................................................................................................................... 6 
3.1.1 
Background ..................................................................................................................... 6 
3.1.2 
Potential effect on immunotherapy .............................................................................. 7 
3.1.3 
Current recommendations ............................................................................................. 8 
3.2 
ACE-inhibitors ......................................................................................................................... 8 
3.2.1 
Background ..................................................................................................................... 8 
3.2.2 
Potential effect on immunotherapy .............................................................................. 8 
3.2.3 
Current recommendations ............................................................................................. 9 
4. 
Justification of the study ................................................................................................................. 9 
5. 
Study criteria ................................................................................................................................. 10 
5.1 
Primary objective .................................................................................................................. 10 
5.2 
Secondary objectives ............................................................................................................ 10 
6. 
Patients and methods ................................................................................................................... 10 
6.1 
Subject eligibility ................................................................................................................... 10 
6.2 
Inclusion criteria ................................................................................................................... 10 
6.3 
Exclusion criteria for phase 2 (no exclusion criteria for phase 1) ....................................... 10 
6.4 
Methods ................................................................................................................................ 11 
6.4.1 
Personal history ............................................................................................................ 11 
6.4.2 
Laboratory tests ............................................................................................................ 11 
6.4.3 
Skin testing (Intradermal skin test and/or prick testing) ............................................ 11 
6.4.4 
Venom immunotherapy (VIT) ....................................................................................... 11 
7. 
Overall study design and plan ....................................................................................................... 12 
8. 
Schedule of study procedures ....................................................................................................... 12 
9. 
Early termination of study ............................................................................................................. 13 
10. 
Data recording and documentation .......................................................................................... 13 
11. 
Statistical methods .................................................................................................................... 13 
12. 
Regulatory and ethical obligations ............................................................................................ 15 
12.1 
Institutional Review Board ................................................................................................... 15 
12.2 
Informed consent.................................................................................................................. 15 
12.3 
Study initiation...................................................................................................................... 15 
12.4 
Case report forms ................................................................................................................. 15 

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13. 
Tables......................................................................................................................................... 16 
13.1 
Table 1 ................................................................................................................................... 16 
13.1.1 
Table 1A ......................................................................................................................... 16 
13.1.2 
Table 1B ......................................................................................................................... 16 
13.2 
Table 2 ................................................................................................................................... 17 
14. 
Abbreviations ............................................................................................................................ 18 
15. 
References ................................................................................................................................. 19 
 
 
 

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1. Study synopsis 
 
APPLICANT / 
COORDINATING 
INVESTIGATOR 
Gunter J. Sturm, MD, PhD 
Department of Dermatology 
Medical University of Graz 
Auenbruggerplatz 8 
8036 Graz, Austria 
Telephone: +43-650-5142129 
Telefax: +43-316-385-12466 
E-mail: gunter.sturm@medunigraz.at 
TITLE OF STUDY 
The effect of antihypertensive drugs on severity of anaphylaxis and 
side-effects during venom immunotherapy 
SHORT TITLE 
EADOAS-Study 
POPULATION 
Patients with a history of anaphylactic sting reaction 
OBJECTIVE(S) 
The primary objective of this study is to evaluate whether subjects 
under antihypertensive treatment with beta-blockers and/or ACE-
inhibitors show more side effects during VIT compared to subjects 
with no antihypertensive treatment. 
INTERVENTION(S) 
Venom immunotherapy (VIT) 
KEY INCLUSION AND 
EXCLUSION CRITERIA 
Inclusion criteria: Subjects aged from 35 to 85 years with a history of 
anaphylactic sting reaction  
Exclusion criteria (only for phase 2): Absolute contraindications for 
VIT, Pretreatment with Omalizumab 
OUTCOME(S) 
Proportion of side-effects during venom immunotherapy 
STUDY TYPE 
Prospective multicenter observational study 
STATISTICAL ANALYSIS The primary analysis will compare the proportion of objective side 
effects between the groups (subjects under antihypertensive 
treatment vs. subjects without antihypertensive treatment) using a 
Mantel-Haensel estimate of the odds ratio stratified by clinic. 
A logistic regression model will be used to control for other possible 
confounders 
ETHICAL APPROVALS 
Participating study centers have to obtain ethical approvals from 
their institutional review boards. 
SPONSORING 
Unrestricted grants from pharmaceutical companies 
SAMPLE SIZE 
1319 
TRIAL DURATION 
July 1, 2014 – December 31, 2019 
(End of inclusion phase: January 31, 2018) 

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PARTICIPATING 
CENTERS 
Name  
Address 
Country 
Prof. Gunter J Sturm, 
MD, PhD 
Department of Dermatology 
Medical University of Graz 
Auenbruggerplatz 8 
8036 Graz, Austria 
Austria 
Prof. Norbert Reider, 
MD 
Clinical Department of 
Dermatology 
Medical University of 
Innsbruck 
Anichstraße 35 
6020 Innsbruck, Austria 
Austria 
Thomas Hawranek, MD 
Department of Dermatology 
SALK 
Paracelsus Medical 
University Salzburg 
Müllner Hauptstraße 48 
5020 Salzburg, Austria 
Austria 
Prim. Univ.-Doz. Georg 
Klein, MD 
Department of Dermatology 
Elisabethinen Hospital Linz 
Fadingerstrasse 1 
4020 Linz, Austria 
Austria 
Priv.-Doz. Stefan Wöhrl, 
MD 
 
Floridsdorf Allergy Center  
Franz-Jonas-Platz 8/6 
1210 Vienna, Austria 
Austria 
Prof. Christof Ebner, MD Ambulatory for Allergy and 
Clinical Immunology - AAKI 
GmbH 
Reumannplatz 17 
1100 Vienna, Austria 
Austria 
 
List to be continued 
 
 
SPONSORING 
Unrestricted grants from pharmaceutical companies 
 
 
 

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2. Indication 
 
There is an ongoing debate whether antihypertensive treatment with beta-blockers and/or 
ACE-inhibitors comprises a risk factor for more severe anaphylactic reactions due to insect 
stings. Side effects under venom immunotherapy (VIT) could be more severe and more 
frequent. In the literature, data are controversial and originate from case reports or 
statistically underpowered studies.  
 
3. Introduction 
 
Since the introdution of beta-blockers in the early 1960s and the availability of ACE-
inhibitors in the early 1980s, there is an ongoing discussion about negative effects of those 
substances on allergic reactions and side-effects during allergen immunotherapy. Although 
there is a theoretical and anectotal clinical evidence for possible interactions, data of studies 
are controversial and their role as risk factors is a debated issue. All available studies have 
drawbacks and are underpowered. Therefore, current recommendations are practice-
oriented but not sufficiently evidence-based. To stop the endless debate, a well planned 
multicenter study ist needed. 
 
3.1 
Beta-blockers 
 
Beta-blockers are mostly used to treat arterial hypertension and are valuable drugs in the 
treatment of cardiovascular disease. However, they are also prescribed for non-cardiac 
conditions like migraine prophylaxis or symptomatic treatment of skeletal muscle tremor. 
 
3.1.1 Background 
 
Four main types of adrenergic receptors (1, 2, 1, 2) can be roughly distinguished 
according to their affinity to norepinephrine and epinephrine. In brief, stimulation of 1 
receptors induces a positive chronotropic and inotropic effect on the heart as well as a renin 
release of the kidney. 2 stimulation results in dilatation of blood vessels and bronchioles, 
and 2 stimulation induces contraction of blood vessels and bronchioles 1. Basically,  
blockade inhibits the effect of both endogenously released and therapeutically administered 
epinephrine on  receptors in case of anaphylaxis. Therefore epinephrine treatment can be 
ineffective or due to the block of 1 and 2 actions may facilitate unopposed -adrenergic 
effects like bronchoconstriction and bradycardia 2. 
 
 

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3.1.2 Potential effect on immunotherapy 
 
- 
Side effects do not appear to be more frequent, but maybe more serious 
- 
Side effects could be refractory to treatment 
- 
Emergency treatment may cause paradoxical treatment effects 
Both beta blockers and allergen immunotherapy are frequently prescribed, therefore 
allergists commonly encounter patients who are candidates for immunotherapy and are 
treated with beta blockers. Fatality studies have shown that particularly elderly patients with 
pre-existing cardiovascular disease die from hymenoptera venom allergy3. Therefore unlike 
for respiratory allergies, immunotherapy with hymenoptera venoms is commonly performed 
in elderly patients who are more likely to be on beta blocker treatment.  
The risk of beta blocker treatment is still questionable. There is plenty of experimental 
human4, 5 and animal studies6-8 mainly performed in the 1970s and 80s as well as anecdotal 
clinical evidence9-15 that anaphylaxis may be influenced by pharmacodynamics of -
blockade. In theory, -blockade perturbs the control of endogenously produced mediators of 
anaphylaxis resulting in an enhanced generation, release, and reduced effects of these 
mediators on the end organs2. If anaphylaxis occurs in a patient on beta-blocker, it may 
therefore be more severe and protracted. There is also evidence that even beta-blocker eye 
drops have systemic effects16-19. However, the plurality of uncontrolled variables makes the 
susceptibility of individual patients to this effect of topically  and orally applied beta-blockers 
largely unpredictable2. The second point is that emergency treatment with epinephrine may 
be ineffective or promote undesired -adrenergic and vagotonic effects20. -blockade 
dramatically alters pharmacotherapeutic actions of epinephrine and isoproterenol, as up to 
80-fold higher doses may be necessary5, 21. Additionally, the block of 1 and 2 actions of 
epinephrine may facilitate unopposed -adrenergic and reflex vagonotic effects, which can 
result in increased mediator release, bronchoconstriction and bradycardia5. The pronounced 
-receptor activation in the presence of epinephrine may also constrict coronary arteries or 
exaggerate systemic pressor effects of epinephrine leading to severe hypertensive episodes. 
There are three clinical studies dealing with the question whether patients taking beta-
blockers are at increased risk of having side effects during immunotherapy. Hepner et al22 
prospectively studied 3178 patients; 68 patients were taking beta-blockers. Although 
statistically 3 patients were expected to have systemic reactions, only one patient taking a 
beta-blocker had a systemic reaction. In a retrospective study of Mueller et al23, 1389 
patients were included, and 25 patients were on beta-blockers during immunotherapy. They 
also did not find an increased incidence of systemic reactions, and reactions were not more 
severe than in the control group. Most recently, an EAACI observational prospective 
multicenter study on 680 patients (15 on beta-blockers) could not identify beta-blocker 
therapy as independent predictor for an emergency intervention24 during immunotherapy. 
Interestingly, in a former EAACI observational study on 962 patients25 (52 on beta-blockers) 
beta blocker were not identified as independent risk factor for severe anaphylaxis, which 

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was consistent with a large Australian study26. In this study, case records of 1149 patients 
were retrospectively analyzed. Univariate analyses suggested that reaction severity was 
influenced by beta-blockers. However, in the multivariate analysis beta-blockers were not 
identified as independent risk factor. Recently, 657 patients suitable for VIT were included in 
a large single-center observational study. 59 were on beta-blocker treatment; 27 on both, 
ACE-inhibitors and beta blockers. Again, beta blockers were not identified to be correlated 
with severe anaphylaxis27. More recently, again controversial data have been published: 
Beta-blockers were not associated with severe anaphylactic symptoms such as syncope or 
hypotension, but with 3 or more organ involvement and hospitalization28.  
 
3.1.3 Current recommendations 
 
There is good evidence in the literature that anaphylaxis is not more frequent in patients 
receiving beta-blockers. On the other side patients may be at increased risk from more 
severe systemic reactions and from ineffective emergency treatment. Therefore there is still 
a relative contraindication for beta blockers in subjects allergic to hymenoptera venom.  
 
3.2 
ACE-inhibitors 
 
ACE-inhibitors are primarily used to treat arterial hypertension and congestive heart failure. 
 
3.2.1 Background 
 
The renin angiotensin aldosterone system (RAS) regulates blood pressure. The system in 
general increases blood pressure by reduced salt and water excretion and vasoconstriction if 
blood pressure acutely drops1. ACE inhibitors block conversion of angiotensin I to 
angiotensin II, which results in vasodilatation and reduced blood volume. Therefore, 
hypotension during anaphylaxis may not sufficiently counteracted by the inhibited RAS.  
 
3.2.2 Potential effect on immunotherapy 
 
- Diminished ability to counteract allergy-induced hypotension 
There is some anecdotal clinical evidence that a subset of patients receiving venom 
immunotherapy tend to have more serious hypotension in case of side effects29, 30. In theory, 
the RAS is part of the compensatory physiologic response to anaphylaxis and thus ACE-
inhibitors may hamper an effective response in some instances of anaphylaxis. However, 
also a dysfunctional RAS in which overall RAS activity is diminished might aggravate 
symptoms due to an insufficient response to anaphylaxis31-33. 

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The role of ACE-inhibitors as risk factor for more severe anaphylaxis is still a debated issue. In 
a large Australian retrospective analysis done by Brown26, 1149 patients who have had 
anaphylaxis were included. Among these, fifty-seven patients were on ACE-inhibitor 
treatment. Multivariate analysis did not identify ACE-inhibitors as independent risk factor. 
However, in an EAACI observational prospective multicenter study on 962 patients with 
hymenoptera allergy, the 42 patients receiving ACE inhibitors had an approximately 2.3-fold 
increased risk for severe anaphylaxis (odds ratio 2.26, 95% CI 1.13 - 4.56) 25. 
The second EAACI observational multicenter study on 680 VIT patients (18 patients on ACE-
inhibitors) did not identify ACE-inhibitors as independent risk factor for side effects. 
Recently, 657 patients suitable for VIT were included in a large single-center observational 
study. 32 were on ACE and 27 on beta-blocker treatment. Again, ACE-inhibitors were not 
identified to be correlated with severe anaphylaxis27. Another retrospective analysis 
revealed that ACE-inhibitors were not associated with severe anaphylactic symptoms such as 
syncope or hypotension, but with 3 or more organ involvement and hospitalization28. Most 
recently, in a study on 743 patients (thereof 90 on ACE inhibitor treatment) ACE inhibitors 
did not increase the frequency of side-effects during the buildup phase of VIT34. 
 
3.2.3 Current recommendations 
 
If ACE-inhibitors increase the risk of more serious anaphylaxis is still a debated issue. 
Currently, the recommendation that patients receiving ACE-inhibitors are more likely to have 
side effects during immunotherapy is only based on case reports. Nevertheless, until there 
will not be new evidence, current guidelines recommend to replace ACE-inhibitors, if 
feasible.  
 
4. Justification of the study 
 
Although a considerable number of studies on this topic were performed, all studies were 
underpowered to identify beta blockers and/or ACE inhibitors as risk factors. The number of 
included patients was usually high; however, the proportion of patients on antihypertensive 
treatment was low ranging from 2-11%22, 34. In the current study we plan to enroll 1319 
patients aged 35-85. Considering retrospective data from our own institution it is assumed 
that 24% (317) will be on beta blockers and/or ACE inhibitors. Based on these data, a clear 
statement on the risk of antihypertensive treatment will be possible. 
 
 
 

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5. Study criteria 
 
5.1 
Primary objective 
 
 The primary objective of this study is to evaluate whether subjects under 
antihypertensive treatment with beta-blockers and/or ACE-inhibitors show more side 
effects during VIT compared to subjects with no antihypertensive treatment. 
5.2 
Secondary objectives  
 
 To evaluate whether subjects under antihypertensive treatment with beta-blockers 
and/or ACE-inhibitors have more severe sting reactions. 
 To correlate the prevalence of cardiovascular diseases and/or hypertension with the risk 
for more severe systemic sting reactions and with more severe and more frequent side 
effects under VIT. 
 To evaluate whether bee venom is associated with a higher frequency of side-effects. 
 To evaluate whether high sIgE levels are correlated to a higher frequency of side-effects. 
 To evaluate whether high tryptase levels are correlated to a higher frequency of side-
effects. 
 To evaluate whether quicker up-dosing protocols are correlated to a higher frequency of 
side-effects. 
 To evaluate efficacy of VIT by sting challenges or field stings and look for differences 
between patients with and without antihypertensive treatment 
 
6. Patients and methods 
 
6.1 
Subject eligibility 
 
Patient selection takes place on the basis of the inclusion and exclusion criteria 
 
6.2 
Inclusion criteria 
 
 Legally competent male and female individuals aged from 35 to 85 years with a 
history of systemic sting reaction (≥ grade I according to the classification by Ring and 
Messmer, Table 1). 
 Age ≥35 and ≤85 years 
6.3 
Exclusion criteria for phase 2 (no exclusion criteria for phase 1) 
 
 Absolute contraindications for VIT 
 Pretreatment with Omalizumab 
 

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6.4 
Methods 
 
6.4.1 Personal history 
 
6.4.2 Personal history is recorded at Visit 1 if patients have met inclusion and exclusion criteria. 
Previous sting reactions, allergies, diseases and current medication will be recorded in the 
CRF. 
Symptoms 
will 
be 
divided 
into 
subjective 
and 
objective 
symptoms.  
Subjective symptoms are: feeling of warmth, isolated pruritus, headache, general fatigue, 
anxiety, dysphagia, throat tightness, chest tightness, nausea, vertigo, perception of 
impending doom 
Objective symptoms are: flush, urticarial, angioedema, dyspnea, hoarseness, drop in blood 
pressure, tachycardia, vomiting, abdominal cramping, bronchospasm, involuntary urination, 
involuntary defecation, loss of consciousness, cardiac arrest, apnoea 
 
 
6.4.3 Laboratory tests 
 
Total and specific IgE (bee and vespid venom, rApi m 1, rVes v 1, rVes v 5) as well as serum 
tryptase will be determined.  
Measurements will be performed as part of clinical routine procedures by ImmunoCAP® 
(Thermo Fisher Scientific, Waltham, MA, USA), according to the manufacturer’s instructions. 
 
6.4.4 Skin testing (Intradermal skin test and/or prick testing) 
 
Skin testing is performed routinely within the standard diagnostic procedure of each center.  
 
6.4.5 Venom immunotherapy (VIT) 
 
There is no standard buildup phase; centers use their own standard protocols. Typically, 
conventional (outpatient), Cluster/Ultrarush- (partial inpatient) and Rush-protocols 
(inpatient) will be performed. The respective venom that is used for VIT will be recorded 
(bee or wasp venom, trade name, company). Injections will be administered subcutaneously 
in the dorsal part of the upper arm, one hand's breadth above the elbow, or in the volar part 
of the thigh. All interventions will be performed according to the in-house protocols of 
participating centers. 
 
 
 

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7. Overall study design and plan 
 
The study is conducted as an open, prospective observational study on an outpatient basis. 
After giving the Informed Consent subjects will be screened at Visit 1. Subjects meeting the 
inclusion and exclusion criteria will be included (phase 1). If subjects agree to receive VIT, 
side effects during the buildup phase will be recorded (phase 2). At the first annual control 
visit side effects during maintenance phase and, if applicable, the outcome of field stings of 
sting challenge tests will be recorded (phase 3). No additional study-related visits are 
required. 
Participation in this study will have no influence on decision-making for venom-
immunotherapy. All procedures have to be in concordance with current EAACI guidelines35, 
36 and will be conducted individually by each study center.  
Detailed schedule of events please see Table 2. 
 
8. Schedule of study procedures 
 
Phase 1 (Screening, inclusion) – Visit 1. (week 0) 
The following procedures will be performed: 
 Ask the subject to read and sign the Informed Consent 
 Review of inclusion and exclusion criteria 
 Collect medical and allergy history, recording of co-medication 
 Collect demographics 
 Perform skin testing and determination of IgE and serum tryptase (CAP) 
 Record decision regarding venom immunotherapy (yes/no) 
 
Phase 2 (up-dosing of VIT) – Visit 2. (0-4 weeks after reaching maintenance dose) 
 Re-collect medical history, recording of co-medication 
 Record of up-dosing scheme and of the respective venom used for VIT 
 Record pre-treatment during VIT 
 Record of side-effects during VIT up-dosing 
 

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Phase 3 (maintenance phase) – Visit 3/3a (at least 12 months [+/- 2 months] after reaching 
maintenance dose) 
 Re-collect medical history, recording of co-medication 
 Record of side-effects during VIT maintenance phase 
Phase 3 (maintenance phase) – Visit 3b/3c optional 
 Document field stings and sting challenges 
 Record outcome of field sting or sting challenge 
 
9. Early termination of study 
 
The subject will be advised in the Informed Consent Form that he/she has the right to 
withdraw from the trial at any time without prejudice. Reasons for a premature treatment 
stop will be documented, if feasible. 
The enrolment of new subjects will be suspended if more than 5 serious anaphylactic 
reactions (≥grade III according to Ring & Messmer; except bronchoconstriction) during 
buildup phase in patients with antihypertensive treatment occur. 
 
10. Data recording and documentation 
 
Data are recorded in case report forms (CRFs). Data will also be collected using a web based 
form. Data regarding this study is recorded, analyzed, and archived in anonymized form.  
 
11. Statistical methods 
All patients who participate in this study belong to one of the following two groups for the 
analyses: the group without antihypertensive medication, and the group on antihypertensive 
medication (beta blockers and/or ACE inhibitors). The analyses will be based on the patients 
who completed buildup phase of immunotherapy. 
Categorical variables will be described with percentages, and continuous variables will be 
expressed as means ± standard deviation or median with interquartile range. 
Statistical analysis will be performed using IBM SPSS Statistics 21. A 5% level of significance 
will be used throughout. In all analyses, an appropriate transformation may be used to 
obtain approximate normality. 
 

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11.1 
Analysis of primary endpoint 
The primary endpoint for the study is the presence of objective side effects during 
immunotherapy which is defined as binary outcome: yes if any grade of objective side effect 
occurred, no otherwise.  
The primary analysis will compare the proportion of objective side effects between the 
groups using a Mantel-Haensel estimate of the odds ratio stratified by center. A logistic 
regression model will be used to control for other possible confounders: age, gender, 
cardiovascular disease, hypertension, chronic bronchial disease or asthma, total IgE, venom-
specific IgE, tryptase levels, mastocytosis, skin test reactivity, and study centers. 
 
11.2 
Analysis of secondary endpoints 
For the analysis of secondary endpoints, comparison between groups will be made by using 
χ2 statistics or the Fisher exact test for categorical variables and by t-test or the Mann-
Whitney U test for continuous variables. 
 
11.3 
Sample size 
It is assumed that 24% of the patients will be on beta blockers and/or ACE inhibitors. A χ2 
test with a two-sided 5% significance level has a 80% power to detect the difference 
between the group without antihypertensive medication with 6% side effects during VIT and 
the group on beta blockers and/or ACE inhibitors with 12.3% side effects during VIT (OR = 
2.2) when the sample sizes are 631 and 200 (a total sample size of 831), respectively.  
The drop-out rate includes study dropouts (30%) who do not start immunotherapy and study 
dropouts (10%) who do not end immunotherapy. This results in a drop-out rate of 37% and a 
required number of 1319 patients. 
 
 
 
 

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12. Regulatory and ethical obligations 
 
12.1 
Institutional Review Board 
 
Each study center will follow the respective regulations of the local ethical review board. 
Approval of the study seems necessary particularly with respect to the statistical evaluation 
of patient data, which have to be processed in an anonymized form. Only routine diagnostic 
procedures will be performed. No additional diagnostic test, treatment or check of efficacy 
with sting challenges will be done solely for the study 
 
12.2 
Informed consent 
 
Informed consent has to be obtained from each patient before inclusion in the study. The 
local policies have to be followed. Translations to the national language have to be done by 
study centers. Informed consent has to be documented. The documentation will remain with 
the study documents throughout the study, and must be available for inspection by any 
authorized personnel. 
 
12.3 
Study initiation 
 
The following documents must be on file at the study sites before the start of this study: 
 Current curricula vitae of all investigators involved in the study 
 Documentation of Institutional Review Board approval of the following: 
- 
Protocol with version number and date, and date of approval  
- 
Informed Consent Form with version number and date, and date of approval 
 
12.4 
Case report forms 
 
The study coordinator will supply copies of the forms. A center code will be assigned to each 
study center. Consecutive patients receive consecutive numbers by the study center. The 
anonymization key is kept together with the patients’ written informed consent at each 
center. Data of each paper-CRF will be entered into an online e-CRF form in anonymised 
form. The originals are kept in the center. 

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13. Tables 
 
13.1 
Table 1 
 
13.1.1 Table 1A 
Classification of systemic reactions modified according to J. Ring and Messmer35, 37 
 
Grade I 
Generalised skin symptoms (e.g. flush, generalised urticaria, 
angioedema) 
Grade II 
Mild to moderate pulmonary, cardiovascular (tachycardia, hypotension, 
dizziness), and/or gastrointestinal symptoms (nausea) 
Grade III 
Anaphylactic shock, loss of consciousness, life-threatening spasm of 
smooth muscles (bronchi, uterus, etc.) 
Grade IV 
Cardiac and/or respiratory arrest 
 
 
13.1.2 Table 1B 
Classification of systemic reactions according to Mueller38 
 
Grade I 
Generalised urticaria, itching, malaise and anxiety 
Grade II 
Any of the above plus two or more of following: 
Generalised oedema; constriction in chest; wheezing; abdominal pain, 
nausea and vomiting; and dizziness. 
Grade III 
Any of the above plus two or more of following: 
Dyspnea; dysphagia; hoarseness or thickened speech; confusion; and 
feeling of impending disaster. 
Grade IV 
Any of above plus two or more of following:  
Cyanosis; fall in blood pressure; collapse incontinence; and 
unconsciousness. 
 
 

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13.2 
Table 2 
 
Study procedures 
Visit 1 
Visit 2 
Visit 3/3a 
Visit 3b/c a 
Screening/Inclusion 
 
Up-dosing  
 
Maintenance  
Phase 
Field sting / 
sting challenge 
Informed consent 
X 
 
 
 
Inclusion/Exclusion 
review 
X 
 
 
 
Allergy history 
X 
 
 
 
Medical history / co-
medication 
X 
X 
X 
X 
Demographics 
X 
 
 
 
Collect results of IDT 
and CAP 
X 
 
 
 
Recording of decision 
regarding venom 
immunotherapy 
(yes/no) 
X 
 
 
 
Recording of venom 
used for VIT 
 
X 
 
 
Recording of side-effects  
 
X 
X 
 
Recording of stinging 
insect 
 
 
 
X 
Recording of sting 
reaction 
 
 
 
X 
 
a if applicable. 
 
 

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14. Abbreviations 
 
ACE 
angiotensin converting enzyme 
CAP 
ImmunoCAP® (test for sIgE determination) 
CI 
confidence interval 
CRF 
case report form 
EAACI 
European Academy of Allergology and Clinical Immunology 
IDT 
intradermal test 
OR 
odds ratio 
RAS 
renin angiotensin (aldosterone) system 
sIgE 
specific IgE antibodies 
tIgE 
total IgE 
VIT 
venom immunotherapy 
 
 

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15. References 
 
1. 
Silbernagel S, Despopoulos A. Color Atlas of Physiology. 6th ed. New York (NY): Thieme 
Publishing Group; 2009. 
2. 
Toogood JH. Beta-blocker therapy and the risk of anaphylaxis. CMAJ 1987; 137:587-8, 90-1. 
3. 
Sasvary T, Muller U. [Fatalities from insect stings in Switzerland 1978 to 1987]. Schweiz Med 
Wochenschr 1994; 124:1887-94. 
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