Wasp and Bee Sting Allergy:
Emergency Action Plan (UK)

Wasp Venom

Contains phospholipases, hyaluronidases, and antigen 5. Wasps can sting multiple times. Reactions tend to be more common in late summer when colonies are at their largest.

Bee Venom

Contains melittin, phospholipase A2, and apamin. Honeybees leave their barbed sting embedded in the skin and die after stinging once. Remove the sting promptly by scraping (not squeezing).

Risk Factors

Elevated baseline serum tryptase, mastocytosis, age over 40, cardiovascular disease, and concurrent ACE inhibitor or beta-blocker use are associated with more severe reactions.

▲ Airway

• Throat tightness or swelling
• Hoarse voice or stridor
• Difficulty swallowing
• Swelling of tongue or lips

△ Breathing

• Shortness of breath
• Wheezing or audible wheeze
• Persistent cough
• Chest tightness or pain

△ Circulation

• Feeling faint or dizzy
• Rapid or weak pulse
• Pale or grey skin
• Collapse or loss of consciousness

△ Skin / Other

• Widespread urticaria (hives)
• Flushing or itching
• Nausea, vomiting, cramping
• Sense of impending doom

Remove the sting (bee stings only)

If stung by a honeybee, scrape the sting away sideways using a fingernail or card edge. Do not use tweezers or pinch the venom sac, as this injects more venom. Wasp stings do not remain embedded in the skin.

Alert someone nearby

Inform a relative, friend, colleague, or bystander that you have been stung and may be having an allergic reaction. Do not remain alone. Tell them where you keep your adrenaline auto-injector.

Sit or lie down — choose the best position

Lie flat with legs raised if you feel faint or dizzy (improves blood flow to the heart). Sit upright if you have breathing difficulty. Lie on your side (recovery position) if you are unconscious or vomiting. Do not stand up suddenly — positional changes can precipitate cardiac arrest in severe anaphylaxis.

Take an antihistamine (for mild reactions)

For mild localised or general urticarial reactions without airway, breathing, or circulatory symptoms, a non-sedating antihistamine — such as cetirizine 10 mg, loratadine 10 mg, or fexofenadine 120 mg — may be taken. Antihistamines are slow-acting and must never replace adrenaline if anaphylaxis features are present. Per updated RCUK 2021 guidance, antihistamines are not recommended as first-line treatment for anaphylaxis in a hospital setting.

USE YOUR ADRENALINE AUTO-INJECTOR immediately if any of these are present:

• Throat tightness, hoarseness, or difficulty swallowing
• Shortness of breath, wheezing, or persistent cough
• Chest tightness or chest pain
• Feeling faint, dizzy, weak, or about to collapse
• Rapid spread of urticaria with any of the above features
• Swelling of the face or tongue

Administer into the outer mid-thigh (can be given through clothing). Hold firmly for 10 seconds. Note the time.

Call 999 immediately after using adrenaline

State: “I am having a severe allergic reaction (anaphylaxis). I have used my adrenaline auto-injector. I need a paramedic ambulance.” Give your exact location. Even if symptoms improve rapidly, all patients who have used an adrenaline auto-injector must be assessed in hospital. Biphasic anaphylaxis — a second wave of symptoms — can occur 1–72 hours later in up to 20% of cases.

Second dose of adrenaline if no improvement after 5 minutes

If symptoms do not improve or worsen within 5 minutes of the first injection, administer the second adrenaline auto-injector into the opposite thigh. Current RCUK 2021 guidance and BSACI recommendations emphasise that a repeat dose of intramuscular adrenaline at 5 minutes is appropriate if the clinical picture does not resolve. Always carry two auto-injectors at all times, as recommended by the MHRA.

Remove the device from its carrier tube. Take off the safety cap.

Grip the device firmly in your dominant hand. Do not put your thumb over the tip.

Place the needle end firmly against the outer mid-thigh (either bare skin or through clothing).

Push the device firmly against the thigh until you hear or feel a click. Hold firmly in place for 10 seconds.

Remove and massage the injection site gently. Hand the used device to the paramedic on arrival — do not re-cap the needle.

Strongly Recommended

• Adults with grade III–IV systemic reactions (cardiovascular/respiratory involvement)
• Adults with grade II reactions AND elevated baseline serum tryptase or mastocytosis
• Individuals with significantly impaired quality of life due to sting fear

Also Considered

• Adults with grade II reactions (urticaria + other systemic features) after full risk assessment
• Children with grade III–IV reactions (grade I–II in children without cardiovascular features generally have a favourable natural history)
• Patients over 60 — evidence from 2025 supports VIT safety and efficacy in older adults

Not Recommended

• Large local reactions alone (no systemic features)
• Normal local reactions

Outdoors

• Avoid walking barefoot on grass or near flowering plants
• Wear shoes, long sleeves and trousers when gardening
• Avoid brightly coloured or floral-patterned clothing
• Keep a lid on drinks when outdoors; check cans before drinking

Food and Fragrance

• Avoid eating sweet foods outdoors in late summer
• Keep food covered at picnics and barbecues
• Avoid heavily perfumed cosmetics, hair products, and sunscreens when outdoors
• Clear fallen fruit from gardens promptly

If an Insect Approaches

• Stay calm and move slowly away — do not swat
• Do not wave arms or run suddenly
• Avoid areas near known nests
• Contact a pest control service to remove nests near your home

Always Carry

• Two in-date adrenaline auto-injectors at all times
• Oral antihistamines for mild reactions
• A copy of your personal emergency action plan
• Medical ID bracelet (e.g. MedicAlert) indicating venom allergy

I have only ever had a large local swelling. Do I need an adrenaline auto-injector?

Large local reactions (LLR) alone, even if very large and uncomfortable, do not carry a significant risk of future anaphylaxis. EAACI guidelines do not routinely recommend prescription of an adrenaline auto-injector for LLR in the absence of systemic features. However, an allergy clinic review is advisable to confirm the diagnosis and provide reassurance. Your allergist will advise on an individual basis.

Can I become allergic to wasp or bee stings even if I have never reacted before?

Yes. Sensitisation to venom can develop over time. The first sting causes sensitisation (production of venom-specific IgE); subsequent stings in a sensitised individual may trigger a systemic reaction. It is therefore not possible to predict who will develop a serious reaction on the basis of previous uneventful stings.

My child had a systemic reaction. Will they need venom immunotherapy?

Children differ from adults in their natural history. Children who experience grade I–II reactions (urticaria and mild systemic features only, without respiratory or cardiovascular involvement) have a generally favourable prognosis and VIT is not routinely recommended. Children who experience grade III–IV reactions should be referred for specialist assessment and VIT is strongly recommended. A paediatric allergy specialist will assess your child individually.

How long does venom immunotherapy take, and is it available privately in London?

Standard VIT involves a build-up phase of weekly injections for approximately 3–4 months, followed by maintenance injections every 4–8 weeks for at least 3–5 years. Accelerated protocols (cluster or rush VIT) can shorten the build-up to days or weeks. Ultra-rush protocols, administered over one to two days as an inpatient or in a supervised clinic setting, are available for selected patients at the London Allergy and Immunology Centre. VIT is available on a private basis at our Harley Street, City of London, and East London clinics.

I take a beta-blocker. Does this affect my treatment for anaphylaxis?

Beta-blockers can blunt the response to adrenaline and make anaphylaxis more difficult to treat, and are associated with more severe reactions in venom allergy patients. If you take a beta-blocker or an ACE inhibitor and have a venom allergy, it is important to discuss this with both your allergist and the prescribing clinician, as switching to an alternative medication may be possible. Adrenaline remains the first-line treatment regardless.