Update in stinging insect hypersensitivity.

The ACAAI//AAAAI Joint Task Force on Practice Parameters periodically develops updated guidance based on all available evidence. This review summarizes advances in diagnosis and management of insect sting allergy from published practice parameters, and developments under review for the 2026 update. Changes in the species and distribution of stinging insects in the US may be due to migration and invasion. Overall prevalence has not changed, but fatalities from insect sting allergy increased 50% in 30 years. Diagnostic evaluation includes both skin and serum immunoglobulinE testing although positive predictive value is dependent on the history. Evaluation may include venom component testing. Mastocytosis and hereditary alpha tryptasemia must be considered in many cases; testing for baseline serum tryptase is now routine. Testing for c-KIT gene mutation in peripheral blood and tryptase genotype are important supplemental tests. The risk of beta blockers and angiotensin converting enzyme inhibitors is relatively low in most cases, and they are not contraindicated during venom immunotherapy (VIT). VIT is indicated in high-risk patients (30-70% risk of anaphylaxis), but is not required in those with cutaneous reactions (3-10% risk of anaphylaxis). VIT can be safely initiated with rush regimens. Recurrent systemic reactions are rare, and may require omalizumab treatment (off-label). VIT can be discontinued after 5 years in most patients, but extended or indefinite VIT (often at 12-week intervals) is recommended in patients with known high-risk factors or where stopping would cause markedly impaired quality of life. Continued research has refined our clinical approach to patients with concerns about stinging insect hypersensitivity.