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Hirose T, Kimbara F, Shinozaki M, Mizushima Y, Yamamoto H, Kishi M, Kiguchi T, Shiono S, Noborio M, Fuke A, Akimoto H, Kimura T, Kaga S, Horiuchi T, Shimazu T. Screening for hereditary angioedema (HAE) at 13 emergency centers in Osaka, Japan: A prospective observational study. Medicine (Baltimore) 2017; 96:e6109. [PMID: 28178173 PMCID: PMC5313030 DOI: 10.1097/md.0000000000006109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hereditary angioedema (HAE) with deficiency of C1 inhibitor (C1-INH) is an autosomal-dominant disease characterized by recurrent episodes of potentially life-threatening angioedema. The objective is to study the incidence of HAE among patients who visit the emergency department.This was a 3-year prospective observational screening study involving 13 urban tertiary emergency centers in Osaka prefecture, Japan. Patients were included if they met the following criteria: unexplained edema of the body, upper airway obstruction accompanied by edema, anaphylaxis, acute abdomen with intestinal edema (including ileus and acute pancreatitis), or asthma attack. C1-INH activity and C4 level were measured at the time of emergency department admission during the period between July 2011 and June 2014.This study comprised 66 patients with a median age of 54.0 (IQR: 37.5-68.3) years. Three patients were newly diagnosed as having HAE, and 1 patient had already been diagnosed as having HAE. C1-INH activity levels of the patients with HAE were below the detection limit (<25%), whereas those of non-HAE patients (n = 62) were 106% (IQR: 85.5%-127.0%) (normal range, 70%-130%). The median level of C4 was significantly lower in the patients with HAE compared with those without HAE (1.2 [IQR: 1-3] mg/dL vs 22 [IQR: 16.5-29.5] mg/dL, P < 0.01) (normal range, 17-45 mg/dL).Three patients with undiagnosed HAE were diagnosed as having HAE in the emergency department during the 3-year period. If patients have signs and symptoms suspicious of HAE, the levels of C1-INH activity and C4 should be measured.
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Affiliation(s)
- Tomoya Hirose
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine
- Emergency and Critical Care Medical Center, Osaka Police Hospital
| | - Futoshi Kimbara
- Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital
| | | | - Yasuaki Mizushima
- Senshu Trauma and Critical Care Center, Rinku General Medical Center
| | | | - Masashi Kishi
- Emergency and Critical Care Medical Center, Osaka Police Hospital
| | | | - Shigeru Shiono
- Osaka Prefectural Nakakawachi Medical Center of Acute Medicine
| | - Mitsuhiro Noborio
- Traumatology and Critical Care Medical Center, National Hospital Organization Osaka National Hospital
| | - Akihiro Fuke
- Emergency and Critical Care Medical Center, Osaka City General Hospital
| | | | - Takaaki Kimura
- Department of Critical Care Medical Center, Kinki University School of Medicine
| | - Shinichiro Kaga
- Department of Trauma and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine
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202
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Masson S, Villerot M, Dalal B. A Rare Case of Hydromorphone-Induced Angioedema Effectively Managed by a Difficult Airway Response Team. ACTA ACUST UNITED AC 2017; 7:188-189. [PMID: 27552239 DOI: 10.1213/xaa.0000000000000379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hydromorphone, unlike other opioids associated with histamine release, has never been reported to cause angioedema. We report a rare case of hydromorphone-induced angioedema in a 34-year-old woman with history of deep venous thrombosis and pulmonary embolism who presented with leg swelling and pain after trauma. Hydromorphone was administered with subsequent rapid development of stridor and edematous changes of the tongue, uvula, and surrounding mucosa. The difficult airway response team was activated, and the airway was secured by emergent awake fiberoptic intubation in the operating room. After being treated with antihistamines and steroids for 24 hours, the airway edema had resolved, leading to a successful extubation.
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Affiliation(s)
- Scott Masson
- From the Departments of *Anesthesiology and †Pulmonary and Critical Care Medicine, Oakland University William Beaumont Hospital, Royal Oak, Michigan
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203
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Sim DW, Park KH, Lee JH, Park JW. A Case of Type 2 Hereditary Angioedema With SERPING1 Mutation. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2017; 9:96-98. [PMID: 27826968 PMCID: PMC5102842 DOI: 10.4168/aair.2017.9.1.96] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 07/25/2016] [Accepted: 08/02/2016] [Indexed: 12/11/2022]
Abstract
Hereditary angioedema is a disease of congenital deficiency or functional defect in the C1 esterase inhibitor (C1-INH) consequent to mutation in the SERPING1 gene, which encodes C1-INH. This disease manifests as recurrent, non-pitting, non-pruritic subcutaneous, or submucosal edema as well as an erythematous rash in some cases. These symptoms result from the uncontrolled localized production of bradykinin. The most commonly affected sites are the extremities, face, gastrointestinal tract, and respiratory system. When the respiratory system is affected by hereditary angioedema, swelling of the airway can restrict breathing and lead to life-threatening obstruction. Herein, we report a case of a 24-year-old woman with type 2 hereditary angioedema who presented with recurrent episodic abdominal pain and swelling of the extremities. She had no family history of angioedema. Although her C4 level was markedly decreased (3.40 mg/dL; normal range: 10-40 mg/dL), she presented with a very high C1-INH level (81.0 mg/dL; normal range: 21.0-39.0 mg/dL) and abnormally low C1-INH activity (less than 25%; normal range: 70%-130%). The SERPING1 gene mutation was confirmed in this patient. She was treated with prophylactic tranexamic acid, as needed, and subsequently reported fewer and less severe episodes. To our knowledge, this is the first reported case of type 2 hereditary angioedema in Korea that was consequent to SERPING1 mutation and involved a significantly elevated level of C1-INH as well as a low level of C1-INH activity.
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Affiliation(s)
- Da Woon Sim
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hee Park
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Won Park
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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204
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Straka BT, Ramirez CE, Byrd JB, Stone E, Woodard-Grice A, Nian H, Yu C, Banerji A, Brown NJ. Effect of bradykinin receptor antagonism on ACE inhibitor-associated angioedema. J Allergy Clin Immunol 2016; 140:242-248.e2. [PMID: 27913306 DOI: 10.1016/j.jaci.2016.09.051] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/23/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The B2 receptor antagonist icatibant is approved for treatment of attacks of hereditary angioedema. Icatibant has been reported to decrease time-to-resolution of angiotensin-converting enzyme (ACE) inhibitor-associated angioedema in 1 study of European patients. OBJECTIVE We sought to test the hypothesis that a bradykinin B2 receptor antagonist would shorten time-to-resolution from ACE inhibitor-associated angioedema. METHODS Patients with ACE inhibitor-associated angioedema (defined as swelling of lips, tongue, pharynx, or face during ACE inhibitor use and no swelling in the absence of ACE inhibitor use) were enrolled at Vanderbilt University Medical Center from October 2007 through September 2015 and at Massachusetts General Hospital in 2012. C1 inhibitor deficiency and patients with bowel edema only were excluded. Patients were randomized within 6 hours of presentation to subcutaneous icatibant 30 mg or placebo at 0 and 6 hours later. Patients assessed severity of swelling using a visual analog scale serially following study drug administration or until discharge. RESULTS Thirty-three patients were randomized and 31 received treatment, with 13 receiving icatibant and 18 receiving placebo. One patient randomized to icatibant did not complete the visual analog scale and was excluded from analyses. Two-thirds of patients were black and two-thirds were women. Time-to-resolution of symptoms was similar in placebo and icatibant treatment groups (P = .19 for the primary symptom and P > .16 for individual symptoms of face, lip, tongue, or eyelid swelling). Frequency of administration of H1 and H2 blockers, corticosteroids, and epinephrine was similar in the 2 treatment groups. Time-to-resolution of symptoms was similar in black and white patients. CONCLUSIONS This study does not support clinical efficacy of a bradykinin B2 receptor antagonist in ACE inhibitor-associated angioedema.
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Affiliation(s)
- Brittany T Straka
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Claudia E Ramirez
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - James B Byrd
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth Stone
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | | | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn
| | | | - Nancy J Brown
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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205
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Soni P, Kumar V, Alliu S, Shetty V. Hereditary angioedema (HAE): a cause for recurrent abdominal pain. BMJ Case Rep 2016; 2016:bcr-2016-217196. [PMID: 27873761 DOI: 10.1136/bcr-2016-217196] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 44-year-old Hispanic woman presented to the emergency room with a 2-day history of sudden onset of severe cramping left lower quadrant abdominal pain associated with ∼20 episodes diarrhoea. Abdominal CT scan exhibited bowel wall oedema and acute extensive colitis. On the basis of the preliminary diagnosis of acute abdomen, the patient was admitted under the surgical team and treated for acute colitis. Since her family history was significant for hereditary angioedema (HAE), complement studies were performed which revealed low complement C4 levels and abnormally low values of C1q esterase inhibitor. Thus, the diagnosis of HAE type I was established. This case report summarises that the symptoms of HAE are often non-specific, hence making the underlying cause difficult to diagnose.
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Affiliation(s)
- Parita Soni
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, New York, USA
| | - Vivek Kumar
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, New York, USA
| | - Samson Alliu
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, New York, USA
| | - Vijay Shetty
- Department of Cardiology, Maimonides Medical Center, Brooklyn, New York, USA
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206
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Abstract
Hereditary angioedema (HAE) patients experience recurrent local swelling in various parts of the body including painful swelling of the intestine and life-threatening laryngeal oedema. Most HAE literature is about attacks located in one anatomical site, though it is mentioned that HAE attacks may also involve multiple anatomical sites simultaneously. A detailed description of such multi-location attacks is currently lacking. This study investigated the occurrence, severity and clinical course of HAE attacks with multiple anatomical locations. HAE patients included in a clinical database of recombinant human C1-inhibitor (rhC1INH) studies were evaluated. Visual analog scale scores filled out by the patients for various symptoms at various locations and investigator symptoms scores during the attack were analysed. Data of 219 eligible attacks in 119 patients was analysed. Thirty-three patients (28%) had symptoms at multiple locations in anatomically unrelated regions at the same time during their first attack. Up to five simultaneously affected locations were reported. The observation that severe HAE attacks often affect multiple sites in the body suggests that HAE symptoms result from a systemic rather than from a local process as is currently believed.
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207
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Frank MM, Zuraw B, Banerji A, Bernstein JA, Craig T, Busse P, Christiansen S, Davis-Lorton M, Li HH, Lumry WR, Riedl M. Management of Children With Hereditary Angioedema Due to C1 Inhibitor Deficiency. Pediatrics 2016; 138:peds.2016-0575. [PMID: 27940765 DOI: 10.1542/peds.2016-0575] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Hereditary angioedema (HAE) is a potentially life-threatening inherited disease characterized by attacks of skin swelling, severe abdominal pain, and upper airway swelling. Attacks typically begin in childhood, but the appropriate diagnosis is often missed. Attacks do not respond to epinephrine, antihistamines, or glucocorticoids. Recently, many effective drugs have been approved for treatment of adults with HAE, and the Medical Advisory Board of the HAE Patient's Association has developed and reported treatment recommendations for adults. Only 1 medication is approved for treatment of children <12 years of age, and there are no reported consensus recommendations for treatment of young children in the United States. The 11-member Medical Advisory Board, with extensive experience in the treatment of children, in concert with the leaders of the HAE Patient's Association, has developed these consensus recommendations to help in recognition, diagnosis, treatment of attacks, and prophylaxis of children with HAE.
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Affiliation(s)
| | - Bruce Zuraw
- University of California Medical Center, San Diego, California
| | | | | | - Timothy Craig
- Pennsylvania State University Medical School, Hershey, Pennsylvania
| | - Paula Busse
- Mount Sinai Icahn School of Medicine, New York, New York
| | | | | | - H Henry Li
- Institute for Asthma and Allergy, Chevy Chase, Maryland; and
| | - William R Lumry
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Marc Riedl
- University of California Medical Center, San Diego, California
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208
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Karadža-Lapić L, Korošec P, Šilar M, Košnik M, Cikojević D, Lozić B, Rijavec M. Frequent life-threatening laryngeal attacks in two Croatian families with hereditary angioedema due to C1 inhibitor deficiency harbouring a novel frameshift mutation in SERPING1. Ann Med 2016; 48:485-491. [PMID: 27187751 DOI: 10.1080/07853890.2016.1185144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is a rare autosomal dominant disease caused by mutations in the SERPING1 gene. It can affect many regions in the body, but potentially life-threatening laryngeal oedemas are of concern. METHODS Twenty-three subjects from two families were recruited for clinical data evaluation and molecular analysis at General Hospital Šibenik, Croatia. RESULTS Decreased levels of C1 inhibitor were detected in 12 adult patients and three young asymptomatic persons. The same novel deletion of two nucleotides on exon 3 (c.74_75delAT) was identified in all of them. A history of laryngeal oedema was present in 10 patients (83%), and all patients reported laryngeal attacks at least once a year. The delay in diagnosis decreased noticeably from the first to the last generation. CONCLUSIONS We identified a novel causative mutation in SERPING1 in several affected members of two apparently unrelated families with a high frequency of laryngeal oedema. Molecular analysis of large C1-INH-HAE families will provide new insights on the genotype-phenotype relationship. Key messages Hereditary angioedema due to C1 inhibitor deficiency is a rare autosomal dominant disease caused by mutations in the SERPING1 gene, and laryngeal oedema is of concern because it can cause death by asphyxiation. A novel causative mutation in SERPING1, a deletion of two nucleotides on exon 3 (c.74_75delAT), was identified in several affected members of two apparently unrelated families with a high frequency of laryngeal oedema. Molecular analysis of large C1-INH-HAE families will provide new insights on the genotype-phenotype relationship because it appears that the mutation type may affect disease severity.
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Affiliation(s)
| | - Peter Korošec
- b University Clinic of Respiratory and Allergic Diseases Golnik , Golnik , Slovenia
| | - Mira Šilar
- b University Clinic of Respiratory and Allergic Diseases Golnik , Golnik , Slovenia
| | - Mitja Košnik
- b University Clinic of Respiratory and Allergic Diseases Golnik , Golnik , Slovenia
| | | | | | - Matija Rijavec
- b University Clinic of Respiratory and Allergic Diseases Golnik , Golnik , Slovenia
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209
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Yu SKH, Callum J, Alam A. C1-esterase inhibitor for short-term prophylaxis in a patient with hereditary angioedema with normal C1 inhibitor function. J Clin Anesth 2016; 35:488-491. [PMID: 27871580 DOI: 10.1016/j.jclinane.2016.08.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 08/14/2016] [Indexed: 10/20/2022]
Abstract
Hereditary angioedema with normal C1-esterase inhibitor (HAE-nC1INH) perioperative is a rare condition which could have potential disastrous ramifications for the anesthesiologist in the perioperative period. However, there is limited evidence and/or guidelines on the optimal way to manage these patients. We present the case of a patient with HAE-nC1INH who was successfully managed in the perioperative period with plasma derived C1-esterase inhibitor (pdC1INH). A 29-year-old woman with a diagnosis of HAE-nC1INH presented to the preoperative consultation in preparation for an upcoming total thyroidectomy. She had a 14-year history of ongoing lip and facial edema sometimes necessitating emergency department visitation. Close consultation with her immunologist, transfusion medicine specialists, and anesthesia care providers allowed for a preoperative plan to provide the patient adequate prophylaxis. Both pdC1INH and tranexamic acid were given preoperatively. The patient underwent surgery with no complications. A multidisciplinary team of clinical immunologists, transfusion medicine specialists, and anesthesiologists facilitated the successful perioperative management of a patient with HAE-nC1INH; pdC1INH may a suitable prophylactic perioperative therapy for this rare patient population.
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Affiliation(s)
- Savio K H Yu
- Department of Anesthesia, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Jeannie Callum
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Asim Alam
- Department of Anesthesia, Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
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210
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Baroso R, Sellier P, Defendi F, Charignon D, Ghannam A, Habib M, Drouet C, Favier B. Kininogen Cleavage Assay: Diagnostic Assistance for Kinin-Mediated Angioedema Conditions. PLoS One 2016; 11:e0163958. [PMID: 27685806 PMCID: PMC5042432 DOI: 10.1371/journal.pone.0163958] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/16/2016] [Indexed: 12/15/2022] Open
Abstract
Background Angioedema without wheals (AE) is a symptom characterised by localised episodes of oedema presumably caused by kinin release from kininogen cleavage. It can result from a hereditary deficiency in C1 Inhibitor (C1Inh), but it can present with normal level of C1Inh. These forms are typically difficult to diagnose although enhanced kinin production is suspected or demonstrated in some cases. Objectives We wanted to investigate bradykinin overproduction in all AE condition with normal C1Inh, excluding cases with enhanced kinin catabolism, and to propose this parameter as a disease biomarker. Methods We retrospectively investigated high molecular weight kininogen (HK) cleavage pattern, using gel electrophoresis and immunorevelation. Plasma samples were drawn using the same standardised procedure from blood donors or AE patients with normal C1Inh conditions, normal kinin catabolism, and without prophylaxis. Results Circulating native HK plasma concentrations were similar in the healthy men (interquartile range: 98–175μg/mL, n = 51) and in healthy women (90–176μg/mL, n = 74), while HK cleavage was lower (p<0.001) in men (0–5%) than women (3–9%). Patients exhibited lower native HK concentration (p<10−4; 21–117μg/mL, n = 31 for men; 0–84μg/mL, n = 41 for women) and higher HK cleavage (p<10−4; 10–30% and 14–89%, respectively) than healthy donors. Pathological thresholds were set at: <72μg/mL native HK, >14.4% HK cleavage for men; <38μg/mL; native HK, >33.0% HK cleavage for women, with >98% specificity achieved for all parameters. In plasma from patients undergoing recovery two months after oestrogen/progestin combination withdrawal (n = 13) or two weeks after AE attack (n = 2), HK cleavage was not fully restored, suggesting its use as a post-attack assay. Conclusion As a diagnostic tool, HK cleavage can offer physicians supportive arguments for kinin production in suspected AE cases and improve patient follow-up in clinical trials or prophylactic management.
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Affiliation(s)
- Rémi Baroso
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
| | - Pauline Sellier
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- KininX SAS, Grenoble, France
| | - Federica Defendi
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- National Reference Center for Angioedema Grenoble, France
| | - Delphine Charignon
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- National Reference Center for Angioedema Grenoble, France
| | - Arije Ghannam
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- KininX SAS, Grenoble, France
| | - Mohammed Habib
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- Qalam-Antibody, La Tronche, France
| | - Christian Drouet
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- National Reference Center for Angioedema Grenoble, France
| | - Bertrand Favier
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- * E-mail:
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211
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Banerji A, Baş M, Bernstein JA, Boccon-Gibod I, Bova M, Dempster J, Grumach AS, Magerl M, Poarch K, Ferreira MB. Expert perspectives on hereditary angioedema: Key areas for advancements in care across the patient journey. ALLERGY & RHINOLOGY 2016; 7:172-181. [PMID: 27661998 PMCID: PMC5244276 DOI: 10.2500/ar.2016.7.0165] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Published literature documents the substantial burden of hereditary angioedema (HAE) with C1 inhibitor deficiency on the quality of life and work productivity of patients. However, despite advances in the field and the availability of guidelines to advise health care providers (HCP) on the diagnosis and management of HAE, there are still many challenges to overcome. For example, delayed diagnosis and misdiagnosis are common, and treatment practices vary worldwide. OBJECTIVE An international expert panel was convened to consider opportunities for improvements that would benefit patients with HAE. METHODS Based on professional and personal experiences, the experts developed schematics to describe the journey of patients through the following stages: (1) onset of symptoms and initial evaluation; (2) referral/diagnosis; and (3) management of HAE. More importantly, the panel identified key areas in which it was possible to optimize the support provided to patients and HCPs along this journey. RESULTS Overall, this approach highlighted the need for wider dissemination of algorithms and scientific data to more effectively educate HCPs from multiple disciplines and the need for more research to inform appropriate treatment decisions. Furthermore, HAE awareness campaigns, accurate online information, and referral to patient advocacy groups were all considered helpful approaches to support patients. CONCLUSION More detailed and widespread information on the diagnosis and management of HAE is needed and may lead to advancements in care throughout the journey of the patient with HAE.
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Affiliation(s)
- Aleena Banerji
- From the Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Murat Baş
- Ear, Nose and Throat Clinic, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Jonathan A. Bernstein
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Isabelle Boccon-Gibod
- University Clinic of Internal Medicine, Grenoble University Hospital, Grenoble, France
| | - Maria Bova
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research, University of Naples Federico II, Naples, Italy
| | - John Dempster
- Immunology Department, Barts and the London NHS Trust, London, United Kingdom
| | | | - Markus Magerl
- Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kimberly Poarch
- Allergy and Asthma Specialists of Dallas, Dallas, Texas, and
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212
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Misra L, Khurmi N, Trentman TL. Angioedema: Classification, management and emerging therapies for the perioperative physician. Indian J Anaesth 2016; 60:534-41. [PMID: 27601734 PMCID: PMC4989802 DOI: 10.4103/0019-5049.187776] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Angioedema is a rare condition which manifests as sudden localised, non-pitting swelling of certain body parts including skin and mucous membranes. It is vital that anaesthesiologists understand this condition, as it may present suddenly in the perioperative period with airway compromise. To identify literature for this review, the authors searched the PubMed, Medline, Embase, Scopus and Web of Science databases for English language articles covering a 10-year period, 2006 through 2016. Angioedema can be either mast-cell mediated or bradykinin-induced. Older therapies for histaminergic symptoms are well known to anaesthesiologists (e.g., adrenaline, anti-histamines and steroids), whereas older therapies for bradykinin-induced symptoms include plasma and attenuated androgens. New classes of drugs for bradykinin-induced symptoms are now available, including anti-bradykinin, plasma kallikrein inhibitor and C1 esterase inhibitors. These can be used prophylactically or as rescue medications. Anaesthesiologists are in a unique position to coordinate perioperative care for this complex group of patients.
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Affiliation(s)
- Lopa Misra
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
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213
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Martinez-Saguer I, Escuriola Ettingshausen C. Delayed diagnosis of hereditary angioedema: Thirty-nine years of inadequate treatment. Ann Allergy Asthma Immunol 2016; 117:554-556. [PMID: 27593101 DOI: 10.1016/j.anai.2016.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/19/2016] [Accepted: 08/10/2016] [Indexed: 10/21/2022]
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214
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Christiansen SC, Davis DK, Castaldo AJ, Zuraw BL. Pediatric Hereditary Angioedema: Onset, Diagnostic Delay, and Disease Severity. Clin Pediatr (Phila) 2016; 55:935-42. [PMID: 26581355 DOI: 10.1177/0009922815616886] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hereditary angioedema (HAE) typically presents in childhood. Large gaps remain in our understanding of the natural history of HAE during childhood. We examined age of onset, delay in diagnosis, androgen exposure, and their influence on ultimate disease severity in a large cohort of patients with HAE. Median age of first swelling was 11 years with a median age at diagnosis of 19 years. Earlier onset of symptoms correlated with longer delays in diagnosis (P < .001) and predicted a more severe disease course, including increased number of attacks per year (P = .0009) and hospital admissions (P = .009). Earlier age of onset also significantly correlated with increased perceived HAE severity (P = .0002), negative overall life impact (P < .0001), and use of anabolic androgen. Our observations highlight the importance of early HAE diagnosis and suggest the necessity of a disease management plan once the diagnosis has been made.
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Affiliation(s)
| | - Donna K Davis
- United States Hereditary Angioedema Association, Honolulu, HI, USA
| | | | - Bruce L Zuraw
- Department of Medicine, University of California, San Diego, CA, USA Department of Medicine, San Diego VA Medical Center, USA
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Safety and Usage of C1-Inhibitor in Hereditary Angioedema: Berinert Registry Data. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:963-71. [DOI: 10.1016/j.jaip.2016.04.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/20/2016] [Accepted: 04/26/2016] [Indexed: 12/20/2022]
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216
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Abstract
Hereditary angioedema (HAE), a rare autosomal dominant genetic disorder, is caused by a deficiency in functional C1 esterase inhibitor (C1-INH). This potentially life-threatening condition manifests as recurrent attacks of subcutaneous and submucosal swelling of the skin, gastrointestinal tract and larynx. The management of HAE includes treatment of acute episodes, short-term prophylaxis in preparation for exposure to known triggers and long-term prophylaxis to decrease the incidence and severity of HAE attacks. Four products are approved in the USA for the treatment of acute attacks of HAE, including one human plasma-derived C1-INH therapy, a recombinant human C1-INH product (rhC1-INH), a plasma kallikrein inhibitor and a bradykinin B2 receptor antagonist. In addition, one human plasma-derived C1-INH therapy and danazol are approved for prophylaxis of HAE attacks. rhC1-INH, extracted from the milk of transgenic rabbits, is a glycoprotein of 478 amino acids with an identical amino acid sequence to the endogenous human C1-INH protein. Population pharmacokinetic analysis of rhC1-INH supports an intravenous dosing strategy of 50 U/kg (maximum 4200 U). The safety and efficacy of rhC1-INH in the treatment of acute attacks in patients with HAE were demonstrated in three randomized, double-blind, placebo-controlled studies and two open-label extension studies. In a pilot prophylaxis study, weekly administration of rhC1-INH 50 U/kg for 8 weeks reduced the incidence of HAE attacks and was well tolerated. Administration of rhC1-INH has not been associated with the development of anti-drug antibodies or antibodies to anti-host-related impurities.
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217
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Hofman ZL, Relan A, Zeerleder S, Drouet C, Zuraw B, Hack CE. Angioedema attacks in patients with hereditary angioedema: Local manifestations of a systemic activation process. J Allergy Clin Immunol 2016; 138:359-66. [DOI: 10.1016/j.jaci.2016.02.041] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 01/31/2016] [Accepted: 02/18/2016] [Indexed: 11/17/2022]
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Bharucha AE, Chakraborty S, Sletten CD. Common Functional Gastroenterological Disorders Associated With Abdominal Pain. Mayo Clin Proc 2016; 91:1118-32. [PMID: 27492916 PMCID: PMC4985027 DOI: 10.1016/j.mayocp.2016.06.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/06/2016] [Accepted: 06/06/2016] [Indexed: 02/07/2023]
Abstract
Although abdominal pain is a symptom of several structural gastrointestinal disorders (eg, peptic ulcer disease), this comprehensive review will focus on the 4 most common nonstructural, or functional, disorders associated with abdominal pain: functional dyspepsia, constipation-predominant and diarrhea-predominant irritable bowel syndrome, and functional abdominal pain syndrome. Together, these conditions affect approximately 1 in 4 people in the United States. They are associated with comorbid conditions (eg, fibromyalgia and depression), impaired quality of life, and increased health care utilization. Symptoms are explained by disordered gastrointestinal motility and sensation, which are implicated in various peripheral (eg, postinfectious inflammation and luminal irritants) and/or central (eg, stress and anxiety) factors. These disorders are defined and can generally be diagnosed by symptoms alone. Often prompted by alarm features, selected testing is useful to exclude structural disease. Identifying the specific diagnosis (eg, differentiating between functional abdominal pain and irritable bowel syndrome) and establishing an effective patient-physician relationship are the cornerstones of therapy. Many patients with mild symptoms can be effectively managed with limited tests, sensible dietary modifications, and over-the-counter medications tailored to symptoms. If these measures are not sufficient, pharmacotherapy should be considered for bowel symptoms (constipation or diarrhea) and/or abdominal pain; opioids should not be used. Behavioral and psychological approaches (eg, cognitive behavioral therapy) can be helpful, particularly in patients with chronic abdominal pain who require a multidisciplinary pain management program without opioids.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Angiœdème bradykinique et médecine d’urgence : vers une optimisation des stratégies de prise en charge. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1209-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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220
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Abstract
Conditions such as chronic rhinitis, urticaria, angioedema, and asthma are frequently seen in clinics and hospitals, and there are a core group of medications that are often used to treat these conditions. Knowing the indications, optimal dosing, and side-effect profile of these medications can improve outcomes. Chronic rhinitis due to various causes is one of the most common reasons for primary care physician visits. Knowing the indications for use, forms of administration, and side-effect profiles of these medications can help improve patient outcomes in these common conditions. This review focuses on the medications used to treat these conditions.
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Affiliation(s)
- Andrew G Ayars
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA 98195, USA; Center for Allergy and Inflammation, UW Medicine at South Lake Union, 750 Republican Street, Box 358061, Seattle, WA 98109-4725, USA.
| | - Matthew C Altman
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA 98195, USA; Center for Allergy and Inflammation, UW Medicine at South Lake Union, 750 Republican Street, Box 358061, Seattle, WA 98109-4725, USA
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Zuraw BL, Davis DK, Castaldo AJ, Christiansen SC. Tolerability and Effectiveness of 17-α-Alkylated Androgen Therapy for Hereditary Angioedema: A Re-examination. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:948-955.e15. [PMID: 27329469 DOI: 10.1016/j.jaip.2016.03.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/09/2016] [Accepted: 03/29/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a genetic disorder clinically characterized by recurrent attacks of subcutaneous and mucosal swelling. 17-α-Alkylated androgens (AA) have been used prophylactically to reduce HAE severity, but there are many questions about the efficacy and tolerability of AA. OBJECTIVE The objective of this study was to investigate the tolerability and effectiveness of AA therapy in a large cohort of patients with HAE. METHODS We performed a retrospective cross-sectional study on 650 subjects with HAE utilizing a one time, anonymous, web-based survey. Based on an initial questionnaire, patients were routed to one of the following questionnaires: currently using AA, previously used but discontinued AA, or never used AA. RESULTS Statistical analysis revealed that androgens decreased attack frequency and severity in previous AA users (P < .0001) and current AA users (P < .0001). Substantial variability in the effectiveness was observed. Users who discontinued AA reported significantly lesser benefit. No dose effect was seen for the beneficial effect of AA; however, almost all users reported frequent side effects that were dose related and often severe. CONCLUSIONS AA therapy is usually effective for the treatment of HAE although a substantial fraction of patients with HAE do not achieve adequate benefit. In contrast, the side effects of AA are seen in almost all subjects who take the medicines. If used, AA should only be recommended in the lowest effective and tolerated dose for carefully selected patients.
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Affiliation(s)
- Bruce L Zuraw
- Department of Medicine, University of California, San Diego, La Jolla, Calif; Medicine Service, VA San Diego Healthcare System, San Diego, Calif.
| | - Donna K Davis
- United States Hereditary Angioedema Association, Seven Waterfront Plaza, Honolulu, Hawaii
| | - Anthony J Castaldo
- United States Hereditary Angioedema Association, Seven Waterfront Plaza, Honolulu, Hawaii
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Complement, Kinins, and Hereditary Angioedema: Mechanisms of Plasma Instability when C1 Inhibitor is Absent. Clin Rev Allergy Immunol 2016; 51:207-15. [PMID: 27273087 DOI: 10.1007/s12016-016-8555-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Plasma of patients with types I and II hereditary angioedema is unstable if incubated in a plastic (i.e., inert) vessel at 37 °C manifested by progressively increasing formation of bradykinin. There is also a persistent low level of C4 in 95 % of patients even when they are symptomatic. These phenomena are due to the properties of the C1r subcomponent of C1, factor XII, and the bimolecular complex of prekallikrein with high molecular weight kininogen (HK). Purified C1r auto-activates in physiologic buffers, activates C1s, which in turn depletes C4. This occurs when C1 inhibitor is deficient. The complex of prekallikrein-HK acquires an inducible active site not present in prekallikrein which in Tris-type buffers cleaves HK stoichiometrically to release bradykinin, or in phosphate buffer auto-activates to generate kallikrein and bradykinin. Thus immunologic depletion of C1 inhibitor from factor XII-deficient plasma (phosphate is the natural buffer) auto-activates on incubation to release bradykinin. Normal C1 inhibitor prevents this from occurring. During attacks of angioedema, if factor XII auto-activates on surfaces, the initial factor XIIa formed converts prekallikrein to kallikrein, and kallikrein cleaves HK to release bradykinin. Kallikrein also rapidly activates most remaining factor XII to factor XIIa. Additional cleavages convert factor XIIa to factor XIIf and factor XIIf activates C1r enzymatically so that C4 levels approach zero, and C2 is depleted. There is also a possibility that kallikrein is generated first as a result of activation of the prekallikrein-HK complex by heat shock protein 90 released from endothelial cells, followed by kallikrein activation of factor XII.
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Abstract
Hereditary angioedema (HAE) is a rare disease caused by deficiency of C1 esterase inhibitor (C1-INH). It is an autosomal dominant disease caused by a variety of mutations in the C1-INH gene. C1-INH is an important regulator of several pathways. One pathway it affects is the kallikrein–kinin pathway, which results in the generation of bradykinin. Bradykinin is an important mediator of edema. Diagnosis is based on low levels of C1-INH. HAE with normal C1-INH is also recognized in the literature and the pathophysiology is due to another aspect of the pathway being affected leading to increased bradykinin level. Bradykinin results in intermittent swelling of the cutaneous and mucosal surfaces. The swelling usually evolves over several hours and lasts a few days. Location of the swelling can involve any part of the body including fatal laryngeal edema. Newer treatments exist to treat acute attacks and reduce the frequency of future attacks. Earlier diagnosis and treatment of hereditary angioedema can prevent HAE-associated mortality. Statement of novelty: New treatments are used to treat these attacks. These treatments are aimed at patients having a more normal life with hereditary angioedema.
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Training hereditary angioedema patients to self-administer intravenous C1 esterase inhibitor concentrate. JOURNAL OF INFUSION NURSING 2016; 37:284-90. [PMID: 24983261 DOI: 10.1097/nan.0000000000000049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hereditary angioedema (HAE) is a rare disorder that causes periodic attacks of sometimes painful swelling that may affect any organ system. HAE results in significant morbidity and diminished quality of life and requires patients to seek urgent medical care. HAE can be treated with C1 esterase inhibitor concentrate (C1-INH), icatibant, and ecallantide. Recent consensus guidelines recommend that all HAE patients be considered for training in self-administration of therapy to treat acute attacks or to prevent attacks. Many patients have safely and successfully self-administered intravenous infusions of C1-INH, resulting in rapid treatment, shortened attacks, and improved quality of life. With proper patient selection and adequate guidance and follow-up, self-administered C1-INH therapy is a viable and favorable option to treat HAE, particularly in patients with a moderate to high frequency of attacks.
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226
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Henao MP, Kraschnewski JL, Kelbel T, Craig TJ. Diagnosis and screening of patients with hereditary angioedema in primary care. Ther Clin Risk Manag 2016; 12:701-11. [PMID: 27194914 PMCID: PMC4859422 DOI: 10.2147/tcrm.s86293] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant disease that commonly manifests with episodes of cutaneous or submucosal angioedema and intense abdominal pain. The condition usually presents due to a deficiency of C1 esterase inhibitor (C1-INH) that leads to the overproduction of bradykinin, causing an abrupt increase in vascular permeability. A less-understood and less-common form of the disease presents with normal C1-INH levels. Symptoms of angioedema may be confused initially with mast cell-mediated angioedema, such as allergic reactions, and may perplex physicians when epinephrine, antihistamine, or glucocorticoid therapies do not provide relief. Similarly, abdominal attacks may lead to unnecessary surgeries or opiate dependence. All affected individuals are at risk for a life-threatening episode of laryngeal angioedema, which continues to be a source of fatalities due to asphyxiation. Unfortunately, the diagnosis is delayed on average by almost a decade due to a misunderstanding of symptoms and general lack of awareness of the disease. Once physicians suspect HAE, however, diagnostic methods are reliable and available at most laboratories, and include testing for C4, C1-INH protein, and C1-INH functional levels. In patients with HAE, management consists of acute treatment of an attack as well as possible short- or long-term prophylaxis. Plasma-derived C1-INH, ecallantide, icatibant, and recombinant human C1-INH are new treatments that have been shown to be safe and effective in the treatment of HAE attacks. The current understanding of HAE has greatly improved in recent decades, leading to growing awareness, new treatments, improved management strategies, and better outcomes for patients.
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Affiliation(s)
- Maria Paula Henao
- Department of Medicine, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Jennifer L Kraschnewski
- Department of Medicine, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Theodore Kelbel
- Division of Allergy and Immunology, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Timothy J Craig
- Department of Medicine and Pediatrics, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
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Hakl R, Kuklínek P, Kadlecová P, Litzman J. Hereditary angio-oedema with C1 inhibitor deficiency: Characteristics and diagnostic delay of Czech patients from one centre. Allergol Immunopathol (Madr) 2016; 44:241-5. [PMID: 26796857 DOI: 10.1016/j.aller.2015.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/12/2015] [Accepted: 09/30/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hereditary angio-oedema (HAE) is manifested by repeated episodes of localised subcutaneous or sub-mucosal oedema. Symptoms are extremely variable in frequency, localisation, and severity. Atypical or mild clinical symptoms of the disease may lead to erroneous diagnosis, causing diagnostic delay. The goal of this study was to assess how diagnostic delay has changed over 33 years at a single referral centre. METHODS We analysed diagnostic delay and first symptoms of HAE in patients who were diagnosed at an immunology department between 1980 and 2013. Patient's records were analysed. RESULTS The median diagnostic delay in 77 HAE type 1 and 2 patients was seven (range, 0-42) years. The difference observed in diagnostic delay between probands (18 [0-42] years) and others (1 [0-37] year) was significant (p<0.001). Our data show a significant negative correlation between the length of diagnostic delay and the year of diagnosis in our group of patients (p=0.024). The median age of first symptoms among all HAE patients (N=64) was 17 (1-40) years. The first symptoms of HAE in 64 patients were analysed. Twenty-six patients had abdominal, seventeen peripheral, five facial, two urogenital, and three had laryngeal oedema as the first manifestation of the disease. The last death that was attributed to HAE was in 1977. CONCLUSIONS Our observations demonstrate improved awareness of HAE among physicians, as documented by the significant decrease in diagnostic delay. It is believed that earlier treatment will improve patient quality of life and life expectancy.
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Affiliation(s)
- R Hakl
- St. Anne's University Hospital in Brno, Czech Republic.
| | - P Kuklínek
- St. Anne's University Hospital in Brno, Czech Republic
| | - P Kadlecová
- International Clinical Research Centre of St. Anne's University Hospital in Brno, Czech Republic
| | - J Litzman
- St. Anne's University Hospital in Brno, Czech Republic; Masaryk University, Department of Clinical Immunology and Allergology, Brno, Czech Republic
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Javaud N, Fain O, Durand-Zaleski I, Launay D, Bouillet L, Gompel A, Sobel A, Woimant M, Rabetrano H, Petrovic T, Lapostolle F, Boccon-Gibod I, Reuter PG, Bertrand P, Coppere B, Floccard B, Kanny G, Martin L, Vicaut E, Adnet F. Dedicated call center (SOS-HAE) for hereditary angioedema attacks: study protocol for a randomised controlled trial. Trials 2016; 17:225. [PMID: 27140403 PMCID: PMC4853856 DOI: 10.1186/s13063-016-1350-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 04/19/2016] [Indexed: 11/28/2022] Open
Abstract
Background Despite the availability of guidelines for the specific treatment of hereditary angioedema (HAE) attacks, HAE morbidity and mortality rates remain substantial. HAE attacks are a major medical issue requiring specific treatment as well as a considerable socio-economic burden. We report a protocol designed to test whether a dedicated call centre is more effective than usual practice in the management of patients experiencing an HAE attack. Methods/design This prospective, cluster-randomised, single-blind, parallel-group, multicentre trial evaluates the morbidity and consequent socio-economic costs of the management of patients experiencing an HAE attack by a dedicated call centre as compared to usual practice. The trial aims to recruit 200 patients. Patients in the intervention arm are provided with an SOS-HAE card with the call centre’s freephone number that they can access in the case of an attack. The centre’s mission is to provide recommended expert advice on early home treatment. The centre can route the call to a local emergency medical service with competency in HAE management or even arrange for the drugs needed for the specific treatment of an HAE attack to be sent to the emergency department of the local hospital. The primary outcome measure is the number of hospital admissions for an HAE attack. Each patient will be followed up every 2 months for 2 years. The study has been approved by the ethics committee (Comité de Protection des Personnes d’Ile de France 10; registration number: 2012-A00044-39; date of approval: 19 January 2012). Discussion The SOS-HAE protocol has been designed to address the handling of attacks experienced by patients with HAE in the home. The proposed trial will determine whether the setting up of a dedicated call centre is more effective than usual practice in terms of reducing morbidity as given by the numbers of hospital admissions. The results are also anticipated to have important implications in terms of socio-economic costs for both healthcare services and patients. Trial registration ClinicalTrials.gov NCT01679912.
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Affiliation(s)
- Nicolas Javaud
- Service des Urgences, Hôpital Louis Mourier, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Assistance Publique - Hôpitaux de Paris, Université Paris 7, 178 Rue des Renouillers, 92 700, Colombes, France.
| | - Olivier Fain
- Service de Médecine Interne, DHUi2B, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, Université Paris 6, 75 012, Paris, France
| | - Isabelle Durand-Zaleski
- URCEco Ile de France, Assistance Publique - Hôpitaux de Paris, Hôpital de l'Hôtel-Dieu, Université Paris 12, 75 004, Paris, France
| | - David Launay
- Service de Médecine Interne, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Université de Lille, CHRU de Lille, 59037, Lille, Cedex, France
| | - Laurence Bouillet
- Service de Médecine Interne, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), CHU de Grenoble, 38043, Grenoble, France
| | - Anne Gompel
- Département d'Endocrinologie Gynécologique, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Assistance Publique - Hôpitaux de Paris, Hôpital Port Royal, Université Paris 5, 75001, Paris, France
| | - Alain Sobel
- T2i, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Assistance Publique - Hôpitaux de Paris, Hôpital Hôtel Dieu, Université Paris 5, 75004, Paris, France
| | - Maguy Woimant
- SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000, Bobigny, France
| | - Hasina Rabetrano
- URCEco Ile de France, Assistance Publique - Hôpitaux de Paris, Hôpital de l'Hôtel-Dieu, Université Paris 12, 75 004, Paris, France
| | - Tomislav Petrovic
- SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000, Bobigny, France
| | - Frédéric Lapostolle
- SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000, Bobigny, France
| | - Isabelle Boccon-Gibod
- Service de Médecine Interne, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), CHU de Grenoble, 38043, Grenoble, France
| | - Paul-Georges Reuter
- SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000, Bobigny, France
| | - Philippe Bertrand
- SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000, Bobigny, France
| | | | - Bernard Floccard
- Service de Réanimation, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), CHU Edouard Herriot, 69 437, Lyon, Cedex, France
| | - Gisele Kanny
- Service de Médecine Interne, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), CHU de Nancy, 54 035, Nancy, France
| | - Ludovic Martin
- Service de Dermatologie, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Université d'Angers, CHU d'Angers, 49 933, Angers, Cedex, France
| | - Eric Vicaut
- Unité de Recherche Clinique, Assistance Publique - Hôpitaux de Paris, Hôpital Fernand Widal, Université Paris 7, 75 010, Paris, France
| | - Frédéric Adnet
- SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000, Bobigny, France
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Aloyouny A, Stoopler ET. Vibrational angioedema: considerations for oral health care providers. SPECIAL CARE IN DENTISTRY 2016; 36:335-338. [DOI: 10.1111/scd.12185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ashwag Aloyouny
- Resident, Department of Oral Medicine; University of Pennsylvania School of Dental Medicine; Philadelphia Pennsylvania
| | - Eric T. Stoopler
- Associate Professor; Department of Oral Medicine; University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
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Steiner UC, Weber-Chrysochoou C, Helbling A, Scherer K, Grendelmeier PS, Wuillemin WA. Hereditary angioedema due to C1 - inhibitor deficiency in Switzerland: clinical characteristics and therapeutic modalities within a cohort study. Orphanet J Rare Dis 2016; 11:43. [PMID: 27101900 PMCID: PMC4839073 DOI: 10.1186/s13023-016-0423-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/12/2016] [Indexed: 11/25/2022] Open
Abstract
Background Registration of trigger factors, prodromal symptoms, swelling localization, therapeutic behavior and gender-specific differences of the largest cohort of patients with hereditary angioedema due to C1-Inhibitor deficiency (C1-INH-HAE) in Switzerland. Methods Questionnaire survey within a cohort study: Consenting eligible patients with diagnosed HAE according to clinical history, physical examination and laboratory results, including plasma values for C1-INH and C4 were selected. To each participant we sent a questionnaire assessing patients’ birthday, sex, date of first symptoms and diagnosis, trigger factors, prodromal symptoms, frequency and localization of angioedema, medication use and co-morbidities. Clinical information was collected in each center and then transmitted to the cohort database. Frequencies and distributions were summarized. Associations between gender and trigger factors or prodromal symptoms or localization of angioedema were assessed in multivariate analyses correcting for patients’ age. Results Of 135 patients, data from 104 patients (77 %) were available for analysis. Fifty- four percent were female, mean age at diagnosis was 19.5 years (SD 14.1), Mean age when completing the questionnaire was 44.0 (SD 19.8). More women than men were symptomatic (44/57 vs. 36/47; p = 0.005). This association remained when correcting for age at diagnosis (16.10. 95%CI (5.17 to 26.70); p = 0.004). Swelling episodes ranged between 1 and 136 episodes/year. Swelling was more common among female than among male (-13.15 (95 % CI; -23.10 to -3.22), p = 0.010). Age at diagnosis was inversely associated with the total number of attacks 0.50 (-0.88 to -.011); p = 0.012). One third of patients were on danazol prophylaxis. Conclusion We found large differences of HAE in male and female both in terms of symptom number and swelling episodes. Women are more affected by intensity and frequency of angioedema episodes than men. Danazol treatment remains widely used as effective prophylaxis despite its side effects. New therapies which selectively influence the hormonal estrogen balance could open new therapeutic options mainly for women and maybe also for men.
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Affiliation(s)
- Urs C Steiner
- Division of Clinical Immunology, University Hospital Zurich, Zurich, Switzerland.
| | | | - Arthur Helbling
- Division of Allergology, University Clinic of Rheumatology, Immunology and Allergology, Inselspital Bern, Bern, Switzerland
| | - Kathrin Scherer
- Allergy Unit, Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | | | - Walter A Wuillemin
- Division of Heamatology and Central Heamatology Laboratory, Department of Internal Medicine, Kantonsspital Lucerne and University of Berne, Berne, Switzerland
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Zuraw BL, Christiansen SC. How we manage persons with hereditary angioedema. Br J Haematol 2016; 173:831-43. [DOI: 10.1111/bjh.14059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Bruce L. Zuraw
- University of California, San Diego; La Jolla CA USA
- San Diego VA Health System; San Diego CA USA
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233
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Complements Are Not Always a Good Thing. Adv Emerg Nurs J 2016; 38:93-108. [DOI: 10.1097/tme.0000000000000097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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234
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Belkhouribchia J, Backaert T, Neyrinck S. Isolated Intestinal Angioedema in the Emergency Department. J Emerg Med 2016; 50:660-2. [DOI: 10.1016/j.jemermed.2015.09.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 09/17/2015] [Indexed: 11/29/2022]
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235
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Mouradides C, Abbes L, Cellier C. Fleeting Gastrointestinal Thickening. Clin Gastroenterol Hepatol 2016; 14:A21-2. [PMID: 26707681 DOI: 10.1016/j.cgh.2015.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/03/2015] [Accepted: 12/12/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Christina Mouradides
- Department of Gastroenterology and Endoscopy, European Georges Pompidou Hospital, Paris, France
| | - Leila Abbes
- Department of Gastroenterology and Endoscopy, European Georges Pompidou Hospital, Paris, France
| | - Christophe Cellier
- Department of Gastroenterology and Endoscopy, European Georges Pompidou Hospital, Paris, France
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Diagnostic and therapeutic management of hereditary angioedema due to C1-inhibitor deficiency: the Italian experience. Curr Opin Allergy Clin Immunol 2016; 15:383-91. [PMID: 26106828 DOI: 10.1097/aci.0000000000000186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Hereditary angioedema (HAE) due to C1-inhibitor (C1-INH) deficiency (C1-INH-HAE) is a rare disease, with a reported prevalence of about 1 : 50 000. C1-INH-HAE causes disabling symptoms, which may be life-threatening if swelling affects upper airways. Diagnostic procedures are now well established and the role of bradykinin as the main mediator of plasma outflow eliciting angioedema formation has been clearly elucidated. RECENT FINDINGS Increased understanding of the pathogenesis of C1-INH-HAE allowed in recent years the development of new drugs targeted to inhibit bradykinin synthesis (Ecallantide) or activity (Icatibant). At the same time, a recombinant C1-INH concentrate (Ruconest) was produced from the milk of transgenic rabbits and two plasma-derived C1-INHs (Berinert, Cinryze) underwent controlled trials to obtain marketing authorization. In 2012, an Italian network for C1-INH-HAE (ITACA) was established by physicians of 17 HAE reference centres to collect data from Italian patients and to homogenize and improve the diagnostic and therapeutic approach to the disease. SUMMARY Although there is a widespread agreement on therapeutic goals and treatment of C1-INH-HAE acute attacks, different approaches to prophylaxis are still present among HAE experts. The clinical experience of ITACA on a large population of C1-INH-HAE patients followed for several years may help in identifying the most effective strategies for the management of the disease.
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Abstract
Hereditary angioedema (HAE) is a rare disorder resulting from decreased functional levels of C1-inhibitor (C1-INH), which manifests as periodic episodes of localized edema which can be extremely painful, debilitating and even fatal if the swelling affects the larynx. HAE can complicate many aspects of obstetric/gynecologic care, and an awareness of the disease is critical for clinicians involved in the care of women because of potential HAE-related complications pertaining to pregnancy, labor and delivery, and other women's health issues. This article provides a review of published literature specific to HAE and its management in female patients, including important concerns regarding obstetric/gynecologic care. A growing body of relevant experience is presented to help guide the care of women with HAE.
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Affiliation(s)
- Aleena Banerji
- Massachusetts General Hospital, Cox 201, 55 Fruit Street, Boston, MA, USA
| | - Marc Riedl
- University of California, San Diego, La Jolla, CA, USA
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238
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Psychometric Field Study of Hereditary Angioedema Quality of Life Questionnaire for Adults: HAE-QoL. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:464-473.e4. [PMID: 26969268 DOI: 10.1016/j.jaip.2015.12.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 12/01/2015] [Accepted: 12/21/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) may affect health-related quality of life (HRQoL). A specific HRQoL questionnaire for adult patients with C1-INH-HAE, the HAE-QoL, has recently been developed in Spain. OBJECTIVE The objective of this study was to perform a cross-cultural validation and psychometric study of the HAE-QoL in an international setting. METHODS Cross-cultural adaptation of the Spanish HAE-QoL draft version and an international rating phase with experts were performed. The resultant version of the HAE-QoL, a clinical questionnaire, and Short Form 36-item Health Survey Version 2.0 (SF-36v2) were pilot tested internationally. Item reduction was based on both descriptive and exploratory factor analysis. Psychometric properties were assessed. RESULTS Cross-cultural adaptation of the HAE-QoL was performed in 18 countries. The draft version of the HAE-QoL was pilot tested in 332 patients, and accurate data were obtained from 290 patients from 11 countries. The reduction process resulted in a new version with 25 items and 7 dimensions (treatment difficulties, physical functioning and health, disease-related stigma, emotional role and social functioning, concern about offspring, perceived control over illness, and mental health). Strong psychometric properties were observed (Cronbach's α 0.92; test-retest reliability 0.87). Convergent validity showed mild to moderate correlations with SF-36v2 physical and mental component summaries (0.45 and 0.64, respectively) and with SF-36v2 dimensions (P < .004). HAE-QoL scores discriminated significantly among severity groups (median: asymptomatic 133.5 vs severe 84.0; P < .001); between patients with and without long-term prophylaxis (median: 101 vs 90; P = .001); and between patients with and without psychiatric and/or psychological care (median: 74 vs 103; P ≤ .001). CONCLUSIONS The HAE-QoL, currently available in 18 languages, showed good reliability and validity evidence.
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García-Menaya JM, Cordobés-Durán C, Zambonino MA, Mahecha AC, Bobadilla-González P. Type 1 hereditary angioedema in a 72-year-old woman. Ann Allergy Asthma Immunol 2016; 116:378-9. [PMID: 26947240 DOI: 10.1016/j.anai.2016.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/21/2016] [Accepted: 01/25/2016] [Indexed: 11/17/2022]
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Freda MF, Savarese L, Bova M, Galante A, De Falco R, De Luca Picione R, Marone G, Petraroli A, Siani G, Valerio P, Triggiani M. Stress and Psychological Factors in the Variable Clinical Phenotype of Hereditary Angioedema in Children: A Pilot Study. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2016. [DOI: 10.1089/ped.2015.0557] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Livia Savarese
- Department of Humanities, University of Naples Federico II, Naples, Italy
| | - Maria Bova
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Anna Galante
- Department of Neuroscience, University of Naples Federico II, Naples, Italy
| | - Raffaella De Falco
- Department of Neuroscience, University of Naples Federico II, Naples, Italy
| | | | - Gianni Marone
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Angelica Petraroli
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Gerarda Siani
- Department of Neuroscience, University of Naples Federico II, Naples, Italy
| | - Paolo Valerio
- Department of Neuroscience, University of Naples Federico II, Naples, Italy
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
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241
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Mühlberg H, Ettl N, Magerl M. An analysis of the teaching of intravenous self-administration in patients with hereditary angio-oedema. Clin Exp Dermatol 2016; 41:366-71. [DOI: 10.1111/ced.12806] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2015] [Indexed: 11/28/2022]
Affiliation(s)
- H. Mühlberg
- Healthcare at Home Deutschland GmbH; Weinheim Germany
| | - N. Ettl
- Healthcare at Home Deutschland GmbH; Weinheim Germany
| | - M. Magerl
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
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242
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Martinez-Saguer I, Farkas H. Erythema Marginatum as an Early Symptom of Hereditary Angioedema: Case Report of 2 Newborns. Pediatrics 2016; 137:e20152411. [PMID: 26759410 DOI: 10.1542/peds.2015-2411] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2015] [Indexed: 11/24/2022] Open
Abstract
Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is a rare genetic disease that causes recurrent swelling attacks that may affect various body tissues. Angioedematous attacks can be fatal in the case of upper airway edema and are often preceded by prodromal symptoms like erythema marginatum. Initial symptoms usually occur in the first decade of life. We report on manifestation of profound and recurrent erythema marginatum in 2 newborns. In both cases, prodromal symptoms could help determine the diagnosis of C1-INH-HAE such that, at a later time, angioedematous attacks could be treated promptly and effectively. Awareness of C1-INH-HAE is low among physicians and even lower among the general public. This report aims at raising the level of awareness and shows that initial symptoms of the potentially life-threatening condition can manifest in newborns and that erythema marginatum can even be present at birth. Recognition of early symptoms and timely diagnosis of the disease along with adequate education of the pediatrician and parents are a prerequisite for prompt and effective treatment of attacks and the successful management of the disease.
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Affiliation(s)
| | - Henriette Farkas
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Hungary
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243
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Idiopathic Thrombocytopenic Purpura Misdiagnosed as Hereditary Angioedema. Case Rep Dermatol Med 2016; 2015:934247. [PMID: 26819784 PMCID: PMC4706890 DOI: 10.1155/2015/934247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/05/2015] [Accepted: 12/15/2015] [Indexed: 12/03/2022] Open
Abstract
Hereditary angioedema is a rare, but potentially life-threatening genetic disorder that results from an autosomal dominant trait. It is characterized by acute, recurrent attacks of severe local edema, most commonly affecting the skin and mucosa. Swelling in hereditary angioedema patients does however not always have to be caused by angioedema but can relate to other concomitant disorders. In this report we are focusing on misdiagnosis in a patient with known hereditary angioedema, whose bleeding episode caused by idiopathic thrombocytopenic purpura was mistaken for an acute attack of hereditary angioedema. The case illustrates how clinicians can have difficulties in handling patients with rare diseases, especially in the emergency care setting.
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244
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García-Rodrigo CG, Maroñas-Jiménez L, Menis D, Larráin H, Martínez LA. Acute and dramatic saxophone penis. Indian Dermatol Online J 2016; 6:462-3. [PMID: 26752411 PMCID: PMC4693375 DOI: 10.4103/2229-5178.169726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
We present a case of intense genital swelling because of a hereditary angioedema. This rare disease should be included in the differential diagnosis of acute and asymptomatic genital edema, because it may prevent future potentially life-threatening episodes of visceral angioedema.
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Affiliation(s)
| | | | - Diana Menis
- Department of Dermatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Hugo Larráin
- Department of Dermatology, Hospital Universitario 12 de Octubre, Madrid, Spain
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245
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Greve J, Hahn J, Nordmann M, Schuler PJ, Bas M, Hoffmann TK, Hajdu Z, Buchberger M, Strassen U. Nanofiltrated C1-esterase-inhibitor in the prophylactic treatment of bradykinin-mediated angioedema. Transfusion 2016; 56:1022-9. [PMID: 26756974 DOI: 10.1111/trf.13462] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/18/2015] [Accepted: 11/26/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients suffering from bradykinin-induced angioedema show recurrent swelling of subcutaneous and submucosal structures. Increased bradykinin levels lead to an increase in vascular permeability and edema formation. Current therapy consists of B2 bradykinin receptor antagonists, C1-esterase-inhibitor (C1-INH) concentrate, or the kallikrein inhibitor ecallantide. In most cases the treatment of acute attacks is sufficient. Prophylactic therapy is recommended only in severe cases. C1-INHc has been shown a safe and efficient option. Its effect on the quality of life has not yet been analyzed. STUDY DESIGN AND METHODS Patients with inadequate disease control despite an "on-demand therapy" including C1-INHc and/or the B2 receptor antagonist icatibant were switched to long-term prophylaxis consisting in an individual dose of intravenous C1-INHc (Cinryze). None of the patients had been previously treated with ecallantide. Disease-specific quality-of-life questionnaires and patient records were used for evaluation. Disease control, quality of life, adverse events, and administered dosage per month were compared for 6 months on on-demand therapy and the following 6 months under prophylactic therapy. RESULTS Data of seven patients with hereditary angioedema (HAE) and one patient with acquired angioedema were evaluated. Prophylactic therapy with Cinryze led to a significant and clinically relevant reduction in the overall attack frequency from 6.7 to 2.3 per month without relevant side effects. The frequency of severe attacks was reduced by 89% and quality of life significantly improved. CONCLUSION Prophylaxis with Cinryze led to a significantly improved quality of life in our cohort of patients with high-frequency bradykinin-induced angioedema attacks that were not sufficiently treated with on-demand medication.
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Affiliation(s)
- Jens Greve
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Janina Hahn
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Melanie Nordmann
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Patrick J Schuler
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Murat Bas
- Department of Oto-Rhino-Laryngology, Technische Universität München, München, Germany
| | - Thomas K Hoffmann
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Zuzana Hajdu
- Department of Oto-Rhino-Laryngology, Technische Universität München, München, Germany
| | - Maria Buchberger
- Department of Oto-Rhino-Laryngology, Technische Universität München, München, Germany
| | - Ulrich Strassen
- Department of Oto-Rhino-Laryngology, Technische Universität München, München, Germany
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246
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Li HH. Self-administered C1 esterase inhibitor concentrates for the management of hereditary angioedema: usability and patient acceptance. Patient Prefer Adherence 2016; 10:1727-37. [PMID: 27660422 PMCID: PMC5019432 DOI: 10.2147/ppa.s86379] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare genetic disease characterized by episodic subcutaneous or submucosal swelling. The primary cause for the most common form of HAE is a deficiency in functional C1 esterase inhibitor (C1-INH). The swelling caused by HAE can be painful, disfiguring, and life-threatening. It reduces daily function and compromises the quality of life of affected individuals and their caregivers. Among different treatment strategies, replacement with C1-INH concentrates is employed for on-demand treatment of acute attacks and long-term prophylaxis. Three human plasma-derived C1-INH preparations are approved for HAE treatment in the US, the European Union, or both regions: Cinryze(®), Berinert(®), and Cetor(®); however, only Cinryze is approved for long-term prophylaxis. Postmarketing studies have shown that home therapy (self-administered or administered by a caregiver) is a convenient and safe option preferred by many HAE patients. In this review, we summarize the role of self-administered plasma-derived C1-INH concentrate therapy with Cinryze at home in the prophylaxis of HAE.
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Affiliation(s)
- Huamin Henry Li
- Institute for Asthma and Allergy, Chevy Chase, MD, USA
- Correspondence: Huamin Henry Li, Institute for Asthma and Allergy, 2 Wisconsin Circle, Suite 250, Chevy Chase, MD 20815, USA, Tel +1 301 986 9262, Fax +1 301 907 7910, Email
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Aygören-Pürsün E, Bygum A, Beusterien K, Hautamaki E, Sisic Z, Boysen HB, Caballero T. Estimation of EuroQol 5-Dimensions health status utility values in hereditary angioedema. Patient Prefer Adherence 2016; 10:1699-707. [PMID: 27660419 PMCID: PMC5019462 DOI: 10.2147/ppa.s100383] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To estimate health status utility (preference) weights for hereditary angioedema (HAE) during an attack and between attacks using data from the Hereditary Angioedema Burden of Illness Study in Europe (HAE-BOIS-Europe) survey. Utility measures quantitatively describe the net impact of a condition on a patient's life; a score of 0.0 reflects death and 1.0 reflects full health. STUDY DESIGN AND METHODS The HAE-BOIS-Europe was a cross-sectional survey conducted in Spain, Germany, and Denmark to assess the real-world experience of HAE from the patient perspective. Survey items that overlapped conceptually with the EuroQol 5-Dimensions (EQ-5D) domains (pain/discomfort, mobility, self-care, usual activities, and anxiety/depression) were manually crosswalked to the corresponding UK population-based EQ-5D utility weights. EQ-5D utilities were computed for each respondent in the HAE-BOIS-Europe survey for acute attacks and between attacks. RESULTS Overall, a total of 111 HAE-BOIS-Europe participants completed all selected survey items and thus allowed for computation of EQ-5D-based utilities. The mean utilities for an HAE attack and between attacks were 0.44 and 0.72, respectively. Utilities for an acute attack were dependent on the severity of pain of the last attack (0.61 for no pain or mild pain, 0.47 for moderate pain, and 0.08 for severe pain). There were no significant differences across countries. Mean utilities derived from the study approach compare sensibly with other disease states for both acute attacks and between attacks. CONCLUSION The impacts of HAE translate into substantial health status disutilities associated with acute attacks as well as between attacks, documenting that the detrimental effects of HAE are meaningful from the patient perspective. Results were consistent across countries with regard to pain severity and in comparison to similar disease states. The results can be used to raise awareness of HAE as a serious disease with wide-ranging personal and social impacts.
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Affiliation(s)
- Emel Aygören-Pürsün
- Angioedema Centre, Department for Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
- Correspondence: Emel Aygören-Pürsün, Angioedema Centre, Department for Children and Adolescents, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany, Tel +49 69 63016312, Fax +49 69 63016491, Email
| | - Anette Bygum
- Hereditary Angioedema Centre Denmark, Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | | | - Emily Hautamaki
- Patient Reported Outcomes, Oxford Outcomes Inc., an ICON plc company, Bethesda, MD, USA
| | - Zlatko Sisic
- ViroPharma Incorporated, Chatsworth House, Maidenhead, UK
| | - Henrik B Boysen
- HAEi – Hereditary Angioedema International Patient Organization for C1 Inhibitor Deficiencies, Skanderborg, Denmark
| | - Teresa Caballero
- Allergy Department, Hospital La Paz Institute for Health Research (IdiPaz), Biomedical Research Network on Rare Diseases U754 (CIBERER), University Hospital La Paz, Madrid, Spain
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Hirose T, Ogura H, Kang J, Nakamura Y, Hosotsubo H, Kitano E, Hatanaka M, Shimazu T. Serial change of C1 inhibitor in patients with sepsis--a preliminary report. Am J Emerg Med 2015; 34:594-8. [PMID: 26782794 DOI: 10.1016/j.ajem.2015.12.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/11/2015] [Accepted: 12/16/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE C1 inhibitor (C1INH) regulates not only the complement system but also the plasma kallikrein-kinin, fibrinolytic, and coagulation systems. The biologic activities of C1INH can be divided into the regulation of vascular permeability and anti-inflammatory functions. The objective was to clarify the serial change of C1INH in patients with sepsis. METHODS We serially examined C1INH activity values (reference range, 70%-130%) and quantitative values (reference range, 160-330 μg/mL) in patients with sepsis admitted into the intensive care unit of the Trauma and Acute Critical Care Center at Osaka University Hospital (Osaka, Japan) during the period between December 2012 and February 2013. We also analyzed their clinical course. We defined "refractory shock" as septic shock requiring steroid administration to maintain hemodynamics. RESULTS The serial change of C1INH was evaluated in 5 patients (4 survivors and 1 nonsurvivor). Two patients were diagnosed as having refractory shock. In the nonsurvivor after refractory shock, C1INH activity on admission was 97.2%, and the quantitative value was 133.1 μg/mL. In the other patient with refractory shock, C1INH activity on admission was 94.4%, and the quantitative value was 126.7 μg/mL. This patient's general condition had improved by day 6, with increases in C1INH activity (139.9%) and quantitative value (250.1 μg/mL). In the 3 nonrefractory shock patients, C1INH activity on admission was 130.6%±8.7%, and the quantitative value was 215±26.5 μg/mL. CONCLUSIONS Enhancement of C1INH activity was not observed in the refractory shock patients, and the C1INH quantitative values were low. Further evaluation of the serial change of C1INH and the validity of C1INH replacement therapy in patients with septic shock may lead to a new strategy for sepsis management.
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Affiliation(s)
- Tomoya Hirose
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Jinkoo Kang
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Youhei Nakamura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Hideo Hosotsubo
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Etsuko Kitano
- Department of Medical Technology, Faculty of Health Sciences, Kobe Tokiwa University, Kobe-shi, Hyogo 653-0838, Japan
| | - Michiyo Hatanaka
- Department of Medical Technology, Faculty of Health Sciences, Kobe Tokiwa University, Kobe-shi, Hyogo 653-0838, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
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Speletas M, Szilágyi Á, Csuka D, Koutsostathis N, Psarros F, Moldovan D, Magerl M, Kompoti M, Varga L, Maurer M, Farkas H, Germenis AE. F12-46C/T polymorphism as modifier of the clinical phenotype of hereditary angioedema. Allergy 2015; 70:1661-4. [PMID: 26248961 DOI: 10.1111/all.12714] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2015] [Indexed: 11/29/2022]
Abstract
The factors influencing the heterogeneous clinical manifestation of hereditary angioedema due to C1-INH deficiency (C1-INH-HAE) represent one of the oldest unsolved problems of the disease. Considering that factor XII (FXII) levels may affect bradykinin production, we investigated the contribution of the functional promoter polymorphism F12-46C/T in disease phenotype. We studied 258 C1-INH-HAE patients from 113 European families, and we explored possible associations of F12-46C/T with clinical features and the SERPING1 mutational status. Given that our cohort consisted of related subjects, we implemented generalized estimating equations (GEEs), an extension of the generalized linear model accounting for the within-subject correlation. F12-46C/T carriers exhibited a significantly delayed disease onset (P < 0.001) and did not need long-term treatment (P = 0.02). In a GEE linear regression model, the presence of F12-46C/T was significantly associated with a 7-year delay in disease onset (P < 0.0001) regardless of SERPING1 mutational status. It is concluded that F12-46C/T carriage acts as an independent modifier of C1-INH-HAE severity.
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Affiliation(s)
- M. Speletas
- Department of Immunology & Histocompatibility; School of Health Sciences; Faculty of Medicine; University of Thessaly; Larissa Greece
| | - Á. Szilágyi
- 3rd Department of Internal Medicine; Hungarian Angioedema Center; Semmelweis University; Budapest Hungary
| | - D. Csuka
- 3rd Department of Internal Medicine; Hungarian Angioedema Center; Semmelweis University; Budapest Hungary
| | - N. Koutsostathis
- Department of Immunology & Histocompatibility; School of Health Sciences; Faculty of Medicine; University of Thessaly; Larissa Greece
| | - F. Psarros
- Department of Allergology; Navy Hospital; Athens Greece
| | - D. Moldovan
- Department of Allergy-Immunology; University of Medicine and Pharmacy; Mures County Hospital; Tîrgu Mureș Romania
| | - M. Magerl
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - M. Kompoti
- Department of Immunology & Histocompatibility; School of Health Sciences; Faculty of Medicine; University of Thessaly; Larissa Greece
| | - L. Varga
- 3rd Department of Internal Medicine; Hungarian Angioedema Center; Semmelweis University; Budapest Hungary
| | - M. Maurer
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - H. Farkas
- 3rd Department of Internal Medicine; Hungarian Angioedema Center; Semmelweis University; Budapest Hungary
| | - A. E. Germenis
- Department of Immunology & Histocompatibility; School of Health Sciences; Faculty of Medicine; University of Thessaly; Larissa Greece
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Xu P, Xu M, Jiang L, Yang Q, Luo Z, Dauter Z, Huang M, Andreasen PA. Design of Specific Serine Protease Inhibitors Based on a Versatile Peptide Scaffold: Conversion of a Urokinase Inhibitor to a Plasma Kallikrein Inhibitor. J Med Chem 2015; 58:8868-76. [PMID: 26536069 DOI: 10.1021/acs.jmedchem.5b01128] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
All serine proteases hydrolyze peptide bonds by the same basic mechanism and have very similar active sites, in spite of the fact that individual proteases have different physiological functions. We here report a strategy for designing high-affinity and high-specificity serine protease inhibitors using a versatile peptide scaffold, a 10-mer peptide, mupain-1 (CPAYSRYLDC). Mupain-1 was previously reported as a specific inhibitor of murine urokinase-type plasminogen activator (Ki = 0.55 μM) without measurable affinity to plasma kallikrein (Ki > 1000 μM). On the basis of a structure-based rational design, we substituted five residues of mupain-1 and converted it to a potent plasma kallikrein inhibitor (Ki = 0.014 μM). X-ray crystal structure analysis showed that the new peptide was able to adapt a new set of enzyme surface interactions by a slightly changed backbone conformation. Thus, with an appropriate re-engineering, mupain-1 can be redesigned to specific inhibitors of other serine proteases.
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Affiliation(s)
- Peng Xu
- Danish-Chinese Centre for Proteases and Cancer, Department of Molecular Biology and Genetics, Aarhus University , Aarhus, 8000, Denmark
| | - Mingming Xu
- Danish-Chinese Centre for Proteases and Cancer, Fujian Institute of Research on the Structure of Matter, Chinese Academy of Sciences , Fuzhou, 350002, China
| | - Longguang Jiang
- Danish-Chinese Centre for Proteases and Cancer, Fujian Institute of Research on the Structure of Matter, Chinese Academy of Sciences , Fuzhou, 350002, China
| | - Qinglan Yang
- Danish-Chinese Centre for Proteases and Cancer, Department of Molecular Biology and Genetics, Aarhus University , Aarhus, 8000, Denmark
| | - Zhipu Luo
- Synchrotron Radiation Research Section, Macromolecular Crystallography Laboratory, National Cancer Institute, Argonne National Laboratory, Argonne, Illinois 60439, United States
| | - Zbigniew Dauter
- Synchrotron Radiation Research Section, Macromolecular Crystallography Laboratory, National Cancer Institute, Argonne National Laboratory, Argonne, Illinois 60439, United States
| | - Mingdong Huang
- Danish-Chinese Centre for Proteases and Cancer, Fujian Institute of Research on the Structure of Matter, Chinese Academy of Sciences , Fuzhou, 350002, China
| | - Peter A Andreasen
- Danish-Chinese Centre for Proteases and Cancer, Department of Molecular Biology and Genetics, Aarhus University , Aarhus, 8000, Denmark
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