1
|
Mormile I, Gigliotti MC, Ferrara AL, Gatti R, Spadaro G, de Paulis A, Loffredo S, Bova M, Petraroli A. Clinical features and potential markers of disease in idiopathic non-histaminergic angioedema, a real-life study. Immunol Res 2024:10.1007/s12026-024-09501-9. [PMID: 38829492 DOI: 10.1007/s12026-024-09501-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Abstract
Idiopathic non-histaminergic acquired angioedema (InH-AAE) is a rare disease, with unknown etiology and pathogenesis, characterized by recurrent clinical manifestations and resistance to antihistamines and corticosteroids. We aim to evaluate clinical features and potential markers of disease in an Italian cohort of patients with InH-AAE. We enrolled 26 patients diagnosed with InH-AAE. Information about clinical features, treatments, routine laboratory investigations, immunological and genetic tests were collected. We assessed plasma levels of complement components, angiogenic and lymphangiogenic mediators, proinflammatory cytokines and chemokines, and activity of phospholipases A2. Finally, patients underwent nailfold videocapillaroscopy (NVC); both quantitative and qualitative capillaroscopic parameters were analyzed. Plasma levels of VEGFs were similar in healthy controls and in InH-AAE patients. ANGPT1 was decreased in InH-AAE patients compared to controls while ANGPT2 was similar to controls. Interestingly, the ANGPT2/ANGPT1 ratio (an index of vascular permeability) was increased in InH-AAE patients compared to controls. sPLA2 activity, elevated in patients with C1-INH-HAE, showed differences also when measured in InH-AAE patients. TNF-α concentration was higher in InH-AAE patients than in healthy controls, conversely, the levels of CXCL8, and IL-6 were similar in both groups. At the NVC, the capillary loops mainly appeared short and tortuous in InH-AAE patients. InH-AAE represents a diagnostic challenge. Due to the potential life-threatening character of this condition, a prompt identification of the potentially bradykinin-mediated forms is crucial. A better comprehension of the mechanism involved in InH-AAE would also lead to the development of new therapeutic approaches to improve life quality of patients affected by this disabling disease.
Collapse
Affiliation(s)
- Ilaria Mormile
- Department of Translational Medical Sciences, University of Naples Federico II, Via Sergio Pansini 5, Naples, 80131, Italy
| | - Maria Celeste Gigliotti
- Department of Translational Medical Sciences, University of Naples Federico II, Via Sergio Pansini 5, Naples, 80131, Italy
| | - Anne Lise Ferrara
- Department of Translational Medical Sciences, University of Naples Federico II, Via Sergio Pansini 5, Naples, 80131, Italy
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Roberta Gatti
- Post-Graduate Program in Clinical Immunology and Allergy, University of Naples Federico II, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Federico II, Via Sergio Pansini 5, Naples, 80131, Italy
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Amato de Paulis
- Department of Translational Medical Sciences, University of Naples Federico II, Via Sergio Pansini 5, Naples, 80131, Italy
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences, University of Naples Federico II, Via Sergio Pansini 5, Naples, 80131, Italy
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Naples, Italy
- Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| | - Maria Bova
- Department of Translational Medical Sciences, University of Naples Federico II, Via Sergio Pansini 5, Naples, 80131, Italy.
- Department of Internal Medicine, A.O.R.N. Antonio Cardarelli, Naples, Italy.
| | - Angelica Petraroli
- Department of Translational Medical Sciences, University of Naples Federico II, Via Sergio Pansini 5, Naples, 80131, Italy
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| |
Collapse
|
2
|
Radojicic C, Anderson J. Hereditary angioedema with normal C1 esterase inhibitor: Current paradigms and clinical dilemmas. Allergy Asthma Proc 2024; 45:147-157. [PMID: 38755781 DOI: 10.2500/aap.2024.45.240010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Background: A diagnosis of hereditary angioedema (HAE) with normal C1 esterase inhibitor (HAE-nl-C1-INH) can be challenging and pharmacologic management is not well defined. Objective: The objective was to discuss practical considerations in the clinical management of HAE-nl-C1-INH by using illustrative clinical vignettes to highlight and/or address select challenges. Methods: This was a narrative review. Results: Symptoms of HAE-nl-C1-INH overlap with HAE types I and II; the heterogeneity of presentation and symptom burden are diagnostic challenges. A patient history, with particular attention to whether urticaria or other symptoms of mast cell mediator release are present, is important because such symptoms would strongly suggest a mast cell-mediated pathway. A family history of angioedema is informative but a lack thereof does not rule out diagnosis. Expected laboratory findings would be normal for C4, C1-INH level and function, and Complement 1q; a genetic mutational analysis may be helpful, but current assays do not include all known mutations; most cases are categorized as unknown. To align with guideline-directed treatment approaches, the following stepwise approach is suggested for suspected HAE-nl-C1-INH: (1) thoroughly investigate the possibility of response to histaminergic and/or mast cell-targeting treatments; (2) if patients with normal C4, C1-INH level and/or function fail adequate trials with histamine/mast cell-directed therapy or have a mutation that suggests bradykinin pathway involvement, follow HAE type I and II treatment guidelines. Response to medications approved for HAE types I/II provides compelling support for a high clinical suspicion of HAE-nl-C1-INH. De-labeling an HAE-nl-C1-INH diagnosis may be appropriate if the initial diagnosis was made without adequate evaluation or if new information and/or testing indicates that the patient does not actually have HAE. Conclusion: Key unmet needs in HAE-nl-C1-INH include lack of confirmatory biomarker(s) for diagnosis and lack of prospective controlled clinical studies of pharmacologic products in this patient population.
Collapse
Affiliation(s)
- Cristine Radojicic
- From the Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Duke University, Durham, North Carolina
| | - John Anderson
- Division of Pulmonary Allergy, Critical Care in Sleep Medicine, Department of Internal Medicine, University of Alabama, Birmingham, Alabama, and
| |
Collapse
|
3
|
Zelin E, Mazzoletti V, Bazzacco G, Toffoli L, Conforti C, Di Meo N, Zalaudek I. Omalizumab for isolated idiopathic angioedema: A case report and short literature review. J Dtsch Dermatol Ges 2024; 22:707-709. [PMID: 38593341 DOI: 10.1111/ddg.15359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/06/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Enrico Zelin
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Vanessa Mazzoletti
- Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Giulia Bazzacco
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Ludovica Toffoli
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Claudio Conforti
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Nicola Di Meo
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Iris Zalaudek
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| |
Collapse
|
4
|
Zelin E, Mazzoletti V, Bazzacco G, Toffoli L, Conforti C, Di Meo N, Zalaudek I. Omalizumab bei isoliertem idiopathischem Angioödem: Ein Fallbericht und kurze Literaturübersicht. J Dtsch Dermatol Ges 2024; 22:707-709. [PMID: 38730512 DOI: 10.1111/ddg.15359_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/06/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Enrico Zelin
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Vanessa Mazzoletti
- Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Giulia Bazzacco
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Ludovica Toffoli
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Claudio Conforti
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Nicola Di Meo
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Iris Zalaudek
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| |
Collapse
|
5
|
Ferrer M, Rodriguez-Garijo N, Sabaté-Brescó M. Medical algorithm: Diagnosis and management of histaminergic angioedema. Allergy 2023; 78:599-602. [PMID: 36478245 DOI: 10.1111/all.15618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/11/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Marta Ferrer
- Department of Allergy and Clinical Immunology, Clinica Universidad de Navarra, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.,RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
| | | | - Marina Sabaté-Brescó
- Department of Allergy and Clinical Immunology, Clinica Universidad de Navarra, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.,RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
| |
Collapse
|
6
|
Zuraw BL, Maurer M, Sexton DJ, Cicardi M. Therapeutic monoclonal antibodies with a focus on hereditary angioedema. Allergol Int 2023; 72:54-62. [PMID: 35787344 DOI: 10.1016/j.alit.2022.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/03/2022] [Accepted: 05/18/2022] [Indexed: 01/25/2023] Open
Abstract
Monoclonal antibodies (mAbs) have been shown to be effective and generally safe across a continually expanding list of therapeutic areas. We describe the advantages and limitations of mAbs as a therapeutic option compared with small molecules. Specifically, we discuss a novel mAb in the treatment of hereditary angioedema (HAE), a rare and potentially life-threatening condition characterized by recurrent unpredictable swelling attacks. HAE is mediated by dysregulation of plasma kallikrein activity leading to overproduction of bradykinin. Current prophylactic treatment for HAE includes androgens or replacement of the endogenous plasma kallikrein inhibitor, C1 inhibitor. However, there remains an unmet need for an effective, less burdensome treatment option. Lanadelumab is a fully human mAb targeting plasma kallikrein. Results from clinical trials, including a pivotal Phase 3 study and its ensuing open-label extension study, demonstrated that lanadelumab is associated with few treatment-related adverse events and reduced the rate of HAE attacks. This novel treatment option has the potential to significantly improve the lives of patients with HAE.
Collapse
Affiliation(s)
- Bruce L Zuraw
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, CA, USA.
| | - Marcus Maurer
- Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | | | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, Luigi Sacco, University of Milan, IRCCS ICS Maugeri, Milano, Italy
| |
Collapse
|
7
|
Buttgereit T, Fijen LM, Vera C, Bergmann KC, Maurer M, Magerl M. Case report: Recurrent angioedema: Diagnosing the rare and the frequent. Front Med (Lausanne) 2022; 9:1048480. [DOI: 10.3389/fmed.2022.1048480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/21/2022] [Indexed: 12/05/2022] Open
Abstract
Hereditary angiodema with normal C1 inhibitor and unknown mutation (HAE-nC1INH-UNK), an exceedingly rare subtype of HAE, appears to be often diagnosed in patients who do not have this condition, but have mast cell-mediated angioedema. Here, we report two patients diagnosed with HAE-nC1INH-UNK by their physicians, who referred them to our center for treatment continuation with costly kallikrein-kinin-system targeted therapies. We describe how we established the correct diagnosis of recurrent mast cell-mediated angioedema after thorough investigation of both patients and initiated effective treatment with omalizumab. Also, we present and discuss the consensus criteria for diagnosing the very rare condition HAE-nC1INH in light of recent research and based on our own clinical experience. In conclusion, HAE-nC1INH-UNK should only be considered after more common differential diagnoses, i.e., mast cell-mediated angioedema, have thoroughly been investigated and ruled out. This approach reduces both the patients’ disease burden and healthcare costs and contributes to meaningful research.
Collapse
|
8
|
Kesh S, Bernstein JA. Isolated Angioedema: A Review of Classification and Update on Management. Ann Allergy Asthma Immunol 2022; 129:692-702. [PMID: 35988876 DOI: 10.1016/j.anai.2022.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this article is to review the various types of angioedema including diagnosis and treatment. DATA SOURCES PubMed search of articles in the English language various types of angioedema STUDY SELECTION: Articles on the subject matter were selected and reviewed. RESULTS Herein, a case based approach is presented for discussing the major types of angioedema including: hereditary angioedema (HAE) TypesI/II and normal complement, acquired angioedema, Angiotensin converting enzyme (ACE) induced angioedema, as well as histaminergic and non-histaminergic angioedema. Emerging treatments of HAE including targets of pre-kalikrein, DNA vector technology replacing C1INH protein, and CRIPSR technology targeting PKK among many others are explored. In addition, other causes as well as mimickers of angioedema are briefly reviewed. Finally, a novel algorithm is proposed to help guide the treating physician through the work up and management of patients with suspected idiopathic angioedema unresponsive to conventional therapy with antihistamines. CONCLUSION Over the years, many strides have been made in both understanding the pathophysiology of various types of angioedema as well as expansion of treatment options. It is important for clinicians to be aware of current and emerging treatment options. We provide a novel practical algorithm to guide clinicians in challenging cases of idiopathic angioedema refractory to antihistamines.
Collapse
Affiliation(s)
- Susamita Kesh
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Division of Immunology and Allergy
| | - Jonathan A Bernstein
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section; Bernstein Allergy Group.
| |
Collapse
|
9
|
Sabaté-Brescó M, Rodriguez-Garijo N, Azofra J, Baeza ML, Donado CD, Gaig P, Guilarte M, Herrera-Lasso V, Labrador-Horrillo M, Sala-Cunill A, Veleiro B, Gil MP, Kaplan A, Ferrer M. A Comparative Study of Sex Distribution, Autoimmunity, Blood, and Inflammatory Parameters in Chronic Spontaneous Urticaria with Angioedema and Chronic Histaminergic Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2284-2292. [PMID: 33831619 DOI: 10.1016/j.jaip.2021.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recurrent idiopathic histaminergic angioedema is currently classified as a subtype of angioedema, as well as a subtype of chronic spontaneous urticaria (CSU), based on the fact that both are mast cell-mediated and respond to the same treatments. OBJECTIVE In the present work, we sought to verify whether chronic histaminergic angioedema (CHA) is an entity distinct from CSU or represents a CSU subtype that lacks hives. METHODS We performed a prospective study comparing 68 CHA patients, angioedema without hives, with 63 CSU patients, with hives and angioedema, from whom we collected demographic and clinical data, as well as blood and serum markers. RESULTS We found key pathogenic features that differentiate CHA from CSU: gender distribution, basophil number, and antibodies against the IgE receptor. The male/female ratio in CHA was 0.78, whereas in CSU it was 0.36 (P = .0466). Basopenia was more often seen in CSU (n = 13 [20%]) than in CHA (n = 5 [7%]). Finally, 31.15% of CSU sera induced basophil activation, whereas no CHA sera were able to activate normal basophils. By contrast, nonspecific inflammation or immune markers, for example, erythrocyte sedimentation rate, C-reactive protein, or IgG antithyroid antibodies, were very similar between both groups. IgE anti-IL-24 could not be assessed because a control population did not differ from CSU. CONCLUSIONS Inclusion of CHA as part of the spectrum of CSU is an assumption not evidence-based, and when studied separately, important differences were observed. Until there is further evidence, CHA and CSU should not necessarily be considered the same disorder, and it is our opinion that review articles and guidelines should reflect that possibility.
Collapse
Affiliation(s)
- Marina Sabaté-Brescó
- Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain; RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
| | | | - Julian Azofra
- Allergy Section, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Maria Luisa Baeza
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER)-U761, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Carmen D Donado
- Allergy Section, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Pere Gaig
- Allergy Section, Hospital Universitari Joan XXIII de Tarragona, Tarragona, Spain; Departament de Medicina i Cirurgia, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain
| | - Mar Guilarte
- RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain; Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Valeria Herrera-Lasso
- Allergy Section, Hospital Universitari Joan XXIII de Tarragona, Tarragona, Spain; Departament de Medicina i Cirurgia, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain
| | - Moisés Labrador-Horrillo
- RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain; Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Anna Sala-Cunill
- RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain; Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Beatriz Veleiro
- Department of Allergy and Clinical Immunology, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - María Pilar Gil
- Department of Dermatology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Allen Kaplan
- Department of Medicine, The Medical University of South Carolina, Charleston, SC
| | - Marta Ferrer
- Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain; RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain.
| |
Collapse
|
10
|
Angioedema. Interdisciplinary diagnostic and therapeutic recommendations of the Polish Dermatological Society (PTD) and Polish Society of Allergology (PTA). Postepy Dermatol Alergol 2020; 37:445-451. [PMID: 32994763 PMCID: PMC7507159 DOI: 10.5114/ada.2020.98226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 11/17/2022] Open
Abstract
Angioedema is a non-inflammatory oedema of the subcutaneous tissue and/or mucosal membranes. It most commonly coexists with urticaria wheals and is considered to be a deep form of urticaria. Less commonly, it occurs in isolation and can take two basic forms: acquired angioedema and hereditary angioedema. Currently, there are 4 defined types of acquired angioedema and 7 types of hereditary angioedema. Treatment of angioedema depends on its form and etiological factors. Especially the genetic form, i.e. hereditary angioedema, is a considerable challenge for medical specialists, particularly dermatologists and allergists.
Collapse
|
11
|
Belbézier A, Bocquet A, Bouillet L. Idiopathic Angioedema: Current Challenges. J Asthma Allergy 2020; 13:137-144. [PMID: 32368100 PMCID: PMC7173836 DOI: 10.2147/jaa.s205709] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 03/13/2020] [Indexed: 11/23/2022] Open
Abstract
The etiological diagnosis of isolated recurrent angioedema poses problems because it must often be done urgently. Angioedema secondary to nonspecific mast cell activation (MC-AE) is the most frequent form and is usually mild. Bradykinin mediated angioedema (BK-AE) is rarer but potentially fatal in the absence of the correct treatment. Few biological markers exist. The C1-inhibitor (C1-inh) functional assay can exclude AE due to C1-inh deficiency. Genetic diagnoses of hereditary AE due to abnormal C1-inh AE have progressed with four currently known mutations. However, determining the physiopathological mechanism leading to some isolated AE cases is sometimes very difficult. In such cases, therapeutic tests are then the only solution: antihistamines at high doses and omalizumab for suspected MC-AE, icatibant for suspected AE-BK. Identifying new markers would be a great help.
Collapse
Affiliation(s)
- Aude Belbézier
- National Reference Center for Angioedema (CREAK), Department of Internal Medicine/Clinical Immunology, Grenoble Alpes University Hospital, Grenoble, France
| | - Alexis Bocquet
- National Reference Center for Angioedema (CREAK), Department of Internal Medicine/Clinical Immunology, Grenoble Alpes University Hospital, Grenoble, France
| | - Laurence Bouillet
- National Reference Center for Angioedema (CREAK), Department of Internal Medicine/Clinical Immunology, Grenoble Alpes University Hospital, Grenoble, France
| |
Collapse
|
12
|
Türk M, Carneiro-Leão L, Kolkhir P, Bonnekoh H, Buttgereit T, Maurer M. How to Treat Patients with Chronic Spontaneous Urticaria with Omalizumab: Questions and Answers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:113-124. [DOI: 10.1016/j.jaip.2019.07.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/29/2019] [Accepted: 07/12/2019] [Indexed: 12/19/2022]
|
13
|
Maurer M, Magerl M. How to control recurrent angioedema using monoclonal antibody therapies? Expert Opin Biol Ther 2019; 20:1-4. [PMID: 31709841 DOI: 10.1080/14712598.2020.1691994] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Marcus Maurer
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Magerl
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
14
|
Hereditary Angioedema: Insights into inflammation and allergy. Mol Immunol 2019; 112:378-386. [PMID: 31279849 DOI: 10.1016/j.molimm.2019.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 11/21/2022]
Abstract
Hereditary Angioedema (HAE) is a rare autosomal recessive bradykinin (BK)-mediated disease characterized by local episodes of non-pitting swelling. Initially considered a complement-mediated disease, novel pathogenic mechanisms uncovered in the last decade have revealed new HAE-associated genes and tight physiological relationships among complement, contact, coagulation, fibrinolysis and inflammation. Uncontrolled production of BK due to inefficient regulation of the plasma contact system, increased activity of contact and coagulation factors or a deficient regulation of BK receptor-triggered intracellular signalling are on the basis of HAE pathology. In this new scenario, HAE can result from different mechanisms that may generate distinct clinical phenotypes of the disease. This review focuses in the recent advances and unsolved challenges in our comprehension of this ever increasingly complex pathology.
Collapse
|
15
|
Depetri F, Tedeschi A, Cugno M. Angioedema and emergency medicine: From pathophysiology to diagnosis and treatment. Eur J Intern Med 2019; 59:8-13. [PMID: 30220453 DOI: 10.1016/j.ejim.2018.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/24/2018] [Accepted: 09/07/2018] [Indexed: 12/30/2022]
Abstract
Angioedema is a self-limiting edema of the subcutaneous or submucosal tissues due to localised increase of microvascular permeability whose mediator may be histamine or bradykinin. Patients present to emergency department when angioedema involves oral cavity and larynx (life-threatening conditions) or gut (mimicking an acute abdomen). After initial evaluation of consciousness and vital signs to manage breathing and to support circulation if necessary, a simple approach can be applied for a correct diagnosis and treatment. Forms of edema such as anasarca, myxedema, superior vena cava syndrome and acute dermatitis should be ruled out. Then, effort should be done to differentiate histaminergic from non-histaminergic angioedema. Concomitant urticaria and pruritus suggest a histaminergic origin. Exposure to allergens and drugs (mainly ACE inhibitors and non steroidal anti-inflammatory drugs) should be investigated as well as a family history of similar symptoms. Allergic histaminergic angioedema has a rapid course (minutes) whereas non histaminergic angioedema is slower (hours). Since frequently the intervention needs to be immediate, the initial diagnosis is only clinical. However, laboratory tests can be subsequently confirmatory. Allergic angioedema is sensitive to standard therapies such as epinephrine, glucocorticoids and antihistamines whereas non histaminergic angioedema is often resistant to these drugs. Therapeutic options for angioedema due C1-inhibitor deficiencies are C1-inhibitor concentrates, icatibant and ecallantide. If these drugs are not available, fresh frozen plasma can be considered. All these medications have been used also in ACE inhibitor-induced angioedema with variable results thus they are not currently recommended whereas experts agree on the discontinuation of the causative drug.
Collapse
Affiliation(s)
- Federica Depetri
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milano, Italy
| | - Alberto Tedeschi
- Unità Operativa di Medicina Generale, Ospedale Bolognini, ASST Bergamo Est, Seriate, Bergamo, Italy
| | - Massimo Cugno
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milano, Italy.
| |
Collapse
|
16
|
Omalizumab for Idiopathic Nonhistaminergic Angioedema: Evidence for Efficacy in 2 Patients. Case Reports Immunol 2018; 2018:8067610. [PMID: 30140474 PMCID: PMC6081528 DOI: 10.1155/2018/8067610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 07/05/2018] [Indexed: 12/03/2022] Open
Abstract
Presently, there is inconclusive evidence regarding the most effective treatment for idiopathic nonhistaminergic acquired angioedema (InH-AAE). Omalizumab may, however, prove to be a promising option. This case report describes two patients who presented with recurrent angioedema attacks, which was refractory to antihistamine therapy. Hence, they were treated with 300 mg omalizumab, every 4 weeks, for a period of 6 months. Both patients had shown a rapid response to the treatment and achieved complete resolution of symptoms without further AE attacks throughout the entire duration of the treatment period. After omalizumab's suspension, one patient remained symptom free for the following 6 months and the other patient had recurrence of symptoms after 2 months for which he was retreated with omalizumab and once again became symptom free. Although omalizumab seems to be effective as a prophylactic treatment for InH-AAE, the determining factors leading to the differences in time-to-relapse between patients after its suspension remain unclear. Further studies are needed in order to better determine the potential therapeutic application of omalizumab and its role in maintenance therapy.
Collapse
|
17
|
Cicardi M, Zuraw BL. Angioedema Due to Bradykinin Dysregulation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1132-1141. [DOI: 10.1016/j.jaip.2018.04.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/25/2018] [Accepted: 04/25/2018] [Indexed: 01/08/2023]
|
18
|
Bucher MC, Petkovic T, Helbling A, Steiner UC. Idiopathic non-histaminergic acquired angioedema: a case series and discussion of published clinical trials. Clin Transl Allergy 2017; 7:27. [PMID: 28861213 PMCID: PMC5577688 DOI: 10.1186/s13601-017-0164-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 07/17/2017] [Indexed: 01/03/2023] Open
Abstract
Background Idiopathic non-histaminergic acquired angioedema (InH-AAE) is a rare disease for which there are no available laboratory parameters to clearly define the disorder. Therapy is often difficult and various treatment options have been proposed. In this paper, we have evaluated the most effective therapies for InH-AAE on the basis of current literature and report the therapeutic effect of omalizumab in three patients with InH-AAE. Methods Literature was searched with a combination of MeSH/EMTREE terms and freetext search for angioedema and therapy/omalizumab in the databases Medline (Ovid), PubMed/Premedline, Embase, Cochrane library and Scopus with no time or language restrictions. In three patients affected by InH-AAE the therapeutic effect of omalizumab was demonstrated by clinical outcome. In one patient the FcεRI receptor density on basophils was monitored under therapy with omalizumab. Results From the review of the current literature, 25 out of 286 publications dealing with relevant therapeutic recommendations for InH-AAE were analyzed. Six publications with 98 patients referred to tranexamic acid, of which 27 had a complete, 70 a partial and 1 no response. In three case reports ecallantide showed 2 patients with a complete and 1 a partial response. In four case reports for Icatibant 2 had a complete and 3 a partial response. When evaluated in three reports, C1-INH found complete and partial responses in 2 patients each. One patient had a complete response to progestin. Omalizumab was described in 6 reports with 20 patients, all of whom showed a complete response. All three patients described in our study responded to omalizumab with a complete remission. Density of FcεRI receptors on basophils, monitored in patient 1 on a long-term course of 31 months, decreased from 74,051.61 to a minimal level of 1907 receptors per cell. Conclusions Omalizumab seems to be the most effective therapy in InH-AAE. The continuous decrease of FcεRI-receptor density on basophils under therapy with omalizumab along with clinical improvement observed in one patient, could serve as a new approach for further studies to evaluate FcεRI-receptor density as a surrogate marker for therapeutic efficacy and for dosing and determining injection intervals of omalizumab. Trial registration BASEC-Nr. Req-2016-00692. Retrospectively registered 24.11.2016. Electronic supplementary material The online version of this article (doi:10.1186/s13601-017-0164-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Martin Christian Bucher
- Department of Clinical Immunology, University Hospital Zurich, Gloriastrasse 23, 8091 Zurich, Switzerland
| | - Tatjana Petkovic
- Adverse Drug Reaction-Analysis and Consulting (ADR-AC) GmbH, Bern, Switzerland
| | - Arthur Helbling
- Department of Rheumatology, Immunology and Allergology, Inselspital, University Bern, Bern, Switzerland
| | - Urs Christian Steiner
- Department of Clinical Immunology, University Hospital Zurich, Gloriastrasse 23, 8091 Zurich, Switzerland
| |
Collapse
|
19
|
Magerl M, Germenis AE, Maas C, Maurer M. Hereditary Angioedema with Normal C1 Inhibitor. Immunol Allergy Clin North Am 2017; 37:571-584. [DOI: 10.1016/j.iac.2017.04.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|