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Lochbaum R, Hoffmann TK, Greve J, Hahn J. Concomitant medication in patients with bradykinin-mediated angioedema - there's more than ACE inhibitors. J Dtsch Dermatol Ges 2023; 21:1283-1289. [PMID: 37483139 DOI: 10.1111/ddg.15154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 05/20/2023] [Indexed: 07/25/2023]
Abstract
Bradykinin-mediated angioedema is a rare, non-allergic, potentially life-threatening disease. ACE inhibitor-induced angioedema and hereditary angioedema (HAE) are the two most common presentations. Therapeutic options, pathophysiology and diagnosis continue to be investigated, with considerable progress in HAE over the last few decades. For all patients with bradykinin-mediated angioedema, there are several medications that should be avoided or administered with caution. Some of the triggering medications are well known, while others are suspected or of unknown significance. A common denominator is that there is no approved therapy for bradykinin-mediated angioedema as a drug side effect. Some medications, such as tissue plasminogen activator, have a higher incidence of angioedema with potential airway compromise than ACE inhibitors, although this fact is widely underappreciated. In this review, we aim to summarize what is currently known and recommended about concomitant medication in HAE patients and the interaction of other bradykinin-influencing drugs.
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Affiliation(s)
- Robin Lochbaum
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Thomas K Hoffmann
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - 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
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Lochbaum R, Hoffmann TK, Greve J, Hahn J. Medikamente als Auslöser Bradykinin-vermittelter Angioödeme - mehr als ACE-Hemmer. J Dtsch Dermatol Ges 2023; 21:1283-1290. [PMID: 37946655 DOI: 10.1111/ddg.15154_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 05/20/2023] [Indexed: 11/12/2023]
Abstract
ZusammenfassungBradykinin‐vermittelte Angioödeme sind seltene, nichtallergische und potenziell lebensbedrohliche Krankheiten. Die beiden bekanntesten Formen sind das ACE‐Hemmer‐induzierte Angioödem und das hereditäre Angioödem (HAE). Die therapeutischen Möglichkeiten, die Pathophysiologie und die Diagnostik werden weiter erforscht, wobei beim HAE in den letzten Jahrzehnten erhebliche Fortschritte erzielt wurden. Für alle Patienten mit Bradykinin‐vermittelten Angioödemen gibt es Medikamente, die vermieden oder mit Vorsicht verabreicht werden sollten. Einige dieser auslösenden Medikamente sind gut bekannt, bei anderen wird ein Zusammenhang vermutet oder ihre Bedeutung ist unbekannt. Ein gemeinsamer Nenner ist, dass es keine zugelassene Therapie für das Bradykinin‐vermittelte Angioödem als Arzneimittelnebenwirkung gibt. Bei einigen Medikamenten, wie dem gewebespezifischen Plasminogenaktivator, ist die Inzidenz von Angioödemen mit möglicher Beeinträchtigung der Atemwege höher als bei ACE‐Hemmern, wobei diese Tatsache weitgehend unterschätzt wird. In dieser Übersichtsarbeit fassen wir zusammen, was derzeit über die Begleitmedikation bei HAE‐Patienten und die Interaktion mit anderen Bradykinin‐beeinflussenden Medikamenten bekannt ist und empfohlen wird.
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Affiliation(s)
- Robin Lochbaum
- Abteilung für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm
| | - Thomas K Hoffmann
- Abteilung für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm
| | - Jens Greve
- Abteilung für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm
| | - Janina Hahn
- Abteilung für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm
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Evcen R, Çölkesen F, Saygın DA, Aykan FS, Kılınç M, Ergün ÜY, Akkuş FA, Önalan T, Yıldız E, Arslan Ş. High digit ratio (2D:4D) is associated with attack frequency and severity in hereditary angioedema patients. Early Hum Dev 2023; 177-178:105724. [PMID: 36827749 DOI: 10.1016/j.earlhumdev.2023.105724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) caused by a deficiency or dysfunction of the plasma protease C1-inhibitor is a rare autosomal-dominant disorder. We explored a possible correlation between the ratio of the second and fourth finger lengths (2D:4D) and the frequency of HEA attacks, and whether the ratio might predict laryngeal attack. METHOD We evaluated 35 HEA patients aged 19 to 66 years; 3 were subsequently excluded. The 2D:4D ratio was calculated by dividing the length of the second finger by that of the fourth finger of both hands. A structured clinical questionnaire exploring HAE course and treatment over the prior year was administered. RESULTS Of the 32 participants, 56.25 % (n = 18) were female. Of them, those with high 2D:4D ratios suffered significantly more laryngeal attacks than others; 93.3% of patients with high 2D:4D ratios experienced ≥5 attacks annually, significantly more than those with low ratios. Among type 2 HEA patients, 75 % of those experiencing ≥5 attacks annually had high 2D:4D ratios; all patients with low 2D:4D ratios reported <5 attacks annually. These significant effects were found for right-hand 2D:4D ratios and not left-hand 2D:4D ratios. CONCLUSION The data suggest that intrauterine sex hormone exposure, which affects the 2D:4D ratio, is significantly associated with HEA attack frequency and severity, and laryngeal edema.
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Affiliation(s)
- Recep Evcen
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey.
| | - Fatih Çölkesen
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Duygu Akın Saygın
- Department of Anatomy, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Filiz Sadi Aykan
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Mehmet Kılınç
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Ümmügülsüm Yılmaz Ergün
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Fatma Arzu Akkuş
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Tuğba Önalan
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Eray Yıldız
- Necip Fazıl City Hospital, Division of Clinical Immunology and Allergy, Kahramanmaraş, Turkey
| | - Şevket Arslan
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
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Hereditary Angioedema During Pregnancy: Considerations in Management. Immunol Allergy Clin North Am 2023; 43:145-157. [PMID: 36411000 DOI: 10.1016/j.iac.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In recent years, hereditary angioedema (HAE) management has substantially advanced but also become more complex with additional therapeutic options. Pregnancy significantly influences the clinical symptoms of HAE in many women because of estrogen effects or other physiologic factors, and also introduces important safety concerns related to HAE medications. Management of HAE during pregnancy requires clinicians to be familiar with the potential clinical course, triggers, and recommended treatment strategies to provide guidance and optimal medical management to women and families affected by the condition. This review provides an overview of data, considerations, and recommendations related to HAE and pregnancy.
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Sundler Björkman L, Thulin M, Ekström M, Nordenfelt P, Egesten A. Trends in Treatments With Disease-Specific and Interfering Drugs in Patients With Hereditary Angioedema in Sweden. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:621-628. [PMID: 36528292 DOI: 10.1016/j.jaip.2022.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/31/2022] [Accepted: 11/17/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is caused by low levels of or defects in C1 inhibitor. Although disease activity may be modified by prophylaxis, emergency treatment, treatment for comorbidities, and oral contraceptives, the extent of their use is unclear. OBJECTIVE To investigate trends in the use of disease-specific and interfering drugs in patients with HAE compared with the general population in Sweden. METHODS In a nationwide, longitudinal study, 239 patients with HAE and 2 383 controls were compared with the Prescribed Drug Register (2005-2019). These data reflect rates of dispensed prescriptions from pharmacies in Sweden. RESULTS Attenuated androgens were used by approximately 10% of patients with HAE. The number of individuals treated with prophylactic plasma-derived C1 inhibitor increased during this period to reach almost 25% in men and 35% in women in 2019. Tranexamic acid was prescribed to 5% to 15% of patients, primarily children and young adults. Rates of prescriptions for icatibant, an emergency medication, showed a steady increase since its introduction in 2010, in particular among middle-aged women, suggesting poorly controlled disease. The use of diuretics, calcium channel blockers, and gestagens was more common in patients with HAE than in controls, whereas angiotensin-converting enzyme inhibitors were rarely collected. CONCLUSIONS Despite concerns regarding side effects, approximately 10% of patients with HAE received attenuated androgens for long-term prophylaxis. The common use of emergency medication also suggests poorly controlled disease in many patients, highlighting the need for increased focus on prophylactic treatment.
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Affiliation(s)
- Linda Sundler Björkman
- Respiratory Medicine, Allergology & Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden.
| | - Måns Thulin
- Department of Mathematics, Uppsala University and Statistikakademin, Uppsala, Sweden
| | - Magnus Ekström
- Respiratory Medicine, Allergology & Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Patrik Nordenfelt
- Respiratory Medicine & Allergology, Department of Internal Medicine, County Hospital of Ryhov, Jönköping, Sweden
| | - Arne Egesten
- Respiratory Medicine, Allergology & Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
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Cancian M, Triggianese P, Modica S, Arcoleo F, Bignardi D, Brussino L, Colangelo C, Di Agosta E, Firinu D, Guarino MD, Giardino F, Giliberti M, Montinaro V, Senter R. The impact of puberty on the onset, frequency, location, and severity of attacks in hereditary angioedema due to C1-inhibitor deficiency: A survey from the Italian Network for Hereditary and Acquired Angioedema (ITACA). Front Pediatr 2023; 11:1141073. [PMID: 37144145 PMCID: PMC10152551 DOI: 10.3389/fped.2023.1141073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/08/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction Hereditary angioedema due to C1-inhibitor deficiency is influenced by hormonal factors, with a more severe course of disease in women. Our study aims to deepen the impact of puberty on onset, frequency, location and severity of attacks. Methods Retrospective data were collected through a semi-structured questionnaire and shared by 10 Italian reference centers of the Italian Network for Hereditary and Acquired Angioedema (ITACA). Results The proportion of symptomatic patients increased significantly after puberty (98.2% vs 83.9%, p=0.002 in males; 96.3% vs 68,4%, p<0.001 in females); the monthly mean of acute attacks was significantly higher after puberty, and this occurred both in females (median (IQR) = 0.41(2) in the three years before puberty vs 2(2.17) in the three years after, p<0.001) and in males (1(1.92) vs 1.25(1.56) respectively, p<0.001). The increase was greater in females. No significant differences were detected in attack location before and after puberty. Discussion Overall, our study confirms previous reports on a more severe phenotype in the female gender. Puberty predisposes to increased numbers of angioedema attacks, in particular in female patients.
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Affiliation(s)
- Mauro Cancian
- UOSD Allergologia, University Hospital of Padua, Padua, Italy
- Correspondence: Mauro Cancian
| | | | | | - Francesco Arcoleo
- UOC di Patologia Clinica e Immunologia, AOR Villa Sofia-Cervello, Palermo, Italy
| | | | - Luisa Brussino
- University Hospital Ordine Mauriziano di Torino, Turin, Italy
| | | | - Ester Di Agosta
- Immunoallergology unit, Careggi University Hospital, Florence, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Francesco Giardino
- Azienda Ospedaliero-Universitaria Policlinico “G.Rodolico-San Marco”, Catania, Italy
| | - Marica Giliberti
- Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | | | - Riccardo Senter
- UOSD Allergologia, University Hospital of Padua, Padua, Italy
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Abstract
Hereditary angioedema is a rare and commonly misdiagnosed disease characterized by recurrent, painful, nonurticarial, and nonpruritic deep tissue swelling attacks, including potentially life-threatening asphyxiation. Nurses can assist in identifying disease hallmarks and provide emergency care, patient support, and education about injectable or infused medications. Hereditary angioedema is a rare and commonly misdiagnosed disease. This article discusses how nurses can assist in identifying disease hallmarks and provide emergency care, patient support, and education.
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Petersen RS, Fijen LM, Levi M, Cohn DM. Hereditary Angioedema: The Clinical Picture of Excessive Contact Activation. Semin Thromb Hemost 2022. [PMID: 36417927 DOI: 10.1055/s-0042-1758820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hereditary angioedema is a rare, genetic disorder characterized by painful, debilitating and potentially life-threatening angioedema attacks in subcutaneous and submucosal tissue. While usually unpredictable, attacks can be provoked by a variety of triggers including physical injury and certain medication and are often preceded by prodromal symptoms. Hereditary angioedema has a profound influence on the patients' lives. The fundamental cause of hereditary angioedema in almost all patients is a mutation in the SERPING1 gene leading to a deficiency in C1-inhibitor. Subsequently, the contact activation cascade and kallikrein-kinin pathway are insufficiently inhibited, resulting in excessive bradykinin production triggering vascular leakage. While C1-inhibitor is an important regulator of the intrinsic coagulation pathway, fibrinolytic system and complement cascade, patients do not have an increased risk of coagulopathy, autoimmune conditions or immunodeficiency disorders. Hereditary angioedema is diagnosed based on C1-inhibitor level and function. Genetic analysis is only required in rare cases where hereditary angioedema with normal C1-inhibitor is found. In recent years, new, highly specific therapies have greatly improved disease control and angioedema-related quality of life. This article reviews the clinical picture of hereditary angioedema, the underlying pathophysiology, diagnostic process and currently available as well as investigational therapeutic options.
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Affiliation(s)
- Remy S Petersen
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Lauré M Fijen
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Marcel Levi
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Danny M Cohn
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
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Mendoza-Alvarez A, Tosco-Herrera E, Muñoz-Barrera A, Rubio-Rodríguez LA, Alonso-Gonzalez A, Corrales A, Iñigo-Campos A, Almeida-Quintana L, Martin-Fernandez E, Martinez-Beltran D, Perez-Rodriguez E, Callero A, Garcia-Robaina JC, González-Montelongo R, Marcelino-Rodriguez I, Lorenzo-Salazar JM, Flores C. A catalog of the genetic causes of hereditary angioedema in the Canary Islands (Spain). Front Immunol 2022; 13:997148. [PMID: 36203598 PMCID: PMC9531158 DOI: 10.3389/fimmu.2022.997148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare disease where known causes involve C1 inhibitor dysfunction or dysregulation of the kinin cascade. The updated HAE management guidelines recommend performing genetic tests to reach a precise diagnosis. Unfortunately, genetic tests are still uncommon in the diagnosis routine. Here, we characterized for the first time the genetic causes of HAE in affected families from the Canary Islands (Spain). Whole-exome sequencing data was obtained from 41 affected patients and unaffected relatives from 29 unrelated families identified in the archipelago. The Hereditary Angioedema Database Annotation (HADA) tool was used for pathogenicity classification and causal variant prioritization among the genes known to cause HAE. Manual reclassification of prioritized variants was used in those families lacking known causal variants. We detected a total of eight different variants causing HAE in this patient series, affecting essentially SERPING1 and F12 genes, one of them being a novel SERPING1 variant (c.686-12A>G) with a predicted splicing effect which was reclassified as likely pathogenic in one family. Altogether, the diagnostic yield by assessing previously reported causal genes and considering variant reclassifications according to the American College of Medical Genetics guidelines reached 66.7% (95% Confidence Interval [CI]: 30.1-91.0) in families with more than one affected member and 10.0% (95% CI: 1.8-33.1) among cases without family information for the disease. Despite the genetic causes of many patients remain to be identified, our results reinforce the need of genetic tests as first-tier diagnostic tool in this disease, as recommended by the international WAO/EAACI guidelines for the management of HAE.
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Affiliation(s)
| | - Eva Tosco-Herrera
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Adrian Muñoz-Barrera
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
| | - Luis A. Rubio-Rodríguez
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
| | - Aitana Alonso-Gonzalez
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Universidad de Santiago de Compostela, Santiago de Compostela, Spain
| | - Almudena Corrales
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Iñigo-Campos
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
| | - Lourdes Almeida-Quintana
- Allergy Service, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Elena Martin-Fernandez
- Allergy Service, Hospital Universitario Dr. Molina Orosa, Las Palmas de Gran Canaria, Spain
| | - Dara Martinez-Beltran
- Allergy Service, Hospital Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Eva Perez-Rodriguez
- Allergy Service, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Ariel Callero
- Allergy Service, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Jose C. Garcia-Robaina
- Allergy Service, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | - Itahisa Marcelino-Rodriguez
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Public Health and Preventive Medicine Area, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Jose M. Lorenzo-Salazar
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
| | - Carlos Flores
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Fernando Pessoa Canarias, Las Palmas de Gran Canaria, Spain
- *Correspondence: Carlos Flores,
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Hsu FI, Lumry W, Riedl M, Tachdjian R. Considerations in the management of hereditary angioedema due to C1-INH deficiency in women of childbearing age. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:64. [PMID: 35831891 PMCID: PMC9281160 DOI: 10.1186/s13223-022-00689-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/22/2022] [Indexed: 02/06/2023]
Abstract
Hereditary angioedema (HAE) is a rare, autosomal disorder that manifests with unpredictable episodes of severe swelling of the skin and mucous membranes. These attacks can be highly disfiguring and range in severity from mild to-in cases of airway swelling-life-threatening. Fluctuations in female sex hormones-such as the changes that occur during puberty, menses, contraceptive use, pregnancy, and menopause-can all affect the frequency and severity of HAE attacks. Disease management decisions for women of childbearing age may be more complex and require additional considerations since they could develop complications related to contraception, pregnancy, labor, delivery, and lactation. In addition, some HAE treatment options are contraindicated during pregnancy. Discussions about medications used to treat HAE should include a risk-benefit assessment of the woman's health status, her preferences, and other factors that are relevant to the choice of therapy. Planning prophylactic therapies that are effective and safe before, during, and after pregnancy can prevent gaps in treatment, ensure continuity of care, and reduce both disease burden and risk of adverse fetal outcomes. The 2020 US Hereditary Angioedema Association (HAEA) Medical Advisory Board and 2021 World Allergy Organization/European Academy of Allergy and Immunology (WAO/EAACI) Guidelines outline key considerations for managing HAE in females of childbearing age (15-45 years), with the goal of improving treatment efficacy and safety for this cohort of patients. Treatment decisions made in a collaborative manner involving the patient, HAE specialist and obstetric/gynecologic specialist, is the best approach to ensure optimal HAE management and safety in this patient population.
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Affiliation(s)
| | | | - Marc Riedl
- University of California - San Diego, La Jolla, CA, USA
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Gabriel N, Marcelino F, Ferriani MPL, Arruda LK, Campos RA, Gonçalves RF, Chong-Neto H, Rosario Filho N, Valle SOR, Pesquero JB, Grumach AS. Pregnancy in Patients With Hereditary Angioedema and Normal C1 Inhibitor. FRONTIERS IN ALLERGY 2022; 3:846968. [PMID: 35386641 PMCID: PMC8974819 DOI: 10.3389/falgy.2022.846968] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/24/2022] [Indexed: 12/04/2022] Open
Abstract
Background HAE with normal C1 inhibitor (HAE-nC1-INH) has been identified as a bradykinin mediated angioedema. Estrogens are one of the main trigger factors. Pregnancy in HAE with C1 inhibitor deficiency showed variable course, however, few reports are available for HAE-nC1-INH. We evaluated the course of pregnancies in women diagnosed with HAE-nC1-INH. Methods Women with diagnosis of HAE-nC1-INH according to the following criteria: clinical manifestations similar to HAE-C1-INH, normal biochemical evaluation and family history were included. A questionnaire about pregnancies was applied after consent. Genetic evaluation for known mutations was performed in all patients. Results A total of 45 pregnancies occurring in 26 HAE-nC1-INH patients were evaluated (7/26 patients with F12 variant). Spontaneous abortion was reported in 8/45 (17.8%) pregnancies. Onset of attacks started before the pregnancy in 18/26 patients; during the pregnancy in 2/26; and after the pregnancy in 6/26. HAE attacks occurred in 24/37 pregnancies (64,7%): during the 1st trimester in 41.7%; 2nd trimester in 12.5%; 3rd trimester in 20.8%; 1st and 3rd trimesters in 4.2% and during the whole pregnancy in 20.8%. Among 15/18 patients who had attacks before pregnancy, symptoms persisted with worsening in 9/15; improvement in 4/15; no change in 1/15, and no response in 1/15. Conclusions The occurrence of abortion in HAE-nC1-INH was similar to the expected for not affected women. The 1st trimester of the pregnancy was more symptomatic for HAE-nC1-INH women. Considering the strong relevance of estrogens in HAE-nC1-INH, pregnancy could worsen the course of disease.
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Affiliation(s)
- Natalia Gabriel
- Clinical Immunology, Faculdade de Medicina, Centro Universitario FMABC, Santo André, Brazil
| | | | | | - L. Karla Arruda
- Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, Brazil
| | - Regis A. Campos
- Department of Internal Medicine, Federal University of Bahia, Salvador, Brazil
| | | | | | | | - Solange O. R. Valle
- Serviço de Imunologia, Hospital Universitário Clementino Fraga Filho (HUCFF-UFRJ), Rio de Janeiro, Brazil
| | - Joao B. Pesquero
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
| | - Anete S. Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitario FMABC, Santo André, Brazil
- *Correspondence: Anete S. Grumach
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Mendoza-Alvarez A, Marcelino-Rodriguez I, Almeida-Quintana L, Martin-Fernandez E, Martinez-Beltran D, Almeida-Sanchez Z, Cruz-Niesvara D, Hernández-Santana G, Garcia-Robaina JC, Flores C, Callero A. First Census of Patients with Hereditary Angioedema in the Canary Islands. J Clin Med 2021; 10:jcm10204711. [PMID: 34682833 PMCID: PMC8540601 DOI: 10.3390/jcm10204711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare genetic condition whose main symptoms are recurrent swelling in the skin, mucosa, and internal organs. Recent studies suggested that the regulation of the inflammatory response and the complement cascade are two of the pathways significantly enriched in the Canary Islands, Spain. Here, we describe the first HAE patient series in this region. Forty-one patients (33 F, 8 M) and nine healthy relatives belonging to twenty-nine families were recruited for this study, obtaining their clinical and demographic features using a data collection form, as well as blood samples for biochemical analysis. The mean age of patients was 36.8 years (ranging from 4 to 72 years). Positive family history of HAE was reported in 13 patients (32.5%), and a mean diagnosis delay of 7.9 (±12.5) years was estimated, ranging from months to 50 years. Cutaneous edema was the most common symptom (53.6%), while airway symptoms was present in 11 patients. Prophylactic treatment was indicated for 23 patients, while 14 also require on-demand rescue treatment. We estimate a minimum prevalence of 1.25:100,000 for HAE due to C1-INH deficiency or dysfunction in the Canary Islands, which is higher than the estimates for mainland Spanish populations. HAE continues to be a disease poorly recognized by health care professionals due to its confusing symptoms, leading to longer diagnosis delay. Altogether, the evidence reinforces the need for a rapid and accurate diagnosis and precision medicine-based studies to improve the patient's quality of life.
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Affiliation(s)
- Alejandro Mendoza-Alvarez
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain; (A.M.-A.); (I.M.-R.); (C.F.)
| | - Itahisa Marcelino-Rodriguez
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain; (A.M.-A.); (I.M.-R.); (C.F.)
| | | | | | - Dara Martinez-Beltran
- Allergy Service, Hospital Universitario Insular-Materno Infantil, 35016 Las Palmas, Spain;
| | | | - David Cruz-Niesvara
- Allergy Service, Hospital General de Fuerteventura Virgen de la Peña, 35600 Las Palmas, Spain;
| | | | - Jose C. Garcia-Robaina
- Allergy Service, Hospital Universitario Nuestra Señora de Candelaria, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain;
| | - Carlos Flores
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain; (A.M.-A.); (I.M.-R.); (C.F.)
- Genomics Division, Instituto Tecnológico y de Energías Renovables, 38600 Santa Cruz de Tenerife, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ariel Callero
- Allergy Service, Hospital Universitario Nuestra Señora de Candelaria, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain;
- Correspondence: ; Tel.: +34-922-602220
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Kulkarni M, Travers JB, Rohan C. High Estrogen States in Hereditary Angioedema: a Spectrum. Clin Rev Allergy Immunol 2021; 60:396-403. [PMID: 34075568 DOI: 10.1007/s12016-021-08863-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 11/25/2022]
Abstract
Sex differences have been well documented within hereditary angioedema (HAE) over the past several decades. Females often experience more frequent and more intense attacks compared to their male counterparts. Additionally, elevated estrogen levels-as seen in pregnancy and use of oral contraceptives-is a widely known trigger for angioedema attacks. In this review article, we will outline how estrogens' downstream effects increase bradykinin, a potent vasodilator and key mediator of HAE. Estrogen-dependent HAE is a rare disorder that provides insight into the relationship between HAE and estrogens. Females affected by this subtype of HAE only experience attacks when under "high estrogen states," such as during pregnancy and when taking exogenous estrogens (most commonly, oral contraceptives). This unique phenotype has been documented in individuals with an activating Factor XII mutation. Thus, based on this clear genotype-phenotype relationship, we conclude that Factor XII may be key in our understanding of estrogens' role in HAE. Lastly, we propose that the sex differences seen in HAE be viewed as a spectrum from exacerbation to underlying genetic mutations in Factor XII.
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Affiliation(s)
- Maansi Kulkarni
- Wright State Physicians Health Center, Department of Pharmacology & Toxicology, 725 University Blvd, Fairborn, OH, USA
| | - Jeffrey B Travers
- Wright State Physicians Health Center, Department of Pharmacology & Toxicology, 725 University Blvd, Fairborn, OH, USA.,Department of Dermatology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA.,Department of Dayton Veterans Administration Medical Center, Dayton, OH, USA
| | - Craig Rohan
- Wright State Physicians Health Center, Department of Pharmacology & Toxicology, 725 University Blvd, Fairborn, OH, USA. .,Department of Dermatology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA.
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Hormonal Effects on Urticaria and Angioedema Conditions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2209-2219. [PMID: 33895364 DOI: 10.1016/j.jaip.2021.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/02/2021] [Accepted: 04/15/2021] [Indexed: 12/18/2022]
Abstract
Women appear to be more frequently affected with urticaria and angioedema. Sex hormones are believed to have an important mechanistic role in regulating pathways involved in these conditions. This effect is likely nonspecific for chronic spontaneous urticaria (CSU) or many forms of angioedema (AE), because many other chronic diseases such as asthma are also affected by sex hormones. The role of sex hormones has been better elucidated for hereditary AE, because they have been shown to have multiple effects including upregulation of FXII, an important activator of the kallikrein pathway. However, their role in the underlying pathogenesis for CSU is less clear. Autoimmunity is clearly linked to CSU, which is more common in women. This suggests that sex hormones could act as adjuvants in activating or upregulating autoimmune pathways. The purpose of this review is to discuss in detail the role of sex hormones in CSU and AE and how a better understanding of the impact hormones has on these conditions might lead to new treatment advancements with better clinical outcomes.
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Molecular Dambusters: What Is Behind Hyperpermeability in Bradykinin-Mediated Angioedema? Clin Rev Allergy Immunol 2021; 60:318-347. [PMID: 33725263 PMCID: PMC7962090 DOI: 10.1007/s12016-021-08851-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 02/08/2023]
Abstract
In the last few decades, a substantial body of evidence underlined the pivotal role of bradykinin in certain types of angioedema. The formation and breakdown of bradykinin has been studied thoroughly; however, numerous questions remained open regarding the triggering, course, and termination of angioedema attacks. Recently, it became clear that vascular endothelial cells have an integrative role in the regulation of vessel permeability. Apart from bradykinin, a great number of factors of different origin, structure, and mechanism of action are capable of modifying the integrity of vascular endothelium, and thus, may participate in the regulation of angioedema formation. Our aim in this review is to describe the most important permeability factors and the molecular mechanisms how they act on endothelial cells. Based on endothelial cell function, we also attempt to explain some of the challenging findings regarding bradykinin-mediated angioedema, where the function of bradykinin itself cannot account for the pathophysiology. By deciphering the complex scenario of vascular permeability regulation and edema formation, we may gain better scientific tools to be able to predict and treat not only bradykinin-mediated but other types of angioedema as well.
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Veronez CL, Mendes AR, Leite CS, Gomes CP, Grumach AS, Pesquero JB. The Panorama of Primary Angioedema in the Brazilian Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:2293-2304.e5. [PMID: 33276216 DOI: 10.1016/j.jaip.2020.11.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary angioedema (PA) is a complex disorder, presenting multiple hereditary (hereditary angioedema) and acquired subtypes (acquired angioedema). Despite a very similar clinical presentation among subtypes, the differential diagnosis is limited by the difficulty to identify bradykinin-mediated PA and the lack of specific biomarkers. OBJECTIVES To report the clinical and genetic features of Brazilian patients with PA. METHODS Brazilian patients referred from 50 centers were diagnosed on the basis of clinical symptoms, C1 inhibitor (C1-INH) and C4 plasma measurements, and DNA sequencing of genes associated with hereditary angioedema. RESULTS We characterized 92 patients with acquired angioedema and 425 with HAE: 125 with C1-INH deficiency, 180 with F12 mutations, and 120 of unknown cause. Thirty-one different mutations were identified in SERPING1 and 2 in F12, in addition to 2 mutations of uncertain significance in the ANGPT1 gene. The molecular diagnosis was decisive for 34 patients with HAE without family history, and for 39% of patients with inconsistent biochemical measurements. The median delay in diagnosis was 10 years, with a maximum of 18 years for HAE with C1-INH deficiency. Androgens and tranexamic acid were the most used drugs for long-term prophylaxis in all the PA subtypes, and they were used on demand by 15% of patients. Only 10% of patients reported the use of specific medication for HAE during attacks. CONCLUSIONS Our analysis exposes a broad picture of PA diagnosis and management in a developing country. Complement measurements presented considerable inconsistencies, increasing the diagnosis delay, while patients with PA with normal C1-INH remain with an inaccurate diagnosis and unspecific treatment.
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Affiliation(s)
- Camila Lopes Veronez
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil; Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, Calif; Research Service, San Diego Veterans Affairs Healthcare, San Diego, Calif.
| | | | | | - Caio Perez Gomes
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
| | - Anete Sevciovic Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitário Saúde ABC, Santo Andre, Brazil
| | - João Bosco Pesquero
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
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Billebeau A, Fain O, Launay D, Boccon-Gibod I, Bouillet L, Gobert D, Plu-Bureau G, Gompel A. Hereditary Angioedema with and Without C1-Inhibitor Deficiency in Postmenopausal Women. J Clin Immunol 2020; 41:163-170. [DOI: 10.1007/s10875-020-00902-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
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