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Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45267-0769, USA. https://twitter.com/edmojo
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2
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Betschel SD, Banerji A, Busse PJ, Cohn DM, Magerl M. Hereditary Angioedema: A Review of the Current and Evolving Treatment Landscape. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2315-2325. [PMID: 37116793 DOI: 10.1016/j.jaip.2023.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/30/2023]
Abstract
Hereditary angioedema (HAE) is a rare disease characterized by sudden and often unprovoked episodes of swelling that can be potentially life-threatening when it involves the upper airway. The treatment options for both acute episodes of HAE and LTP, used to minimize the frequency and severity of angioedema attacks, were limited historically to very few options, had considerable side effects, and/or had considerable burden of treatment. Fortunately, through the elucidation of the pathophysiology of HAE, the development of newer targeted therapies has been possible both for acute therapy and long-term prophylaxis and even more are on the horizon. Because of the rapid development of these therapies, it can be challenging for clinicians to keep abreast of newer and developing treatments for HAE. This review article will outline the current and potential future treatments for HAE. It will also highlight important considerations when treating special HAE patient populations including women and pediatric patients.
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Affiliation(s)
- Stephen D Betschel
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Aleena Banerji
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Mass.
| | - Paula J Busse
- Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Danny M Cohn
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Markus Magerl
- Institute of Allergology, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin), Berlin, Germany; Department of Immunology and Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany
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Shen JK, Zhang HT. Function and structure of bradykinin receptor 2 for drug discovery. Acta Pharmacol Sin 2023; 44:489-498. [PMID: 36075965 PMCID: PMC9453710 DOI: 10.1038/s41401-022-00982-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/11/2022] [Indexed: 11/08/2022] Open
Abstract
Type 2 bradykinin receptor (B2R) is an essential G protein-coupled receptor (GPCR) that regulates the cardiovascular system as a vasodepressor. Dysfunction of B2R is also closely related to cancers and hereditary angioedema (HAE). Although several B2R agonists and antagonists have been developed, icatibant is the only B2R antagonist clinically used for treating HAE. The recently determined structures of B2R have provided molecular insights into the functions and regulation of B2R, which shed light on structure-based drug design for the treatment of B2R-related diseases. In this review, we summarize the structure and function of B2R in relation to drug discovery and discuss future research directions to elucidate the remaining unknown functions of B2R dimerization.
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Affiliation(s)
- Jin-Kang Shen
- Hangzhou Institute of Innovative Medicine, Institute of Pharmacology and Toxicology, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Hai-Tao Zhang
- Hangzhou Institute of Innovative Medicine, Institute of Pharmacology and Toxicology, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China.
- The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China.
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Hébert J, Boursiquot JN, Chapdelaine H, Laramée B, Desjardins M, Gagnon R, Payette N, Lepeshkina O, Vincent M. Bradykinin-induced angioedema in the emergency department. Int J Emerg Med 2022; 15:15. [PMID: 35350995 PMCID: PMC8966254 DOI: 10.1186/s12245-022-00408-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/26/2021] [Indexed: 11/25/2022] Open
Abstract
Background Acute airway angioedema commonly occurs through two distinct mechanisms: histamine- and bradykinin-dependent. Although they respond to distinct treatments, these two potentially life-threatening states present similarly. Poor recognition of the bradykinin-dependent pathway leads to treatment errors in the emergency department (ED), despite the availability of multiple pharmacologic options for hereditary angioedema (HAE) and other forms of bradykinin-induced angioedema. Here, we consider the pathophysiology and clinical features of bradykinin-induced angioedema, and we present a systematic literature review exploring the effectiveness of the available therapies for managing such cases. Methods PubMed searches using ‘emergency’, ‘bradykinin’ and various therapeutic product names identified studies reporting the efficacy of treatments for bradykinin-induced angioedema in the ED setting. In all, 22 studies met prespecified criteria and are analysed here. Findings Whereas histamine-induced angioedema has a faster onset and often presents with urticaria, bradykinin-induced angioedema is slower in onset, with greater incidence of abdominal symptoms. Acute airway angioedema in the ED should initially be treated with anaphylactic protocols, focusing on airway management and treatment with epinephrine, antihistamine and systemic steroids. Bradykinin-induced angioedema should be considered if this standard treatment is not effective, despite proper dosing and regard of beta-adrenergic blockade. Therapeutics currently approved for HAE appear as promising options for this and other forms of bradykinin-induced angioedema encountered in the ED. Conclusion Diagnostic algorithms of bradykinin-induced angioedema should be followed in the ED, with early use of approved therapies to improve patient outcomes.
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Affiliation(s)
| | | | | | - Benoit Laramée
- Polyclinique Médicale Pierre-Le Gardeur, Terrebonne, Canada
| | | | - Rémi Gagnon
- CHU de Québec, Université Laval, Québec, Canada
| | | | | | - Matthieu Vincent
- McGill University, Montréal, Canada.,CHU Sainte-Justine, Université de Montréal, Montréal, Canada.,Université de Sherbrooke, Sherbrooke, Canada.,Hôpital Charles-Le Moyne, Greenfield Park, Canada
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Specific Targeting of Plasma Kallikrein for Treatment of Hereditary Angioedema: A Revolutionary Decade. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:716-722. [PMID: 34838707 DOI: 10.1016/j.jaip.2021.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 10/01/2021] [Accepted: 11/19/2021] [Indexed: 11/21/2022]
Abstract
Hereditary angioedema (HAE) is a rare, chronic, genetic disease that presents with nonpruritic angioedema of the face, extremities, airway (can be life-threatening), genitourinary system, and abdomen. These symptoms can significantly impair daily activities. Hereditary angioedema is classified into HAE owing to a deficiency of functional C1INH (HAE-C1INH) or HAE with normal C1INH (HAE-nl-C1INH). Both type I and II HAE-C1INH result from inherited or spontaneous mutations in the SERPING1 gene, which encodes for C1INH. These mutations result in C1INH dysfunction, leading to uncontrolled plasma kallikrein activity with excessive bradykinin production. Bradykinin receptor activation leads to vasodilation, increased vascular permeability, and smooth muscle contractions, resulting in submucosal angioedema through fluid extravasation. Hereditary angioedema nl-C1INH is caused by either a known or unknown genetic mutation. The underlying mechanism of HAE-nl-C1INH is less well understood but is thought to be related to bradykinin signaling. Plasma kallikrein inhibitors have been developed to inhibit the kallikrein-kinin pathway to prevent (prophylactic) and treat on-demand (acute) HAE attacks. Several of these medications are delivered through subcutaneous or intravenous injection, although new and emerging therapies include oral formulations. This article provides a historical review and describes the evolving landscape of available kallikrein inhibitors to treat HAE-C1INH.
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Sylvestre S, Craig T, Ajewole O, Craig S, Kaur S, Al-Shaikhly T. Racial and Ethnic Disparities in the Research and Care of Hereditary Angioedema Patients in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:4441-4449.e2. [PMID: 34464751 PMCID: PMC8671245 DOI: 10.1016/j.jaip.2021.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) affects all races and both sexes equally. Minority patients are underrepresented in clinical trials and may be at risk for additional disease burden. OBJECTIVES To examine racial and ethnic disparities in the research and care of patients with HAE. METHODS We conducted a retrospective population-based study using TriNetX Diamond Network. International Classification of Diseases, 10th Revision, Current Procedural Terminology, and RxNorm codes identified patients with HAE. The proportions of White, Black, and Hispanic patients with HAE were contrasted with racial and ethnic distributions of patients with HAE in clinical trials. Lifetime prevalence of mental health disorders and HAE treatments was contrasted among different racial and ethnic groups. RESULTS A population-based search identified 2122 patients with HAE. The prevalence of HAE among Black patients (1.64/100,000 patients) mirrored that of White patients (1.47/100,000 patients), whereas there was a lower HAE prevalence among Hispanic patients (0.80/100,000 patients). The demographics of the 1274 patients with HAE included in phase 2/3 clinical trials differed significantly from population-based data with overrepresentation of White patients (89.9% vs 77.9%) and underrepresentation of Black patients (3.8% vs 13.6%) and Hispanic patients (1.3% vs 8.1%). Across the different racial and ethnic groups of patients with HAE, the prevalence of mental health disorders was comparatively higher than among patients without HAE. Whereas depression was equally prevalent across the different HAE racial and ethnic groups, anxiety was more prevalent among White patients. CONCLUSIONS Clinical trials for Food and Drug Administration-approved HAE medications underrepresent minority patients. Hereditary angioedema remains underdiagnosed in Hispanic patients. Other than a lower prevalence of anxiety disorders among Black patients relative to White patients, the mental health impact of HAE is equally distributed across the different racial and ethnic groups.
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Affiliation(s)
- Sebastian Sylvestre
- Section of Allergy, Asthma and Immunology, Department of Medicine, Penn State University, Hershey, Pa
| | - Timothy Craig
- Section of Allergy, Asthma and Immunology, Department of Medicine, Penn State University, Hershey, Pa
| | | | - Sansanee Craig
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Sundeep Kaur
- Section of Allergy, Asthma and Immunology, Department of Medicine, Penn State University, Hershey, Pa
| | - Taha Al-Shaikhly
- Section of Allergy, Asthma and Immunology, Department of Medicine, Penn State University, Hershey, Pa.
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7
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Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45267-0769, USA. https://twitter.com/edmojo
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Jia Z, Liu Y, Ji X, Zheng Y, Li Z, Jiang S, Li H, Kong Y. DAKS1, a Kunitz Scaffold Peptide from the Venom Gland of Deinagkistrodon acutus Prevents Carotid-Artery and Middle-Cerebral-Artery Thrombosis via Targeting Factor XIa. Pharmaceuticals (Basel) 2021; 14:ph14100966. [PMID: 34681191 PMCID: PMC8539665 DOI: 10.3390/ph14100966] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 02/07/2023] Open
Abstract
Scaffold-based peptides (SBPs) are fragments of large proteins that are characterized by potent bioactivity, high thermostability, and low immunogenicity. Some SBPs have been approved by the FDA for human use. In the present study, we developed SBPs from the venom gland of Deinagkistrodon acutus (D. acutus) by combining transcriptome sequencing and Pfam annotation. To that end, 10 Kunitz peptides were discovered from the venom gland of D. acutus, and most of which peptides exhibited Factor XIa (FXIa) inhibitory activity. One of those, DAKS1, exhibiting strongest inhibitory activity against FXIa, was further evaluated for its anticoagulant and antithrombotic activity. DAKS1 prolonged twofold APTT at a concentration of 15 μM in vitro. DAKS1 potently inhibited thrombosis in a ferric chloride-induced carotid-artery injury model in mice at a dose of 1.3 mg/kg. Furthermore, DAKS1 prevented stroke in a transient middle cerebral-artery occlusion (tMCAO) model in mice at a dose of 2.6 mg/kg. Additionally, DAKS1 did not show significant bleeding risk at a dose of 6.5 mg/kg. Together, our results indicated that DAKS1 is a promising candidate for drug development for the treatment of thrombosis and stroke disorders.
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Affiliation(s)
| | | | | | | | | | | | | | - Yi Kong
- Correspondence: ; Tel.: +86-025-832-712-82
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9
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A novel murine in vivo model for acute hereditary angioedema attacks. Sci Rep 2021; 11:15924. [PMID: 34354123 PMCID: PMC8342443 DOI: 10.1038/s41598-021-95125-0] [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: 07/24/2020] [Accepted: 06/15/2021] [Indexed: 12/03/2022] Open
Abstract
Hereditary Angioedema (HAE) is a rare genetic disease generally caused by deficiency or mutations in the C1-inhibitor gene, SERPING1, a member of the Serpin family. HAE results in acute attacks of edema, vasodilation, GI pain and hypotension. C1INH is a key inhibitor of enzymes controlling complement activation, fibrinolysis and the contact system. In HAE patients, contact system activation leads to uncontrolled production of bradykinin, the vasodilator responsible for the characteristic symptoms of HAE. In this study, we present the first physiological in vivo model to mimic acute HAE attacks. We evaluate hypotension, one of the many hallmark symptoms of acute HAE attacks using Serping1 deficient mice (serping1−/−) and implanted telemetry. Attacks were induced by IV injection of a silica nanoparticle (SiNP) suspension. Blood pressure was measured in real time, in conscious and untethered mice using implanted telemetry. SiNP injection induced a rapid, reversible decrease in blood pressure, in the presence of angiotensin converting enzyme (ACE) inhibition. We also demonstrate that an HAE therapeutic, ecallantide, can prevent HAE attacks in this model. The in vivo murine model described here can facilitate the understanding of acute HAE attacks, support drug development and ultimately contribute to improved patient care.
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Shamanaev A, Emsley J, Gailani D. Proteolytic activity of contact factor zymogens. J Thromb Haemost 2021; 19:330-341. [PMID: 33107140 PMCID: PMC8552315 DOI: 10.1111/jth.15149] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/16/2020] [Accepted: 10/22/2020] [Indexed: 02/06/2023]
Abstract
Contact activation is triggered when blood is exposed to compounds or "surfaces" that promote conversion of the plasma zymogens factor XII (FXII) and prekallikrein to the active proteases FXIIa and kallikrein. FXIIa promotes blood coagulation by converting zymogen factor XI (FXI) to the protease FXIa. Contact activation appears to represent an enhancement of the propensity for FXII and prekallikrein to reciprocally activate each other by surface-independent limited proteolysis. The nature of the activities that perpetuate this process, and that trigger contact activation, are debated. FXII and prekallikrein, like most members of the chymotrypsin/trypsin protease family, are synthesized as single polypeptides that are presumed to be in an inactive state. Internal cleavage leads to conformational changes in the protease domain that convert the enzyme active site from a closed conformation to an open conformation accessible to substrates. We observed that FXII expresses a low level of activity as a single-chain zymogen that catalyzes prekallikrein activation in solution, as well as surface-dependent activation of prekallikrein, FXI, and FXII (autoactivation). Prekallikrein also expresses activity that promotes cleavage of kininogen to release bradykinin, and surface-dependent FXII activation. Modeling suggests that a glutamine residue at position 156 in the FXII and prekallikrein protease domains stabilizes an open active site conformation by forming hydrogen bonds with Asp194. The activity inherent in FXII and prekallikrein suggests a mechanism for sustaining reciprocal activation of the proteins and for initiating contact activation, and supports the premise that zymogens of some trypsin-like enzymes are active proteases.
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Affiliation(s)
- Aleksandr Shamanaev
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Jonas Emsley
- Biodiscovery Institute, Centre for Biomedical Science, University of Nottingham, Nottingham, UK
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
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Mansour E, Bueno FF, de Lima-Júnior JC, Palma A, Monfort-Pires M, Bombassaro B, Araujo EP, Bernardes AF, Ulaf RG, Nunes TA, Ribeiro LC, Falcão ALE, Santos TM, Trabasso P, Dertkigil RP, Dertkigil SS, Maia RP, Benaglia T, Moretti ML, Velloso LA. Evaluation of the efficacy and safety of icatibant and C1 esterase/kallikrein inhibitor in severe COVID-19: study protocol for a three-armed randomized controlled trial. Trials 2021; 22:71. [PMID: 33472675 PMCID: PMC7816150 DOI: 10.1186/s13063-021-05027-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/06/2021] [Indexed: 12/24/2022] Open
Abstract
Background SARS-CoV-2, the virus that causes COVID-19, enters the cells through a mechanism dependent on its binding to angiotensin-converting enzyme 2 (ACE2), a protein highly expressed in the lungs. The putative viral-induced inhibition of ACE2 could result in the defective degradation of bradykinin, a potent inflammatory substance. We hypothesize that increased bradykinin in the lungs is an important mechanism driving the development of pneumonia and respiratory failure in COVID-19. Methods This is a phase II, single-center, three-armed parallel-group, open-label, active control superiority randomized clinical trial. One hundred eighty eligible patients will be randomly assigned in a 1:1:1 ratio to receive either the inhibitor of C1e/kallikrein 20 U/kg intravenously on day 1 and day 4 plus standard care; or icatibant 30 mg subcutaneously, three doses/day for 4 days plus standard care; or standard care alone, as recommended in the clinical trials published to date, which includes supplemental oxygen, non-invasive and invasive ventilation, antibiotic agents, anti-inflammatory agents, prophylactic antithrombotic therapy, vasopressor support, and renal replacement therapy. Discussion Accumulation of bradykinin in the lungs is a common side effect of ACE inhibitors leading to cough. In animal models, the inactivation of ACE2 leads to severe acute pneumonitis in response to lipopolysaccharide (LPS), and the inhibition of bradykinin almost completely restores the lung structure. We believe that inhibition of bradykinin in severe COVID-19 patients could reduce the lung inflammatory response, impacting positively on the severity of disease and mortality rates. Trial registration Brazilian Clinical Trials Registry Universal Trial Number (UTN) U1111-1250-1843. Registered on May/5/2020.
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Affiliation(s)
- Eli Mansour
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Flávia F Bueno
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, São Paulo, Brazil
| | - José C de Lima-Júnior
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, São Paulo, Brazil
| | - Andre Palma
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Milena Monfort-Pires
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, São Paulo, Brazil
| | - Bruna Bombassaro
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, São Paulo, Brazil
| | - Eliana P Araujo
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, São Paulo, Brazil.,School of Nursing, University of Campinas, Campinas, São Paulo, Brazil
| | - Ana Flavia Bernardes
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Raisa G Ulaf
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Thyago A Nunes
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Luciana C Ribeiro
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Antônio Luís E Falcão
- Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Thiago Martins Santos
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Plinio Trabasso
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Rachel P Dertkigil
- Department of Radiology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Sergio S Dertkigil
- Department of Radiology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Rafael P Maia
- Department of Statistics, Institute of Mathematics, Statistics, and Scientific Computation, University of Campinas, Campinas, São Paulo, Brazil
| | - Tatiana Benaglia
- Department of Statistics, Institute of Mathematics, Statistics, and Scientific Computation, University of Campinas, Campinas, São Paulo, Brazil
| | - Maria Luiza Moretti
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Licio A Velloso
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil. .,Obesity and Comorbidities Research Center, University of Campinas, Campinas, São Paulo, Brazil.
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12
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Molecular Mechanisms of Premature Aging in Hemodialysis: The Complex Interplay Between Innate and Adaptive Immune Dysfunction. Int J Mol Sci 2020; 21:ijms21103422. [PMID: 32408613 PMCID: PMC7279398 DOI: 10.3390/ijms21103422] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 02/07/2023] Open
Abstract
Hemodialysis (HD) patient are known to be susceptible to a wide range of early and long-term complication such as chronic inflammation, infections, malnutrition, and cardiovascular disease that significantly affect the incidence of mortality. A large gap between the number of people with end-stage kidney disease (ESKD) and patients who received kidney transplantation has been identified. Therefore, there is a huge need to explore the underlying pathophysiology of HD complications in order to provide treatment guidelines. The immunological dysregulation, involving both the innate and adaptive response, plays a crucial role during the HD sessions and in chronic, maintenance treatments. Innate immune system mediators include the dysfunction of neutrophils, monocytes, and natural killer (NK) cells with signaling mediated by NOD-like receptor P3 (NLRP3) and Toll-like receptor 4 (TLR4); in addition, there is a significant activation of the complement system that is mediated by dialysis membrane-surfaces. These effectors induce a persistent, systemic, pro-inflammatory, and pro-coagulant milieu that has been described as inflammaging. The adaptive response, the imbalance in the CD4+/CD8+ T cell ratio, and the reduction of Th2 and regulatory T cells, together with an altered interaction with B lymphocyte by CD40/CD40L, have been mainly implicated in immune system dysfunction. Altogether, these observations suggest that intervention targeting the immune system in HD patients could improve morbidity and mortality. The purpose of this review is to expand our understanding on the role of immune dysfunction in both innate and adaptive response in patients undergoing hemodialysis treatment.
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13
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Abstract
Angioedema is a localized swelling of the skin and submucosal tissues and is generally benign and self-limiting. However, it can be life threatening if angioedema involves the upper airway, resulting in airway obstruction. Airway protection would be critical and lifesaving in patients with angioedema irrespective of the underlying etiology. Detailed history and physical examination can help identify the underlying mechanism of angioedema in an individual patient (ie, mast-cell versus bradykinin-mediated angioedema). Treatment of angioedema depends on the underlying etiology. Mast cell-mediated angioedema is generally responsive to steroids, antihistamines, and epinephrine (when indicated), unlike bradykinin-mediated disease. [Pediatr Ann. 2019;48(12):e473-e478.].
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Betschel S, Badiou J, Binkley K, Borici-Mazi R, Hébert J, Kanani A, Keith P, Lacuesta G, Waserman S, Yang B, Aygören-Pürsün E, Bernstein J, Bork K, Caballero T, Cicardi M, Craig T, Farkas H, Grumach A, Katelaris C, Longhurst H, Riedl M, Zuraw B, Berger M, Boursiquot JN, Boysen H, Castaldo A, Chapdelaine H, Connors L, Fu L, Goodyear D, Haynes A, Kamra P, Kim H, Lang-Robertson K, Leith E, McCusker C, Moote B, O’Keefe A, Othman I, Poon MC, Ritchie B, St-Pierre C, Stark D, Tsai E. The International/Canadian Hereditary Angioedema Guideline. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2019; 15:72. [PMID: 31788005 PMCID: PMC6878678 DOI: 10.1186/s13223-019-0376-8] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/10/2019] [Indexed: 12/20/2022]
Abstract
This is an update to the 2014 Canadian Hereditary Angioedema Guideline with an expanded scope to include the management of hereditary angioedema (HAE) patients worldwide. It is a collaboration of Canadian and international HAE experts and patient groups led by the Canadian Hereditary Angioedema Network. The objective of this guideline is to provide evidence-based recommendations, using the GRADE system, for the management of patients with HAE. This includes the treatment of attacks, short-term prophylaxis, long-term prophylaxis, and recommendations for self-administration, individualized therapy, quality of life, and comprehensive care. New to the 2019 version of this guideline are sections covering the diagnosis and recommended therapies for acute treatment in HAE patients with normal C1-INH, as well as sections on pregnant and paediatric patients, patient associations and an HAE registry. Hereditary angioedema results in random and often unpredictable attacks of painful swelling typically affecting the extremities, bowel mucosa, genitals, face and upper airway. Attacks are associated with significant functional impairment, decreased health-related quality of life, and mortality in the case of laryngeal attacks. Caring for patients with HAE can be challenging due to the complexity of this disease. The care of patients with HAE in Canada, as in many countries, continues to be neither optimal nor uniform. It lags behind some other countries where there are more organized models for HAE management, and greater availability of additional licensed therapeutic options. It is anticipated that providing this guideline to caregivers, policy makers, patients, and advocates will not only optimize the management of HAE, but also promote the importance of individualized care. The primary target users of this guideline are healthcare providers who are managing patients with HAE. Other healthcare providers who may use this guideline are emergency and intensive care physicians, primary care physicians, gastroenterologists, dentists, otolaryngologists, paediatricians, and gynaecologists who will encounter patients with HAE and need to be aware of this condition. Hospital administrators, insurers and policy makers may also find this guideline helpful.
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Affiliation(s)
| | | | | | | | - Jacques Hébert
- Department of Medicine, Laval University, Quebec City, QC Canada
| | - Amin Kanani
- Division of Allergy and Clinical Immunology, St. Paul’s Hospital, Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Paul Keith
- Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Gina Lacuesta
- Department of Medicine, Dalhousie University, Halifax, NS Canada
| | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Bill Yang
- University of Ottawa Medical School, Ottawa, ON Canada
| | | | - Jonathan Bernstein
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH USA
| | - Konrad Bork
- Department of Dermatology, University Hospital of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | | | - Marco Cicardi
- Department of Internal Medicine, Universita degli Studi di Milano, Ospedale L. Sacco, Milan, Italy
| | - Timothy Craig
- Departments of Medicine and Pediatrics, Penn State University, Hershey, PA USA
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Anete Grumach
- Laboratory of Clinical Immunology, Faculdade de Medicine ABC, Sao Paulo, Brazil
| | - Connie Katelaris
- Campbelltown Hospital, Western Sydney University, New South Wales, Australia
| | - Hilary Longhurst
- Addenbrooke’s Hospital, Cambridge and University College Hospital, London, England UK
| | - Marc Riedl
- University of California, San Diego, San Diego, CA USA
| | - Bruce Zuraw
- University of California, San Diego, San Diego, CA USA
| | | | - Jean-Nicolas Boursiquot
- Division of Allergy and Clinical Immunology, Centre hospitalier universitaire de Québec, Laval University, Quebec City, QC Canada
| | | | | | - Hugo Chapdelaine
- Institut de recherches cliniques de Montréal, Montreal, QC Canada
| | - Lori Connors
- Department of Medicine, Dalhousie University, Halifax, NS Canada
| | - Lisa Fu
- Toronto Allergy Group, Toronto, ON Canada
| | - Dawn Goodyear
- Southern Alberta Rare Blood and Bleeding Disorders Program, Foothills Medical Centre, University of Calgary, Calgary, AB Canada
| | - Alison Haynes
- Division of Pediatrics, Faculty of Medicine, Memorial University, St John’s, NF Canada
| | - Palinder Kamra
- Janeway Children’s Health and Rehabilitation Centre, Memorial University, St John’s, NF Canada
| | - Harold Kim
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON Canada
| | | | - Eric Leith
- Department of Medicine, University of Toronto, Oakville, ON Canada
| | - Christine McCusker
- Department of Immunology, McGill University Health Centre, Montreal, QC Canada
| | - Bill Moote
- Department of Medicine, Western University, London, ON Canada
| | - Andrew O’Keefe
- Division of Pediatrics, Faculty of Medicine, Memorial University, St John’s, NF Canada
| | - Ibraheem Othman
- College of Medicine, University of Saskatchewan, Regina, SK Canada
| | - Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, University of Calgary Cumming School of Medicine, Calgary, AB Canada
| | - Bruce Ritchie
- Departments of Medicine and Medical Oncology, University of Alberta, Edmonton, AB Canada
| | | | - Donald Stark
- Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Ellie Tsai
- Department of Internal Medicine, Queen’s University, Kingston, ON Canada
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Valerieva A, Senter R, Wu MA, Zanichelli A, Cicardi M. Lanadelumab for the prevention of attacks in hereditary angioedema. Expert Rev Clin Immunol 2019; 15:1239-1248. [PMID: 31721602 DOI: 10.1080/1744666x.2020.1693261] [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: 10/25/2022]
Abstract
Introduction: Hereditary angioedema (HAE) with C1 esterase inhibitor deficiency (C1-INH-HAE) is a rare disease that manifests with cutaneous and/or submucosal swellings due to uncontrolled activation of the contact/kinin system. Attacks recur with unpredictable frequency and severity, laryngeal edema is potentially lethal, and the disease burden may severely disrupt patients' lives.Areas covered: This review provides an overview of lanadelumab, a human monoclonal antibody targeted against plasma kallikrein that was recently approved for prevention of symptoms in C1-INH-HAE.Expert opinion: The phase III HELP Study demonstrated the efficacy of lanadelumab in reducing HAE attacks. These positive results are being further confirmed in the open-label extension study. This agent addresses some of the limitations of existing prophylactic options as tolerability issues, the need for intravenous administration and frequent dosing. Therefore, lanadelumab can profoundly improve the quality of life of patients with C1-INH-HAE.
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Affiliation(s)
- Anna Valerieva
- Department of Allergology, Medical University of Sofia, Sofia, Bulgaria
| | | | | | | | - Marco Cicardi
- Biomedical and Clinical Sciences, University of Milan, Milan, Italy.,Rehabilitation and Internal Medicine Department, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
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Abstract
Introduction: Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is a rare yet still probably underdiagnosed clinical condition. Recurrent episodes of subcutaneous and sub-mucosal swelling may involve the skin, the gastrointestinal tract or even the upper airways, exposing the patients to the risk of death. With the aim of improving patients' quality of life, the therapeutic scenario has expanded over the years.Areas covered: The focus of the present review is lanadelumab, a fully human, κ-light-chain, monoclonal immunoglobulin G1 against plasma kallikrein, currently approved for long-term prophylaxis of C1-INH-HAE attacks in the USA and Canada and designated as an orphan drug by the European Medicines Agency.Expert opinion: Lanadelumab is able to inhibit plasma kallikrein with high selectivity and affinity. The subsequent phases of drug development and the ongoing open-label trial have proven its safety and efficacy. It overcomes some of the limitations of other drugs available for long-term prophylaxis, given the easy route of administration, the simple administration schedule and the possibility to tailor the treatment to each patient. Further studies are needed to test its efficacy also in other types of angioedema for which a central role of plasma kallikrein is envisaged.
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Affiliation(s)
- Maddalena Alessandra Wu
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital - Polo Universitario - University of Milan, Milan, Italy
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Long BJ, Koyfman A, Gottlieb M. Evaluation and Management of Angioedema in the Emergency Department. West J Emerg Med 2019; 20:587-600. [PMID: 31316698 PMCID: PMC6625683 DOI: 10.5811/westjem.2019.5.42650] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 01/14/2023] Open
Abstract
Angioedema is defined by non-dependent, non-pitting edema that affects several different sites and is potentially life-threatening due to laryngeal edema. This narrative review provides emergency physicians with a focused overview of the evaluation and management of angioedema. Two primary forms include histamine-mediated and bradykinin-mediated angioedema. Histamine-mediated forms present similarly to anaphylaxis, while bradykinin-mediated angioedema presents with greater face and oropharyngeal involvement and higher risk of progression. Initial evaluation and management should focus on evaluation of the airway, followed by obtaining relevant historical features, including family history, medications, and prior episodes. Histamine-mediated angioedema should be treated with epinephrine intramuscularly, antihistaminergic medications, and steroids. These medications are not effective for bradykinin-mediated forms. Other medications include C1-INH protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists. Evidence is controversial concerning the efficacy of these medications in an acute episode, and airway management is the most important intervention when indicated. Airway intervention may require fiberoptic or video laryngoscopy, with preparation for cricothyrotomy. Disposition is dependent on patient's airway and respiratory status, as well as the sites involved.
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Affiliation(s)
- Brit Jeffrey Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Pharmacological Management of Hereditary Angioedema with C1-Inhibitor Deficiency in Pediatric Patients. Paediatr Drugs 2018; 20:135-151. [PMID: 29214395 DOI: 10.1007/s40272-017-0273-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hereditary angioedema with C1-inhibitor deficiency (C1-INH-HAE) is a form of bradykinin-mediated angioedema. It is a rare disorder with an onset during childhood in most instances. Therefore, familiarity with the options for the management of pediatric cases is indispensable. The recurrent angioedematous episodes do not respond to conventional treatments and may evolve into a life-threatening condition. In view of the recommendations adopted by international consensus in 2016, patient management and follow-up should be guided by an individualized strategy. During the last decade, various medicinal products with novel modes of action and different posology have been developed for the treatment of C1-INH-HAE. These drugs either inhibit the release of bradykinin (plasma-derived C1-inhibitors, recombinant C1-inhibitors, kallikrein inhibitors) or prevent the released bradykinin from binding to its receptor (bradykinin B2 receptor antagonists). This review summarizes the properties of the medicinal products currently available for the treatment of C1-INH-HAE, the indications for their use in pediatric patients, and the findings of the clinical trials conducted in this patient population. It is concluded by a brief outline of future therapeutic options.
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Yancey R. Anesthetic Management of the Hypertensive Patient: Part I. Anesth Prog 2018; 65:131-138. [PMID: 29952638 PMCID: PMC6022786 DOI: 10.2344/anpr-65-02-12] [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: 04/27/2018] [Accepted: 04/30/2018] [Indexed: 12/20/2022] Open
Abstract
Hypertension is an important health challenge that affects millions of people across the world and is a major risk factor for cardiovascular disease. It is critical that anesthesia providers have a working knowledge of the systemic implications of hypertension. This review article will discuss the medical definitions of hypertension, the physiology of maintaining blood pressure, outpatient treatment of hypertension, anesthetic implications, and the common medications used by anesthesia providers in the treatment of hypertension. Part I will provide an overview of hypertension and blood pressure regulation. In addition, drugs affecting predominantly renal control of hypertension, such as diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and renin-inhibiting agents, will be discussed. In part II, the remaining major antihypertensive medications will be reviewed as well as anesthetic implications of managing patients with hypertension.
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Affiliation(s)
- Russell Yancey
- PGY-2 Resident, New York University–Langone Hospital Dental Anesthesiology Service, Brooklyn, New York
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20
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Abstract
Antibodies have proved to be a valuable mode of therapy for numerous diseases, mainly owing to their high target binding affinity and specificity. Unfortunately, antibodies are also limited in several respects, chief amongst those being the extremely high cost of manufacture. Therefore, non-antibody binding proteins have long been sought after as alternative therapies. New binding protein scaffolds are constantly being designed or discovered with some already approved for human use by the FDA. This review focuses on protein scaffolds that are either already being used in humans or are currently being evaluated in clinical trials. Although not all are expected to be approved, the significant benefits ensure that these molecules will continue to be investigated and developed as therapeutic alternatives to antibodies. Based on the location of the amino acids that mediate ligand binding, we place all the protein scaffolds under clinical development into two general categories: scaffolds with ligand-binding residues located in exposed flexible loops, and those with the binding residues located in protein secondary structures, such as α-helices. Scaffolds that fall under the first category include adnectins, anticalins, avimers, Fynomers, Kunitz domains, and knottins, while those belonging to the second category include affibodies, β-hairpin mimetics, and designed ankyrin repeat proteins (DARPins). Most of these scaffolds are thermostable and can be easily produced in microorganisms or completely synthesized chemically. In addition, many of these scaffolds derive from human proteins and thus possess very low immunogenic potential. Additional advantages and limitations of these protein scaffolds as therapeutics compared to antibodies will be discussed.
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Affiliation(s)
- Rudo Simeon
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, TX, 77845, USA
| | - Zhilei Chen
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, TX, 77845, USA.
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22
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Li Z, Partridge J, Silva-Garcia A, Rademacher P, Betz A, Xu Q, Sham H, Hu Y, Shan Y, Liu B, Zhang Y, Shi H, Xu Q, Ma X, Zhang L. Structure-Guided Design of Novel, Potent, and Selective Macrocyclic Plasma Kallikrein Inhibitors. ACS Med Chem Lett 2017; 8:185-190. [PMID: 28197309 DOI: 10.1021/acsmedchemlett.6b00384] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 12/06/2016] [Indexed: 11/28/2022] Open
Abstract
A series of macrocyclic analogues were designed and synthesized based on the cocrystal structure of small molecule plasma kallikrein (pKal) inhibitor, 2, with the pKal protease domain. This led to the discovery of a potent macrocyclic pKal inhibitor 29, with an IC50 of 2 nM for one olefinic isomer and 42.3 nM for the other olefinic isomer.
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Affiliation(s)
- Zhe Li
- Global Blood Therapeutics, South San Francisco, California 94080, United States
| | - James Partridge
- Global Blood Therapeutics, South San Francisco, California 94080, United States
| | - Abel Silva-Garcia
- Global Blood Therapeutics, South San Francisco, California 94080, United States
| | - Peter Rademacher
- Global Blood Therapeutics, South San Francisco, California 94080, United States
| | - Andreas Betz
- Global Blood Therapeutics, South San Francisco, California 94080, United States
| | - Qing Xu
- Global Blood Therapeutics, South San Francisco, California 94080, United States
| | - Hing Sham
- Global Blood Therapeutics, South San Francisco, California 94080, United States
| | - Yunjin Hu
- Pharmaron Xi’an Co., Xi’an, Shaanxi 710018, China
| | - Yuqing Shan
- Pharmaron Xi’an Co., Xi’an, Shaanxi 710018, China
| | - Bin Liu
- Pharmaron Xi’an Co., Xi’an, Shaanxi 710018, China
| | - Ying Zhang
- Pharmaron Xi’an Co., Xi’an, Shaanxi 710018, China
| | - Haijuan Shi
- Pharmaron Xi’an Co., Xi’an, Shaanxi 710018, China
| | - Qiong Xu
- Pharmaron Xi’an Co., Xi’an, Shaanxi 710018, China
| | - Xubo Ma
- Pharmaron Xi’an Co., Xi’an, Shaanxi 710018, China
| | - Li Zhang
- Pharmaron Xi’an Co., Xi’an, Shaanxi 710018, China
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MacBeth LS, Volcheck GW, Sprung J, Weingarten TN. Perioperative course in patients with hereditary or acquired angioedema. J Clin Anesth 2016; 34:385-91. [DOI: 10.1016/j.jclinane.2016.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 04/27/2016] [Accepted: 05/02/2016] [Indexed: 11/30/2022]
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Zeerleder S, Levi M. Hereditary and acquired C1-inhibitor-dependent angioedema: from pathophysiology to treatment. Ann Med 2016; 48:256-67. [PMID: 27018196 DOI: 10.3109/07853890.2016.1162909] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Uncontrolled generation of bradykinin (BK) due to insufficient levels of protease inhibitors controlling contact phase (CP) activation, increased activity of CP proteins, and/or inadequate degradation of BK into inactive peptides increases vascular permeability via BK-receptor 2 (BKR2) and results in subcutaneous and submucosal edema formation. Hereditary and acquired angioedema due to C1-inhibitor deficiency (C1-INH-HAE and -AAE) are diseases characterized by serious and potentially fatal attacks of subcutaneous and submucosal edemas of upper airways, facial structures, abdomen, and extremities, due to inadequate control of BK generation. A decreased activity of C1-inhibitor is the hallmark of C1-INH-HAE (types 1 and 2) due to a mutation in the C1-inhibitor gene, whereas the deficiency in C1-inhibitor in C1-INH-AAE is the result of autoimmune phenomena. In HAE with normal C1-inhibitor, a significant percentage of patients have an increased activity of factor XIIa due to a FXII mutation (FXII-HAE). Treatment of C1-inhibitor-dependent angioedema focuses on restoring control of BK generation by inhibition of CP proteases by correcting the balance between CP inhibitors and BK breakdown or by inhibition of BK-mediated effects at the BKR2 on endothelial cells. This review will address the pathophysiology, clinical picture, diagnosis and available treatment in C1-inhibitor-dependent angioedema focusing on BK-release and its regulation. Key Messages Inadequate control of bradykinin formation results in the formation of characteristic subcutaneous and submucosal edemas of the skin, upper airways, facial structures, abdomen and extremities as seen in hereditary and acquired C1-inhibitor-dependent angioedema. Diagnosis of hereditary and acquired C1-inhibitor-dependent angioedema may be troublesome as illustrated by the fact that there is a significant delay in diagnosis; a certain grade of suspicion is therefore crucial for quick diagnosis. Submucosal edema formation in hereditary and acquired C1-inhibitor-dependent angioedema is potentially life threatening and can occur at any age. To date effective therapies for acute and prophylactic treatment are available.
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Affiliation(s)
- Sacha Zeerleder
- a Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the AMC , Amsterdam , The Netherlands ;,b Department of Hematology , Academic Medical Center, University of Amsterdam , The Netherlands
| | - Marcel Levi
- c Department of Internal Medicine , Academic Medical Center, University of Amsterdam , The Netherlands
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Nasr IH, Manson AL, Al Wahshi HA, Longhurst HJ. Optimizing hereditary angioedema management through tailored treatment approaches. Expert Rev Clin Immunol 2015; 12:19-31. [PMID: 26496459 DOI: 10.1586/1744666x.2016.1100963] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hereditary angioedema (HAE) is a rare but serious and potentially life threatening autosomal dominant condition caused by low or dysfunctional C1 esterase inhibitor (C1-INH) or uncontrolled contact pathway activation. Symptoms are characterized by spontaneous, recurrent attacks of subcutaneous or submucosal swellings typically involving the face, tongue, larynx, extremities, genitalia or bowel. The prevalence of HAE is estimated to be 1:50,000 without known racial differences. It causes psychological stress as well as significant socioeconomic burden. Early treatment and prevention of attacks are associated with better patient outcome and lower socioeconomic burden. New treatments and a better evidence base for management are emerging which, together with a move from hospital-centered to patient-centered care, will enable individualized, tailored treatment approaches.
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Affiliation(s)
- Iman H Nasr
- a Department of Immunology, Barts Health NHS Trust , London , UK
| | - Ania L Manson
- a Department of Immunology, Barts Health NHS Trust , London , UK
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Vazquez-Lombardi R, Phan TG, Zimmermann C, Lowe D, Jermutus L, Christ D. Challenges and opportunities for non-antibody scaffold drugs. Drug Discov Today 2015; 20:1271-83. [PMID: 26360055 DOI: 10.1016/j.drudis.2015.09.004] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 08/06/2015] [Accepted: 09/01/2015] [Indexed: 12/22/2022]
Abstract
The first candidates from the promising class of small non-antibody protein scaffolds are now moving into clinical development and practice. Challenges remain, and scaffolds will need to be further tailored toward applications where they provide real advantages over established therapeutics to succeed in a rapidly evolving drug development landscape.
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Affiliation(s)
- Rodrigo Vazquez-Lombardi
- Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; The University of New South Wales, Faculty of Medicine, St Vincent's Clinical School, Darlinghurst, Sydney, NSW 2010, Australia
| | - Tri Giang Phan
- Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; The University of New South Wales, Faculty of Medicine, St Vincent's Clinical School, Darlinghurst, Sydney, NSW 2010, Australia
| | - Carsten Zimmermann
- University of San Diego, School of Business Administration, 5998 Alcala Park, San Diego, CA 92110, USA
| | - David Lowe
- MedImmune Ltd., Granta Park, Cambridge CB21 6GH, UK
| | - Lutz Jermutus
- MedImmune Ltd., Granta Park, Cambridge CB21 6GH, UK; Trinity Hall, University of Cambridge, Trinity Lane CB2 1TJ, UK.
| | - Daniel Christ
- Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; The University of New South Wales, Faculty of Medicine, St Vincent's Clinical School, Darlinghurst, Sydney, NSW 2010, Australia.
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Lomonosova AV, Ovchinnikova EV, Kazakov AS, Denesyuk AI, Sofin AD, Mikhailov RV, Ulitin AB, Mirzabekov TA, Permyakov EA, Permyakov SE. Extremophilic 50S Ribosomal RNA-Binding Protein L35Ae as a Basis for Engineering of an Alternative Protein Scaffold. PLoS One 2015; 10:e0134906. [PMID: 26247602 PMCID: PMC4527664 DOI: 10.1371/journal.pone.0134906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 07/15/2015] [Indexed: 01/05/2023] Open
Abstract
Due to their remarkably high structural stability, proteins from extremophiles are particularly useful in numerous biological applications. Their utility as alternative protein scaffolds could be especially valuable in small antibody mimetic engineering. These artificial binding proteins occupy a specific niche between antibodies and low molecular weight substances, paving the way for development of innovative approaches in therapeutics, diagnostics, and reagent use. Here, the 50S ribosomal RNA-binding protein L35Ae from the extremophilic archaea Pyrococcus horikoshii has been probed for its potential to serve as a backbone in alternative scaffold engineering. The recombinant wild type L35Ae has a native-like secondary structure, extreme thermal stability (mid-transition temperature of 90°C) and a moderate resistance to the denaturation by guanidine hydrochloride (half-transition at 2.6 M). Chemical crosslinking and dynamic light scattering data revealed that the wild type L35Ae protein has a propensity for multimerization and aggregation correlating with its non-specific binding to a model cell surface of HEK293 cells, as evidenced by flow cytometry. To suppress these negative features, a 10-amino acid mutant (called L35Ae 10X) was designed, which lacks the interaction with HEK293 cells, is less susceptible to aggregation, and maintains native-like secondary structure and thermal stability. However, L35Ae 10X also shows lowered resistance to guanidine hydrochloride (half-transition at 2.0M) and is more prone to oligomerization. This investigation of an extremophile protein’s scaffolding potential demonstrates that lowered resistance to charged chemical denaturants and increased propensity to multimerization may limit the utility of extremophile proteins as alternative scaffolds.
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Affiliation(s)
- Anna V. Lomonosova
- Institute for Biological Instrumentation of the Russian Academy of Sciences, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
| | - Elena V. Ovchinnikova
- Institute for Biological Instrumentation of the Russian Academy of Sciences, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
| | - Alexei S. Kazakov
- Institute for Biological Instrumentation of the Russian Academy of Sciences, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
| | - Alexander I. Denesyuk
- Institute for Biological Instrumentation of the Russian Academy of Sciences, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
- Department of Biosciences, Åbo Akademi University, Turku, 20520, Finland
| | - Alexander D. Sofin
- Institute for Biological Instrumentation of the Russian Academy of Sciences, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
| | - Roman V. Mikhailov
- Antherix, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
| | - Andrei B. Ulitin
- Antherix, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
| | - Tajib A. Mirzabekov
- Antherix, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
- Biomirex Inc., 304 Pleasant Street, Watertown, Massachusetts, 02472, United States of America
| | - Eugene A. Permyakov
- Institute for Biological Instrumentation of the Russian Academy of Sciences, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
| | - Sergei E. Permyakov
- Institute for Biological Instrumentation of the Russian Academy of Sciences, Institutskaya str., 7, Pushchino, Moscow region, 142290, Russia
- * E-mail:
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Betschel S, Badiou J, Binkley K, Hébert J, Kanani A, Keith P, Lacuesta G, Yang B, Aygören-Pürsün E, Bernstein J, Bork K, Caballero T, Cicardi M, Craig T, Farkas H, Longhurst H, Zuraw B, Boysen H, Borici-Mazi R, Bowen T, Dallas K, Dean J, Lang-Robertson K, Laramée B, Leith E, Mace S, McCusker C, Moote B, Poon MC, Ritchie B, Stark D, Sussman G, Waserman S. Canadian hereditary angioedema guideline. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2014; 10:50. [PMID: 25352908 PMCID: PMC4210625 DOI: 10.1186/1710-1492-10-50] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 09/10/2014] [Indexed: 11/26/2022]
Abstract
Hereditary angioedema (HAE) is a disease which is associated with random and often unpredictable attacks of painful swelling typically affecting the extremities, bowel mucosa, genitals, face and upper airway. Attacks are associated with significant functional impairment, decreased Health Related Quality of Life, and mortality in the case of laryngeal attacks. Caring for patients with HAE can be challenging due to the complexity of this disease. The care of patients with HAE in Canada is neither optimal nor uniform across the country. It lags behind other countries where there are more organized models for HAE management, and where additional therapeutic options are licensed and available for use. The objective of this guideline is to provide graded recommendations for the management of patients in Canada with HAE. This includes the treatment of attacks, short-term prophylaxis, long-term prophylaxis, and recommendations for self-administration, individualized therapy, quality of life, and comprehensive care. It is anticipated that by providing this guideline to caregivers, policy makers, patients and their advocates, that there will be an improved understanding of the current recommendations regarding management of HAE and the factors that need to be considered when choosing therapies and treatment plans for individual patients. The primary target users of this guideline are healthcare providers who are managing patients with HAE. Other healthcare providers who may use this guideline are emergency physicians, gastroenterologists, dentists and otolaryngologists, who will encounter patients with HAE and need to be aware of this condition. Hospital administrators, insurers and policy makers may also find this guideline helpful.
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Affiliation(s)
| | | | | | - Jacques Hébert
- />Department of Medicine, Laval University, Quebec City, Quebec Canada
| | - Amin Kanani
- />Department of Medicine, University of British Columbia, Vancouver, British Columbia Canada
| | - Paul Keith
- />Department of Medicine, McMaster University, Hamilton, Ontario Canada
| | - Gina Lacuesta
- />Department of Medicine, Dalhousie University, Halifax, Nova Scotia Canada
| | - Bill Yang
- />University of Ottawa Medical School, Ottawa, Ontario Canada
| | | | - Jonathan Bernstein
- />Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio USA
| | - Konrad Bork
- />Department of Dermatology, University Hospital of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | | | - Marco Cicardi
- />Department of Internal Medicine, UniversitadegliStudi di Milano, Ospedale L. Sacco, Milan, Italy
| | - Timothy Craig
- />Departments of Medicine and Pediatrics, Penn State University, Hershey, Pennsylvania USA
| | - Henriette Farkas
- />3rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Hilary Longhurst
- />Department of Immunology, Barts and the London NHS Trust, London, England, UK
| | - Bruce Zuraw
- />University of California, San Diego, San Diego, California USA
| | | | | | - Tom Bowen
- />Departments of Medicine and Paediatrics, University of Calgary, Calgary, Alberta Canada
| | - Karen Dallas
- />Saskatoon Health Region, Saskatoon, Saskatchewan Canada
| | - John Dean
- />BC Children’s Hospital, Vancouver, British Columbia Canada
| | | | - Benoît Laramée
- />Centre hospitalier de l’université de Montréal, Montréal, Quebec Canada
| | - Eric Leith
- />Department of Medicine, University of Toronto, Oakville, Ontario Canada
| | - Sean Mace
- />University of Toronto, Toronto, Ontario Canada
| | - Christine McCusker
- />Department of Immunology, McGill University Health Centre, Montreal, Quebec Canada
| | - Bill Moote
- />Department of Medicine, Western University, London, Ontario Canada
| | - Man-Chiu Poon
- />Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Calgary, Alberta Canada
| | - Bruce Ritchie
- />Departments of Medicine and Medical Oncology, University of Alberta, Edmonton, Alberta Canada
| | - Donald Stark
- />Department of Medicine, University of British Columbia, Vancouver, British Columbia Canada
| | | | - Susan Waserman
- />Department of Medicine, McMaster University, Hamilton, Ontario Canada
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Cai W, Naimuddin M, Inagaki H, Kameyama K, Ishida N, Kubo T. Directed evolution of three-finger toxin to produce serine protease inhibitors. J Recept Signal Transduct Res 2013; 34:154-61. [PMID: 24308378 DOI: 10.3109/10799893.2013.865747] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Directed evolution is a very popular strategy for improving biophysical properties and even for generating proteins with novel functions. Recent advances in combinatorial protein engineering mean it is now possible to develop protein scaffolds that could substitute for whole antibody-associated properties as emerging therapeutic proteins. In particular, disulfide-rich proteins are attractive templates for directed evolution in the search for novel molecules because they can regulate the activities of receptors, enzymes, and other molecules. Previously, we demonstrated that functional regulatory molecules against interleukin-6 receptor (IL-6R) could be obtained by directed evolution of the three-finger toxin (3F) scaffold. In the present study, trypsin was selected as a target for directed evolution to further explore the potential use of the 3F cDNA display library. After seven rounds of selection, the DNA sequences converged. The recombinant proteins produced by the selected candidates had inhibitory activity against trypsin (Ki of 33-450 nM). Three of the six groups had Ki values that were comparable to bovine pancreatic trypsin inhibitor and soybean trypsin inhibitor. Two of the candidates also had inhibitory effects against chymotrypsin and kallikrein. This study suggests that 3F protein is suitable for the preparation of high-diversity libraries that can be utilized to obtain protease inhibitors. In addition to our previous successful targeting of IL-6R, the technique developed in our studies may have wide applications in the generation of regulatory molecules for targets of interest, such as receptors, enzymes for research, diagnostic applications, and therapeutic uses.
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Affiliation(s)
- Weiyan Cai
- Graduate School of Life and Environmental Sciences, University of Tsukuba , Tsukuba, Ibaraki , Japan
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Successful treatment of idiopathic angioedema with ecallantide. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:297-8. [PMID: 24565489 DOI: 10.1016/j.jaip.2013.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/13/2013] [Accepted: 03/15/2013] [Indexed: 11/24/2022]
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Xu YY, Buyantseva LV, Agarwal NS, Olivieri K, Zhi YX, Craig TJ. Update on treatment of hereditary angioedema. Clin Exp Allergy 2013; 43:395-405. [DOI: 10.1111/cea.12080] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Y.-Y. Xu
- Department of Allergy, Peking Union Medical College Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing; China
| | - L. V. Buyantseva
- Department of Internal Medicine; Pinnacle Heal System; Harrisburg Hospital; Harrisburg; PA; USA
| | - N. S. Agarwal
- Department of Pediatrics; Weill Cornell Medical Center; New York Presbyterian Hospital; New York; NY; USA
| | | | - Y.-X. Zhi
- Department of Allergy, Peking Union Medical College Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing; China
| | - T. J. Craig
- Division of Pulmonary, Allergy and Critical Care; Medicine and Pediatrics; Milton S. Hershey Medical Center; Penn State University; Hershey; PA; USA
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Abstract
Hereditary Angioedema (HAE) is a rare disease and for this reason proper diagnosis and appropriate therapy are often unknown or not available for physicians and other health care providers. For this reason we convened a group of specialists that focus upon HAE from around the world to develop not only a consensus on diagnosis and management of HAE, but to also provide evidence based grades, strength of evidence and classification for the consensus. Since both consensus and evidence grading were adhered to the document meets criteria as a guideline. The outcome of the guideline is to improve diagnosis and management of patients with HAE throughout the world and to help initiate uniform care and availability of therapies to all with the diagnosis no matter where the residence of the individual with HAE exists.
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Li HH, Campion M, Craig TJ, Soteres DF, Riedl M, Lumry WR, MacGinnitie AJ, Shea EP, Bernstein JA. Analysis of hereditary angioedema attacks requiring a second dose of ecallantide. Ann Allergy Asthma Immunol 2013; 110:168-72. [PMID: 23548526 DOI: 10.1016/j.anai.2012.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/30/2012] [Accepted: 12/09/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Effective treatment of acute attacks is critical in managing hereditary angioedema (HAE). Ecallantide, a plasma kallikrein inhibitor, is approved for the treatment of HAE attacks. Occasionally, a second dose is needed when treating attacks of HAE. OBJECTIVE To evaluate the characteristics of HAE attacks requiring a second dose (dose B) of ecallantide. METHODS Data from all ecallantide clinical trials (EDEMA2, EDEMA4, and DX-88/19) that allowed an open-label dose B were included in this analysis. Patient and attack characteristics potentially predictive of dose B after ecallantide were analyzed by logistic regression. A multivariate model was built using a backward selection process, incorporating variables from the univariate model with P < .20 and removing factors with the highest P value until only significant (P < .05) factors remained. RESULTS The analysis included 732 ecallantide-treated HAE attacks in 179 patients. Dose B was required in 88 attacks (12.0%), most (80.5%) for incomplete response. By attack location, 31 of 325 abdominal attacks (9.5%), 17 of 158 laryngeal attacks (10.8%), and 40 of 242 peripheral attacks (16.5%) required dose B. On the basis of the univariate analysis, baseline severity (odds ratio = 1.33, P = .15) and peripheral attack (odds ratio = 1.80, P = .01) were identified as potential predictive factors; abdominal attacks had an inverse correlation (odds ratio = 0.64, P = .055). However, the multivariate analysis identified only peripheral attacks as statistically significantly correlated (P < .05) with dose B requirement. CONCLUSION A single, 30-mg dose of ecallantide was effective for most HAE attacks (88.0%). Patients with peripheral attacks of HAE were more likely to require a second dose of ecallantide after 4 hours. TRIAL REGISTRATION clinicaltrials.gov Identifiers: not applicable for EDEMA2 (trial was conducted before registration requirements were implemented), NCT00457015 for EDEMA4, and NCT00456508 for DX-88/19.
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Affiliation(s)
- H Henry Li
- Institute for Asthma and Allergy, Wheaton, MD 20902, USA.
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Martello JL, Woytowish MR, Chambers H. Ecallantide for treatment of acute attacks of hereditary angioedema. Am J Health Syst Pharm 2012; 69:651-7. [PMID: 22472866 DOI: 10.2146/ajhp110227] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The pharmacology, pharmacokinetics, efficacy, safety, dosage, administration, adverse effects, and place in therapy of ecallantide, a kallikrein inhibitor for the treatment of hereditary angioedema (HAE), are reviewed. SUMMARY Ecallantide is the first member of the kallikrein inhibitor class approved for the treatment of acute attacks of HAE. Ecallantide works by binding to kallikrein, preventing the conversion of kininogen to bradykinin, which reduces vascular permeability, thus reducing the swelling associated with acute attacks of HAE. Ecallantide has been studied for the treatment of HAE in three Phase II studies and two Phase III studies. These studies were collectively known as the EDEMA (Evaluation of DX-88's Effect in Mitigating Angioedema) studies. Phase III clinical trials found that ecallantide is superior to placebo in ameliorating patient symptoms associated with acute attacks of HAE at any anatomical site. Ecallantide has a favorable safety profile, with the most common adverse effects being gastrointestinal effects, headache, and injection site reactions. The most severe adverse effects of ecallantide are the risk of anaphylaxis and the possible development of antiecallantide antibodies. A risk evaluation and mitigation strategy program has been approved by the Food and Drug Administration to help ensure the safety and efficacy of ecallantide use. The recommended dose is 30 mg given as three separate subcutaneous injections. CONCLUSION Ecallantide is a novel agent approved for the treatment of acute attacks of HAE at any anatomical site. It is one of only three medications approved for this indication in the United States, presents a unique mechanism of action, and appears to be safe and effective when used for its labeled indication.
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Affiliation(s)
- Jay L Martello
- School of Pharmacy, West Virginia University, Morgantown, WV 26506, USA.
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Stolz LE, Sheffer AL. Prospective, double-blind, placebo-controlled trials of ecallantide for acute attacks of hereditary angioedema. Expert Rev Clin Immunol 2012; 8:25-32. [PMID: 22149337 DOI: 10.1586/eci.11.81] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hereditary angioedema (HAE) is a rare genetic disorder characterized by unpredictable, episodic, incapacitating attacks of well-demarcated angioedema in the absence of urticaria and pruritus. HAE is due to deficient or dysfunctional C1-esterase inhibitor activity, which results in unopposed activation of plasma kallikrein, resulting in increased levels of bradykinin. Ecallantide is a potent and specific plasma kallikrein inhibitor approved for the treatment of acute attacks of HAE affecting any anatomic site. In Phase III clinical trials, subcutaneously administered ecallantide demonstrated significant, rapid and durable symptom relief. Ecallantide was effective for all attack types, including potentially life-threatening laryngeal attacks. The main safety concern is potentially serious hypersensitivity reactions, including anaphylaxis. Ecallantide represents an important treatment option for the management of acute attacks of HAE.
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Abstract
Hereditary angio-oedema is caused by a heterozygous deficiency of C1 inhibitor. This inhibitor regulates several inflammatory pathways, and patients with hereditary angio-oedema have intermittent cutaneous or mucosal swellings because of a failure to control local production of bradykinin. Swellings typically evolve in several hours and persist for a few days. In addition to orofacial angio-oedema, painless swellings affect peripheries, which causes disfigurement or interference with work and other activities of daily living. Angio-oedema affecting the gastrointestinal tract or abdominal viscera causes severe pain often with vomiting due to oedematous bowel obstruction. About 2% of swellings involve the larynx and can be fatal if untreated. About 50% of patients have laryngeal swellings that are potentially fatal despite prophylaxis. In this Seminar we review the clinical features, diagnosis, and management of hereditary angio-oedema, with specific emphasis on the new treatments available for acute swellings.
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Affiliation(s)
- Hilary Longhurst
- Department of Immunology, Barts and The London National Health Service Trust, Whitechapel, London, UK.
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Caballero T, Farkas H, Bouillet L, Bowen T, Gompel A, Fagerberg C, Bjökander J, Bork K, Bygum A, Cicardi M, de Carolis C, Frank M, Gooi JH, Longhurst H, Martínez-Saguer I, Nielsen EW, Obtulowitz K, Perricone R, Prior N. International consensus and practical guidelines on the gynecologic and obstetric management of female patients with hereditary angioedema caused by C1 inhibitor deficiency. J Allergy Clin Immunol 2012; 129:308-20. [DOI: 10.1016/j.jaci.2011.11.025] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 10/27/2011] [Accepted: 11/21/2011] [Indexed: 10/14/2022]
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Cicardi M, Bork K, Caballero T, Craig T, Li HH, Longhurst H, Reshef A, Zuraw B. Evidence-based recommendations for the therapeutic management of angioedema owing to hereditary C1 inhibitor deficiency: consensus report of an International Working Group. Allergy 2012; 67:147-57. [PMID: 22126399 DOI: 10.1111/j.1398-9995.2011.02751.x] [Citation(s) in RCA: 270] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Angioedema owing to hereditary deficiency of C1 inhibitor (HAE) is a rare, life-threatening, disabling disease. In the last 2 years, the results of well-designed and controlled trials with existing and new therapies for this condition have been published, and new treatments reached the market. Current guidelines for the treatment for HAE were released before the new trials and before the new treatments became available and were essentially based on observational studies and expert opinion. To provide evidence-based HAE treatment guidelines supported by the new studies, a conference was held in Gargnano del Garda, Italy, from September 26 to 29, 2010. The meeting hosted 58 experienced HAE expert physicians, representatives of pharmaceutical companies and representatives of HAE patients' associations. Here, we report the topics discussed during the meeting and evidence-based consensus about management approaches for HAE in adult/adolescent patients.
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Affiliation(s)
- M Cicardi
- Dipartimento di Scienze Cliniche "Luigi Sacco", Università di Milano, Ospedale L. Sacco, Milano, Italy.
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Affiliation(s)
- Jerry G. Webb
- Department of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston, South Carolina
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Abstract
CONTEXT Hereditary angioedema (HAE) is a rare autosomal-dominant disease characterized by recurrent self-limiting episodes of skin and mucosal edema. Morbidity and mortality are significant, and new and pending therapies are now available to reduce the risk associated with the disease. OBJECTIVE To update the reader on new advances in HAE to improve patient care. METHODS We performed a literature search of Ovid, PubMed, and Google to develop this review. Articles that are necessary for the understanding and use of the new therapeutic options for HAE were chosen, and studies of high quality were used to support the use of therapies, and in most cases, results from phase III studies were used. RESULTS Until recently, therapy for HAE attacks in the United States consisted of symptom relief with narcotics, hydration, and fresh-frozen plasma, which contains active C1 inhibitor. Therapy to prevent HAE attacks has been confined to androgens and, occasionally, antifibrinolytic agents; however, both drug groups have significant adverse effects. The approval of C1-inhibitor concentrate for prevention and acute therapy has improved efficacy and safety. Ecallantide has also been approved for therapy of attacks, and icatibant is expected to be approved in the next few months for attacks. Recombinant C1 inhibitor is presently in phase III studies and should be available for attacks in the near future. CONCLUSION In this article we review the changing therapeutic options available for patients in 2011 and beyond.
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Affiliation(s)
- Niti Sardana
- Department of Pediatrics, Weill Cornell Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
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Abstract
Hereditary angioedema (HAE) is characterized by acute attacks of edema with multiple localizations, the laryngeal angioedema being the most potentially lethal. In HAE, C1-INH impairments cause episodic increase in kallikrein activity leading to attacks of angioedema. Several therapies have recently become available to treat or to prevent HAE attacks, and others are under evaluation for this indication. Plasma-derived C1-INH, bradykinin receptor antagonists (icatibant), kallikrein inhibitors (ecallantide), or recombinant C1-INH is authorized on the market for HAE attack therapy or prophylaxis. Some of these compounds can be used exclusively to treat HAE attacks, whereas others can also be used as prophylactic therapies. Such therapies, although not available worldwide, can improve disease outcome due to their different mechanisms of action.
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Maurer M, Bader M, Bas M, Bossi F, Cicardi M, Cugno M, Howarth P, Kaplan A, Kojda G, Leeb-Lundberg F, Lötvall J, Magerl M. New topics in bradykinin research. Allergy 2011; 66:1397-406. [PMID: 21859431 DOI: 10.1111/j.1398-9995.2011.02686.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Bradykinin has been implicated to contribute to allergic inflammation and the pathogenesis of allergic conditions. It binds to endothelial B(1) and B(2) receptors and exerts potent pharmacological and physiological effects, notably, decreased blood pressure, increased vascular permeability and the promotion of classical symptoms of inflammation such as vasodilation, hyperthermia, oedema and pain. Towards potential clinical benefit, bradykinin has also been shown to exert potent antithrombogenic, antiproliferative and antifibrogenic effects. The development of pharmacologically active substances, such as bradykinin receptor blockers, opens up new therapeutic options that require further research into bradykinin. This review presents current understanding surrounding the role of bradykinin in nonallergic angioedema and other conditions seen by allergists and emergency physicians, and its potential role as a therapeutic target.
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Affiliation(s)
- M Maurer
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité- Universitätsmedizin, Berlin, Germany.
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Prematta MJ, Prematta T, Craig TJ. Treatment of hereditary angioedema with plasma-derived C1 inhibitor. Ther Clin Risk Manag 2011; 4:975-82. [PMID: 19209279 PMCID: PMC2621399 DOI: 10.2147/tcrm.s3172] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Plasma-derived C1 inhibitor (C1-INH) concentrate is a treatment option for acute hereditary angioedema (HAE) attacks and is considered the standard-of-care in many countries, although it is not yet available in the United States. Studies are still being conducted to establish its safety and efficacy as required by the FDA. OBJECTIVE To review the medical literature to determine if C1-INH concentrate is a safe and effective treatment for acute HAE attacks. METHODS THE FOLLOWING KEYWORDS WERE SEARCHED IN PUBMED AND OVID: C1 esterase inhibitor, C1-inhibitor, C1 inhibitor, and hereditary angioedema treatment. English-language articles were searched from 1966 to the present to look for studies demonstrating the efficacy and the safety of C1-INH concentrate. RESULTS The English-language literature search revealed several studies showing significantly improved relief of HAE symptoms with the administration of C1-INH concentrate - many studies demonstrated some improvement of symptoms within 30 minutes. Side effects have been similar to placebo, and no proven cases of viral transmission have occurred in over 20 years. CONCLUSION C1-INH concentrate appears to be a very safe and effective treatment option for HAE.
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Affiliation(s)
- Michael J Prematta
- Section of Allergy and Immunology, Penn State University, Milton S. Hershey Medical Center, PA, USA
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Affiliation(s)
- Erin Sears
- Department of Pharmacy Services, Baylor University Medical Center, Dallas, Texas
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Kolte D, Bryant J, Holsworth D, Wang J, Akbari P, Gibson G, Shariat-Madar Z. Biochemical characterization of a novel high-affinity and specific plasma kallikrein inhibitor. Br J Pharmacol 2011; 162:1639-49. [PMID: 21175583 DOI: 10.1111/j.1476-5381.2010.01170.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Kallikrein acts on high molecular weight kininogen (HK) to generate HKa (cleaved HK) and bradykinin (BK). BK exerts its effects by binding to B(2) receptors. The activation of B(2) receptors leads to the formation of tissue plasminogen activator, nitric oxide (NO) and prostacyclin (PGI(2) ). An elevated kallikrein-dependent pathway has been linked to cardiovascular disease risk. The aim of this study was to investigate whether our novel plasma kallikrein inhibitor abolishes kallikrein-mediated generation of BK from HK and subsequent BK-induced NO and PGI(2) formation, thereby influencing endothelial pathophysiology during chronic inflammatory diseases. EXPERIMENTAL APPROACH Kinetic analysis was initially used to determine the potency of PF-04886847. Biochemical ligand binding assays, immunological methods and calcium flux studies were used to determine the selectivity of the kallikrein inhibitor. In addition, the effect of PF-04886847 on BK-induced relaxation of the rat aortic ring was determined in a model of lipopolysaccharide-induced tissue inflammation. KEY RESULTS Evidence was obtained in vitro and in situ, indicating that PF-04886847 is a potent and specific inhibitor of plasma kallikrein. PF-04886847 efficiently blocked calcium influx as well as NO and PGI(2) formation mediated through the BK-stimulated B(2) receptor signalling pathway. PF-04886847 blocked kallikrein-induced endothelial-dependent relaxation of isolated rat aortic rings pre-contracted with phenylephrine. CONCLUSIONS AND IMPLICATIONS PF-04886847 was shown to be the most potent small molecule inhibitor of plasma kallikrein yet described; it inhibited kallikrein in isolated aortic rings and cultured endothelial cells. Overall, our results indicate that PF-04886847 would be useful for the treatment of kallikrein-mediated inflammatory disorders.
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Affiliation(s)
- D Kolte
- Department of Pharmacology, School of Pharmacy, University of Mississippi, University, MS, USA CVMED Exploratory, Pfizer Global Research and Development, Groton, CT, USA
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Sheffer AL, Campion M, Levy RJ, Li HH, Horn PT, Pullman WE. Ecallantide (DX-88) for acute hereditary angioedema attacks: Integrated analysis of 2 double-blind, phase 3 studies. J Allergy Clin Immunol 2011; 128:153-159.e4. [DOI: 10.1016/j.jaci.2011.03.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 02/24/2011] [Accepted: 03/01/2011] [Indexed: 10/18/2022]
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Farkas H, Varga L. Ecallantide is a novel treatment for attacks of hereditary angioedema due to C1 inhibitor deficiency. Clin Cosmet Investig Dermatol 2011; 4:61-8. [PMID: 21760740 PMCID: PMC3133501 DOI: 10.2147/ccid.s10322] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Indexed: 11/23/2022]
Abstract
Hereditary angioedema (HAE) resulting from the deficiency of the C1 inhibitor protein is a rare disease, characterized by paroxysms of edema formation in the subcutis and in the submucosa. Edema can cause obstruction of the upper airway, which may lead to suffocation. Prompt elimination of edema is necessary to save patients from this life-threatening condition. Essentially, these edematous attacks are related to the activation of the kinin-kallikrein system and the consequent release of bradykinin. Ecallantide (known as DX-88 previously), a potent and specific inhibitor of plasma kallikrein is an innovative medicinal product. This is the only agent approved recently by the FDA for all localizations of edematous HAE attacks. Its advantages include no risk of viral contamination, high selectivity, very rapid onset of action, good tolerability, and straightforward subcutaneous administration. Owing to the risk of anaphylaxis, ecallantide should be administered by a health care professional. A postmarketing survey to improve risk-assessment and risk-minimization has been launched. The results of these studies may lead to the approval of ecallantide for self-administration.
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Affiliation(s)
- Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
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Abstract
Hereditary angioedema (HAE) is a clinical disorder characterized by a deficiency of C1 esterase inhibitor (C1-INH). HAE has traditionally been divided into two subtypes. Unique among the inherited deficiencies of the complement system, HAE Types I and II are inherited as an autosomal dominant disorder. The generation of an HAE attack is caused by the depletion and/or consumption of C1-inhibitor manifested as subcutaneous or submucosal edema of the upper airway, face, extremities, or gastrointestinal tract mediated by bradykinin. Attacks can be severe and potentially life-threatening, particularly with laryngeal involvement and treatment of acute attacks in the United States has been severely limited. In December 2009 the FDA approved ecallantide for the treatment of acute HAE attacks. Ecallantide is a small recombinant protein acting as a potent, specific and reversible inhibitor of plasma kallikrein which binds to plasma kallikrein blocking its binding site, directly inhibiting the conversion of high molecular weight kininogen to bradykinin. Administered subcutaneously, ecallantide was demonstrated in two clinical trials, EDEMA3 and EDEMA4, to decrease the length and severity of acute HAE attacks. Although there is a small risk for anaphylaxis, which limits home administration, ecallantide is a novel, safe, effective and alternative treatment for acute HAE attacks.
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Affiliation(s)
- Michael Lunn
- Penn State Hershey Section of Allergy and Immunology, Hershey, PA 17033, USA
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Kaplan AP. Enzymatic pathways in the pathogenesis of hereditary angioedema: The role of C1 inhibitor therapy. J Allergy Clin Immunol 2010; 126:918-25. [DOI: 10.1016/j.jaci.2010.08.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 06/24/2010] [Accepted: 08/05/2010] [Indexed: 11/24/2022]
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