Successful hereditary angioedema prophylaxis with C1 inhibitor in orthognathic surgery

Hereditary angioedema: Report of the dental treatment of 12 Brazilian patients

OBJECTIVE

The aim of this study was to report on clinical experience in Brazil in the dental treatment and the oral conditions of a group of patients with hereditary angioedema (HAE).

STUDY DESIGN

The study analyzed demographic data, type of HAE, intensity of attacks, long-term and short-term prophylaxis, dental procedures, and occurrence of crises after the procedures were performed. Radiographic evaluation of the number of teeth and bone loss was also performed.

RESULTS

Data from 12 patients were collected; most were women, presenting with C1-INH-HAE type I and a history of severe attacks. All patients reported use of regular medications (long-term prophylaxis), mostly attenuated androgens, to prevent/attenuate HAE attacks. These patients had several missing teeth and alveolar bone loss. Tooth extraction was the most common procedure. In half the patients, the procedures had been performed without modification in long-term prophylaxis. The others were treated with an additional prophylaxis protocol (short-term prophylaxis), particularly those who underwent tooth extraction. None of the study patients developed HAE attacks after dental procedures.

CONCLUSION

The occurrence and intensity of a possible HAE attack after dental procedures are unpredictable, but with careful preliminary screening by dental and immunology teams and the use of therapeutic prophylaxis, the risk could be minimized.

Orthognathic Surgery in Hereditary Angioedema With Normal C1 Inhibitor: A Clinical Response to Concentrated C1 Inhibitor Against Angioedema Attack

Hereditary angioedema (HAE) is a rare autosomal dominant disorder characterized by episodes of localized swelling, often of life-threatening severity. HAE due to C1 inhibitor (C1-INH) deficiency is common and is divided into types 1 and 2, but HAE with normal C1-INH is exceedingly rare. Herein, we describe the case of a patient with HAE with normal C1-INH undergoing orthognathic surgery. A 24-year-old woman came to our hospital with a diagnosed jaw deformity and commenced preoperative orthodontic treatment before scheduled orthognathic surgery. During the preoperative period, she experienced mild hoarseness. The hoarseness worsened, and computed tomography revealed mild laryngeal edema. Serum C1-INH, C3, C4, and CH50 levels were normal. Her younger sister had reportedly experienced a similar episode of lip edema previously. These findings supported a diagnosis of HAE with normal C1-INH. She underwent orthognathic surgery in close consultation with a hematologist and anesthesiologist at the age of 33 years. The surgery was completed without complications. She reported throat tightness 4 days after surgery, although her facial swelling was consistent with the procedure performed and was not remarkable. Concentrated C1-INH was administered, and the throat tightness slowly resolved within approximately 1 hour. Twenty-five days after surgery, she was discharged with reduced facial swelling. In the present case, orthognathic surgery was performed successfully in a patient with the exceedingly rare condition of HAE with normal C1-INH, in close consultation with a hematologist and an anesthesiologist. Postoperative throat tightness was successfully treated via the administration of concentrated C1-INH. Concentrated C1-INH administration can be considered in patients with HAE and normal C1-INH who experience angioedemic attack, keeping in mind that it may be slow to take effect.

Management of patients with hereditary angio-oedema in dental, oral, and maxillofacial surgery: a review

Hereditary angio-oedema (HEA) is an autosomal dominant, life-threatening genetic disorder that is caused by insufficiency or dysfunction of the C1 esterase inhibitor that develops coincidentally with recurrent oedema in the skin, internal organs, and upper respiratory tract. Increased production of bradykinin secondary to increased plasma kallikrein activity is the primary cause of attacks. Dental procedures cause emotional stress and mechanical trauma and may also initiate attacks. The most feared complication is asphyxiation as a result of laryngeal oedema. Cases that resulted in death after tooth extraction have been reported, so dentists and oral and maxillofacial surgeons should take maximum care in the treatment of patients with HAO, consult with the patient's doctor, and ensure that prophylaxis is given before the procedure. They should work as atraumatically as possible and use procedures to minimise stress. In the event of an attack of HAO, despite all the correct measures having been taken, the procedure should be terminated immediately and treatment of the attack started as soon as possible. The first drugs for the treatment of acute attacks are C1-INH (C1 inhibitor), ecallantide, or icatibant.

Angioedema: Classification, management and emerging therapies for the perioperative physician

Angioedema is a rare condition which manifests as sudden localised, non-pitting swelling of certain body parts including skin and mucous membranes. It is vital that anaesthesiologists understand this condition, as it may present suddenly in the perioperative period with airway compromise. To identify literature for this review, the authors searched the PubMed, Medline, Embase, Scopus and Web of Science databases for English language articles covering a 10-year period, 2006 through 2016. Angioedema can be either mast-cell mediated or bradykinin-induced. Older therapies for histaminergic symptoms are well known to anaesthesiologists (e.g., adrenaline, anti-histamines and steroids), whereas older therapies for bradykinin-induced symptoms include plasma and attenuated androgens. New classes of drugs for bradykinin-induced symptoms are now available, including anti-bradykinin, plasma kallikrein inhibitor and C1 esterase inhibitors. These can be used prophylactically or as rescue medications. Anaesthesiologists are in a unique position to coordinate perioperative care for this complex group of patients.

Plasma-derived C1-INH for managing hereditary angioedema in pediatric patients: A systematic review

Presently, medications approved for children with Hereditary Angioedema (HAE) are extremely limited. This is especially the case for children under 12 years of age. For this reason we reviewed and summarized the data on treatment of children with HAE. Available data indicate that plasma derived C1-inhibitor is a safe, effective treatment option for HAE in pediatric patients, including those below 12 years of age. Other therapies are also appear safe for the under 12 year of age, but less data are available. Importantly, home-based treatment of HAE in this age group appears to be safe and effective and can improve quality of life. These findings support current HAE consensus guidelines which strongly recommend the use of plasma derived C1-inhibitor as a first-line treatment in children and encourage home and self-treatment.

Perioperative management for patients with hereditary angioedema

Hereditary angioedema (HAE) is a rare autosomal dominant disease that results from mutations in the C1-esterase inhibitor (C1-INH) gene. HAE is characterized by recurrent episodes of angioedema of the skin (face, extremities, genitalia, trunk), the gastrointestinal tract, and respiratory tract. Symptoms experienced can be debilitating, may impact quality of life, and can be life threatening. Preventing attacks particularly for patients undergoing procedures is critical. Patients with HAE may now treat acute attacks or prevent attacks with medications that have recently become available in the United States; however, these same medications can be used for perioperative management for patients undergoing medical, surgical, and dental procedures. Periprocedural planning is important for patients to reduce the incidence of acute attacks. Education is critical and increasing awareness of short-term prophylaxis options will allow providers to develop an appropriate action plan for their patients. The goal of this review is to increase awareness for HAE treating physicians, surgeons, anesthesia, and emergency room physicians by examining the available treatment options, researching the literature, and summarizing available data for periprocedural management. The availability of treatment options has increased over the past few years, expanding options for physicians and patients living with HAE and improve safety during the perioperative period and at the time of other procedures.