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Petersen RS, Fijen LM, Levi M, Cohn DM. Hereditary Angioedema: The Clinical Picture of Excessive Contact Activation. Semin Thromb Hemost 2024; 50:978-988. [PMID: 36417927 PMCID: PMC11407848 DOI: 10.1055/s-0042-1758820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hereditary angioedema is a rare, genetic disorder characterized by painful, debilitating and potentially life-threatening angioedema attacks in subcutaneous and submucosal tissue. While usually unpredictable, attacks can be provoked by a variety of triggers including physical injury and certain medication and are often preceded by prodromal symptoms. Hereditary angioedema has a profound influence on the patients' lives. The fundamental cause of hereditary angioedema in almost all patients is a mutation in the SERPING1 gene leading to a deficiency in C1-inhibitor. Subsequently, the contact activation cascade and kallikrein-kinin pathway are insufficiently inhibited, resulting in excessive bradykinin production triggering vascular leakage. While C1-inhibitor is an important regulator of the intrinsic coagulation pathway, fibrinolytic system and complement cascade, patients do not have an increased risk of coagulopathy, autoimmune conditions or immunodeficiency disorders. Hereditary angioedema is diagnosed based on C1-inhibitor level and function. Genetic analysis is only required in rare cases where hereditary angioedema with normal C1-inhibitor is found. In recent years, new, highly specific therapies have greatly improved disease control and angioedema-related quality of life. This article reviews the clinical picture of hereditary angioedema, the underlying pathophysiology, diagnostic process and currently available as well as investigational therapeutic options.
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Affiliation(s)
- Remy S Petersen
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Lauré M Fijen
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Marcel Levi
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Danny M Cohn
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
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Ritter AMV, Silva S, de Paula R, Senra J, Carvalho F, Ribeiro T, Valle SOR. A real-world study of hereditary angioedema patients due to C1 inhibitor deficiency treated with danazol in the Brazilian Public Health System. Front Med (Lausanne) 2024; 11:1343547. [PMID: 39309672 PMCID: PMC11414478 DOI: 10.3389/fmed.2024.1343547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 07/15/2024] [Indexed: 09/25/2024] Open
Abstract
Introduction Hereditary angioedema (HAE) due to C1 inhibitor (C1-INH) deficiency is an ultra-rare autosomal dominant inherited disease that affects 1 in 67,000 people in the world. The attacks are based on subcutaneous and submucosal edema that can lead to death if not properly managed. Considering the lack of information on the clinical management of Brazilian patients with HAE, this study aimed to identify and characterize patients with HAE-C1-INH that used danazol prophylactic treatment in the Brazilian Public Health System (SUS) and the healthcare resource utilization (HCRU). Methods This was an observational retrospective database study with patients treated with danazol from January 2011 until December 2021 within the SUS. The HAE cohort included patients with 12 years or older with at least one record for ICD-10 D84.1, one claim for danazol record, and at least 6 months of available history in the database. Results Our study included 799 patients treated in the SUS, with a mean (SD) age at danazol initiation of 40 years (16). The number of patients with HAE showed a similar distribution over this 10-year period analyzed with the highest number of patients in 2015 (n = 509) and 2016 (n = 480). A total of 253 (32%) patients had a record of at least one attack. Of those, 45 (17.8%) had at least one procedure HAE-related hospital admission, and 128 (50.6%) had at least one HAE-related hospital admission. The mean (SD) hospitalization length of stay was 5 (8) days. Over 14% (n = 36) of HAE patients with attack (n = 253) had at least one HAE-related ICU admission. Conclusion This database study is the strategy used to allow us to find and describe the characteristics of patients with HAE who use danazol for long-term prophylaxis in the SUS and identify HCRU outcomes of interest such as hospitalizations, inpatient, and outpatient settings. The high rate of attacks, hospitalizations, and general resource uses highlights the necessity to increase awareness of new strategies and accurate approaches to treat HAE patients. Therefore, our findings are important indicators that our health system and guidelines need to be revised and improved to properly diagnose, treat, and assist patients with HAE.
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Do T, Riedl MA. Current and Emerging Therapeutics in Hereditary Angioedema. Immunol Allergy Clin North Am 2024; 44:561-576. [PMID: 38937016 DOI: 10.1016/j.iac.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Angioedema is characterized by transient movement of fluid from the vasculature into the interstitial space leading to subcutaneous or submucosal non-pitting edema. Current evidence suggests that most angioedema conditions can be grouped into 2 categories: mast cell-mediated (previously termed histaminergic) or bradykinin-mediated angioedema. Although effective therapies for mast cell-mediated angioedema have existed for decades, specific therapies for bradykinin-mediated angioedema have more recently been developed. In recent years, rigorous studies of these therapies in treating hereditary angioedema (HAE) have led to regulatory approvals of medication for HAE management thereby greatly expanding HAE treatment options.
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Affiliation(s)
- Toan Do
- Division of Allergy & Immunology, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Marc A Riedl
- Division of Allergy & Immunology, University of California, San Diego, 8899 University Center Lane, Suite 230, La Jolla, CA 92122, USA.
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Sarkar A, Nwagwu C, Craig T. An Overview of Hereditary Angioedema for the Primary Care Physician. Med Clin North Am 2024; 108:747-755. [PMID: 38816115 DOI: 10.1016/j.mcna.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Hereditary angioedema is a rare autosomal dominant condition characterized by episodes of swelling of the upper airway, intestines, and skin. The disorder is characterized by deficiency in C1 esterase inhibitor (C1-INH) or a decrease in functional C1-INH. Treatment options include on demand therapy (treatment of acute attacks), long-term prophylaxis, and short-term prophylaxis. Corticosteroids, epinephrine, and antihistamines are not effective for this form of angioedema. The high mortality in patients undiagnosed underscores a need for broader physician awareness to identify these patients and initiate therapy.
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Affiliation(s)
- Arindam Sarkar
- Department of Family and Community Medicine, Baylor College of Medicine, 1100 West 34th Street, Houston, TX 77007, USA.
| | - Crystal Nwagwu
- Department of Family and Community Medicine, Baylor College of Medicine, 1100 West 34th Street, Houston, TX 77007, USA
| | - Timothy Craig
- Pediatrics and Biomedical Sciences, Penn State University, 500 University Drive, Hershey, PA 17033, USA
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Kumar Jindal A, Basu S, Tyagi R, Barman P, Sil A, Chawla S, Kaur A, Tyagi R, Jangra I, Machhua S, Sendhil Kumaran M, Dogra S, Vinay K, Bishnoi A, Sharma R, Garg R, Saka R, Suri D, Pandiarajan V, Pilania R, Dhaliwal M, Sharma S, Rawat A, Singh S. Delay in diagnosis is the most important proximate reason for mortality in hereditary angio-oedema: our experience at Chandigarh, India. Clin Exp Dermatol 2024; 49:368-374. [PMID: 38039144 DOI: 10.1093/ced/llad428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Hereditary angio-oedema (HAE) is a rare autosomal dominant disorder characterized clinically by recurrent episodes of nonpruritic subcutaneous and/or submucosal oedema. Laryngeal oedema is the commonest cause of mortality in patients with HAE. Prior to the availability of first-line treatment options for the management of HAE, mortality was as high as 30%. Mortality has significantly declined in countries where first-line treatment options are available and patients can access these therapies. There is a paucity of literature on the outcomes of patients with HAE in developing countries where availability of and access to first-line treatment options are still a challenge. OBJECTIVES To report our experience on mortality in patients with HAE and to report factors associated with the death of these patients. METHODS We carried out a record review of all patients diagnosed with HAE between January 1996 and August 2022. Families with HAE who had reported the death of at least one family member/relative from laryngeal oedema were studied in detail. RESULTS Of the 65 families (170 patients) registered in the clinic, 16 families reported the death of at least one family member/relative from laryngeal oedema (total of 36 deaths). Of these 16 families, 14 reported that 1 or more family members had experienced at least 1 attack of laryngeal oedema. One patient died during follow-up when she was taking long-term prophylaxis with stanozolol and tranexamic acid, while the remaining 35 patients were not diagnosed with HAE at the time of their death. At the time of death of all 36 patients, at least 1 other family member had symptoms suggestive of HAE, but the diagnosis was not established for the family. CONCLUSIONS To our knowledge, this is the largest single-centre cohort of patients with HAE in India reporting mortality data and factors associated with death in these families. The delay in diagnosis is the most important reason for mortality.
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Affiliation(s)
- Ankur Kumar Jindal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Suprit Basu
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Reva Tyagi
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prabal Barman
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Archan Sil
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanchi Chawla
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anit Kaur
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rahul Tyagi
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Isheeta Jangra
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanghamitra Machhua
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Muthu Sendhil Kumaran
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Keshavamurthy Vinay
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anuradha Bishnoi
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajni Sharma
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravinder Garg
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ruchi Saka
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vignesh Pandiarajan
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Pilania
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manpreet Dhaliwal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saniya Sharma
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Peter JG, Desai B, Tomita D, Collis P, Stobiecki M. Assessment of HAE prophylaxis transition from androgen therapy to berotralstat: A subset analysis of the APeX-S trial. World Allergy Organ J 2023; 16:100841. [PMID: 38020288 PMCID: PMC10665923 DOI: 10.1016/j.waojou.2023.100841] [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: 12/02/2022] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Given the recent approval of oral berotralstat in several countries for hereditary angioedema (HAE) prophylaxis, transition from long-term androgens to berotralstat may occur in clinical practice. The open-label, Phase II APeX-S trial provided an opportunity to assess the safety and effectiveness of berotralstat in patients previously treated with differing durations of androgens and shorter transition periods. Therefore, we examined the safety, effectiveness, and impact on quality of life of berotralstat after prior androgen use in patients from the APeX-S trial. Alanine aminotransferase (ALT) elevations were also examined because of the association with androgen exposure and hepatic function impairment. Methods We conducted an analysis of a subset of 39 patients from the APeX-S trial aged ≥12 years with HAE due to C1 inhibitor deficiency (HAE-C1-INH) with prior androgen use who discontinued androgen therapy within <60 days of receiving berotralstat. Patients received daily berotralstat (150 mg) and were divided into subgroups for this analysis based on time between androgen discontinuation and berotralstat commencement (<14 days versus 14 to <60 days). Results Berotralstat was generally well tolerated, with nasopharyngitis (21%), upper respiratory tract infection (15%), nausea (15%), diarrhea (15%), and abdominal pain (10%) being the most common adverse events occurring in ≥10% of the total subset. Only 7/145 (5%) of all APeX-S study patients with a prior history of androgen therapy experienced ALT elevations, 6 of which were grade 3 or 4 toxicities. All 7 patients recovered without sequelae and belonged to the subgroup of patients who transitioned <14 days after discontinuing androgens (n = 18). A reduction in monthly attack rate versus Month 1 was observed over 12 months for all patients who transitioned from prior androgen therapy to berotralstat prophylaxis in under 60 days, irrespective of duration of prior androgen therapy or timing of transition (N = 39). Similarly, meaningful patient-reported improvements from both Angioedema Quality of Life Questionnaire and Treatment Satisfaction Questionnaire for Medication scores were achieved, with a sustained benefit shown over the berotralstat treatment period. Conclusions Berotralstat treatment led to sustained HAE symptom control irrespective of duration of prior androgen therapy or timing of transition. Most patients safely transitioned from long-term androgens to berotralstat. Although occurring in a small group of patients, liver-related adverse events following berotralstat treatment may be associated with a shorter androgen washout period, but further research is required to confirm this. Clinical trial registration NCT03472040. Retrospectively registered March 21, 2018.
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Affiliation(s)
- Jonny G. Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | - Phil Collis
- BioCryst Pharmaceuticals, Inc., Durham, NC, USA
| | - Marcin Stobiecki
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, 10 Śniadeckich St, 31-531 Krakow, Poland
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Wilkerson RG, Winters ME. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. Immunol Allergy Clin North Am 2023; 43:513-532. [PMID: 37394257 DOI: 10.1016/j.iac.2022.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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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.
| | - Michael E Winters
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/critcareguys
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Sinnathamby ES, Issa PP, Roberts L, Norwood H, Malone K, Vemulapalli H, Ahmadzadeh S, Cornett EM, Shekoohi S, Kaye AD. Hereditary Angioedema: Diagnosis, Clinical Implications, and Pathophysiology. Adv Ther 2023; 40:814-827. [PMID: 36609679 PMCID: PMC9988798 DOI: 10.1007/s12325-022-02401-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/05/2022] [Indexed: 01/09/2023]
Abstract
Hereditary angioedema (HAE) is an autosomal dominant disorder caused by a mutation in the C1 esterase inhibitor gene. HAE affects 1/50,000 people worldwide. Three main types of HAE exist: type I, type II, and type III. Type I is characterized by a deficiency in C1-INH. C1-INH is important in the coagulation complement, contact systems, and fibrinolysis. Most HAE cases are type I. Type I and II HAE result from a mutation in the SERPING1 gene, which encodes C1-INH. Formally known as type III HAE is typically an estrogen-dependent or hereditary angioedema with normal C1-INH activity. Current guidelines now recommend subdividing hereditary angioedema with normal C1 esterase inhibitor gene (HAE-nl-C1-INH formerly known as HAE type III) based on underlying mutations such as in kininogen-1 (HAE-KNG1), plasminogen gene (PLG-HAE), myoferlin gene mutation (MYOF-HAE), heparan sulfate-glucosamine 3-sulfotransferase 6 (HS3ST6), mutation in Hageman factor (factor XII), and in angiopoietin-1 (HAE-ANGPT-1). The clinical presentation of HAE varies between patients, but it usually presents with nonpitting angioedema and occasionally abdominal pain. Young children are typically asymptomatic. Those affected by HAE usually present with symptoms in their early 20s. Symptoms can arise as a result of stress, infection, or trauma. Laboratory testing shows abnormal levels of C1-INH and high levels of bradykinin. C4 and D-dimer levels can also be monitored if an acute HAE attack is suspected. Acute treatment of HAE can include IV infusions of C1-INH, receptor antagonists, and kallikrein inhibitors. Short- and long-term prophylaxis can also be administered to patients with HAE. First-line therapies for long-term prophylaxis also include IV infusion of C1-INH. This review aims to thoroughly understand HAE, its clinical presentation, and how to treat it.
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Affiliation(s)
- Evan S Sinnathamby
- School of Medicine, Louisiana State University Health Science Center at New Orleans, New Orleans, LA, 70112, USA.
| | - Peter P Issa
- School of Medicine, Louisiana State University Health Science Center at New Orleans, New Orleans, LA, 70112, USA
| | - Logan Roberts
- School of Medicine, Louisiana State University Health Science Center at New Orleans, New Orleans, LA, 70112, USA
| | - Haley Norwood
- School of Medicine, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Kevin Malone
- School of Medicine, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Harshitha Vemulapalli
- School of Medicine, Louisiana State University Health Science Center at New Orleans, New Orleans, LA, 70112, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
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Abstract
Hereditary angioedema is a rare autosomal dominant condition characterized by episodes of swelling of the upper airway, intestines, and skin. The disorder is characterized by deficiency in C1 esterase inhibitor (C1-INH) or a decrease in functional C1-INH. Treatment options include on demand therapy (treatment of acute attacks), long-term prophylaxis, and short-term prophylaxis. Corticosteroids, epinephrine, and antihistamines are not effective for this form of angioedema. The high mortality in patients undiagnosed underscores a need for broader physician awareness to identify these patients and initiate therapy.
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Affiliation(s)
- Arindam Sarkar
- Department of Family and Community Medicine, Baylor College of Medicine, 1100 West 34th Street, Houston, TX 77007, USA.
| | - Crystal Nwagwu
- Department of Family and Community Medicine, Baylor College of Medicine, 1100 West 34th Street, Houston, TX 77007, USA
| | - Timothy Craig
- Pediatrics and Biomedical Sciences, Penn State University, 500 University Drive, Hershey, PA 17033, USA
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Yeich A, Elhatw A, Ashoor Z, Park K, Craig T. Safety of medications for hereditary angioedema during pregnancy and lactation. Expert Opin Drug Saf 2023; 22:17-24. [PMID: 36744397 DOI: 10.1080/14740338.2023.2177269] [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: 02/07/2023]
Abstract
INTRODUCTION Hereditary Angioedema (HAE) attacks show an increased frequency and severity for pregnant and lactating females secondary to the hormonal changes. The diagnosis and management of HAE in pregnant and lactating females pose a challenge for physicians due to the rarity of the disease and the paucity of the data for specific management. AREAS COVERED In this manuscript, we discuss the diagnosis and special presentation of HAE types 1 and 2 in pregnant and lactating females, including acute management, short-term prophylaxis, long-term prophylaxis, and drugs that should be avoided. Relevant publications were found through key word search of papers indexed in both Google Scholar and PubMed on 1 July 2022. EXPERT OPINION Treatment of HAE in the past has been mainly provided by experts; however, with more medications and an increasing number of patients, knowledge of how to care for HAE patients during pregnancy and lactation is important to review. Despite approval of additional medications in many countries, plasma-derived C1-inhibitor remains the drug of first choice for treatment in this unique population. Additional research is needed to increase safe access to other therapy options. We hope that future clinical studies, registries, and databases will shed additional light on this subject.
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Affiliation(s)
- Andrew Yeich
- Department of Allergy, Asthma and Immunology, Medical Student, Penn State College of Medicine, Hershey, PA, USA
| | - Ahmed Elhatw
- Department of Allergy, Asthma and Immunology, Resident, Cairo University School of Medicine, Giza, Egypt
| | - Zaynab Ashoor
- Department of Allergy, Asthma and Immunology, Medical Student, Cairo University School of Medicine, Giza, Egypt
| | - Kristen Park
- Department of Allergy, Asthma and Immunology, Medical Student, Penn State College of Medicine, Hershey, PA, USA
| | - Timothy Craig
- Department of Allergy, Asthma, and Immunology, Professor of Medicine, Pediatrics, and Biomedical Sciences, Hershey, PA, USA
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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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Maurer M, Magerl M, Betschel S, Aberer W, Ansotegui IJ, Aygören-Pürsün E, Banerji A, Bara NA, Boccon-Gibod I, Bork K, Bouillet L, Boysen HB, Brodszki N, Busse PJ, Bygum A, Caballero T, Cancian M, Castaldo AJ, Cohn DM, Csuka D, Farkas H, Gompels M, Gower R, Grumach AS, Guidos-Fogelbach G, Hide M, Kang HR, Kaplan AP, Katelaris CH, Kiani-Alikhan S, Lei WT, Lockey RF, Longhurst H, Lumry W, MacGinnitie A, Malbran A, Martinez Saguer I, Matta Campos JJ, Nast A, Nguyen D, Nieto-Martinez SA, Pawankar R, Peter J, Porebski G, Prior N, Reshef A, Riedl M, Ritchie B, Sheikh FR, Smith WB, Spaeth PJ, Stobiecki M, Toubi E, Varga LA, Weller K, Zanichelli A, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema - The 2021 revision and update. World Allergy Organ J 2022; 15:100627. [PMID: 35497649 PMCID: PMC9023902 DOI: 10.1016/j.waojou.2022.100627] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/05/2021] [Accepted: 12/21/2021] [Indexed: 12/21/2022] Open
Abstract
Hereditary Angioedema (HAE) is a rare and disabling disease for which early diagnosis and effective therapy are critical. This revision and update of the global WAO/EAACI guideline on the diagnosis and management of HAE provides up-to-date guidance for the management of HAE. For this update and revision of the guideline, an international panel of experts reviewed the existing evidence, developed 28 recommendations, and established consensus by an online DELPHI process. The goal of these recommendations and guideline is to help physicians and their patients in making rational decisions in the management of HAE with deficient C1-inhibitor (type 1) and HAE with dysfunctional C1-inhibitor (type 2), by providing guidance on common and important clinical issues, such as: 1) How should HAE be diagnosed? 2) When should HAE patients receive prophylactic on top of on-demand treatment and what treatments should be used? 3) What are the goals of treatment? 4) Should HAE management be different for special HAE patient groups such as children or pregnant/breast feeding women? 5) How should HAE patients monitor their disease activity, impact, and control? It is also the intention of this guideline to help establish global standards for the management of HAE and to encourage and facilitate the use of recommended diagnostics and therapies for all patients.
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Affiliation(s)
- Marcus Maurer
- Institute of Allergology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Frauhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Markus Magerl
- Institute of Allergology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Frauhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | | | - Werner Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Ignacio J. Ansotegui
- Department of Allergy & Immunology, Hospital Quironsalúd Bizkaia, Bilbao-Errandio, Spain
| | - Emel Aygören-Pürsün
- Center for Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Noémi-Anna Bara
- Romanian Hereditary Angioedema Expertise Centre, Mediquest Clinical Research Center, Sangeorgiu de Mures, Romania
| | - Isabelle Boccon-Gibod
- National Reference Center for Angioedema (CREAK), Angioedema Center of Reference and Excellence (ACARE), Grenoble Alpes, France
- University Hospital, Grenoble, France
| | - Konrad Bork
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Laurence Bouillet
- National Reference Center for Angioedema (CREAK), Angioedema Center of Reference and Excellence (ACARE), Grenoble Alpes, France
- University Hospital, Grenoble, France
| | | | - Nicholas Brodszki
- Department of Pediatric Immunology, Childrens Hospital, Skåne University Hospital, Lund, Sweden
| | - Paula J. Busse
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Anette Bygum
- Clinical Institute, University of Southern Denmark, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Teresa Caballero
- Allergy Department, Hospital Universitario La Paz, IdiPaz, CIBERER U754, Madrid, Spain
| | - Mauro Cancian
- Department of Systems Medicine, University Hospital of Padua, Padua, Italy
| | | | - Danny M. Cohn
- Department of Vascular Medicine, Amsterdam UMC/University of Amsterdam, Amsterdam, the Netherlands
| | - Dorottya Csuka
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Mark Gompels
- Clinical Immunology, North Bristol NHS Trust, Bristol, United Kingdom
| | - Richard Gower
- Marycliff Clinical Research, Principle Research Solutions, Spokane, WA, United States
| | - Anete S. Grumach
- Clinical Immunology, Centro Universitario FMABC, Sao Paulo, Brazil
| | | | - Michihiro Hide
- Department of Dermatology, Hiroshima Citizens Hospital, Hiroshima, Japan
- Department of Dermatology, Hiroshima University, Hiroshima, Japan
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Allen P. Kaplan
- Division of Pulmonary, Critical Care, Allergy and Immunology, Medical University of South Carolina, Charleston, SC, United States
| | - Constance H. Katelaris
- Department of Medicine, Campbelltown Hospital and Western Sydney University, Sydney, NSW, Australia
| | | | - Wei-Te Lei
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Richard F. Lockey
- Division of Allergy and Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Hilary Longhurst
- Department of Immunology, Auckland District Health Board and Department of Medicine, University of Auckland, Auckland, New Zealand
| | - William Lumry
- Internal Medicine, Allergy Division, University of Texas Health Science Center, Dallas, TX, United States
| | - Andrew MacGinnitie
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Alejandro Malbran
- Unidad de Alergia, Asma e Inmunología Clínica, Buenos Aires, Argentina
| | | | | | - Alexander Nast
- Department of Dermatology, Venereology and Allergology, Division of Evidence-Based Medicine Charité–Universitätsmedizin, Berlin, Germany
- Corporate Member of Free University of Berlin, Humboldt University of Berlin, Berlin Institute of Health, Berlin, Germany
| | - Dinh Nguyen
- Respiratory, Allergy and Clinical Immunology Unit, Internal Medicine Department, Vinmec Healthcare System, College of Health Sciences, VinUniversity, Hanoi, Viet Nam
| | | | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Jonathan Peter
- Division of Allergy and Clinical Immunology, University of Cape Town, Cape Town, South Africa
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Nieves Prior
- Allergy, Hospital Universitario Severo Ochoa, Madrid, Spain
| | - Avner Reshef
- Angiedema Center, Barzilai University Medical Center, Ashkelon, Israel
| | - Marc Riedl
- Division of Rheumatology, Allergy and Immunology, University of California San Diego, La Jolla, CA, USA
| | - Bruce Ritchie
- Departments of Medicine and Medical Oncology, University of Alberta, Edmonton, AB, Canada
| | - Farrukh Rafique Sheikh
- Section of Adult Allergy & Immunology, Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - William B. Smith
- Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Peter J. Spaeth
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Marcin Stobiecki
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Elias Toubi
- Division of Allergy and Clinical Immunology, Bnai Zion Medical Center, Affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Lilian Agnes Varga
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Karsten Weller
- Institute of Allergology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Frauhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Andrea Zanichelli
- Department of Internal Medicine, ASST Fatebenefratelli Sacco, Ospedale Luigi Sacco-University of Milan, Milan, Italy
| | - Yuxiang Zhi
- Department of Allergy and Clinical Immunology, Bejing Union Medical College Hospital, Chinese Academy of Medical Sciences, Bejing, China
| | - Bruce Zuraw
- University of California, San Diego, San Diego, CA, United States
| | - Timothy Craig
- Departments of Medicine and Pediatrics, Penn State University, Hershey, PA, USA
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Maurer M, Magerl M, Betschel S, Aberer W, Ansotegui IJ, Aygören‐Pürsün E, Banerji A, Bara N, Boccon‐Gibod I, Bork K, Bouillet L, Boysen HB, Brodszki N, Busse PJ, Bygum A, Caballero T, Cancian M, Castaldo A, Cohn DM, Csuka D, Farkas H, Gompels M, Gower R, Grumach AS, Guidos‐Fogelbach G, Hide M, Kang H, Kaplan AP, Katelaris C, Kiani‐Alikhan S, Lei W, Lockey R, Longhurst H, Lumry WB, MacGinnitie A, Malbran A, Martinez Saguer I, Matta JJ, Nast A, Nguyen D, Nieto‐Martinez SA, Pawankar R, Peter J, Porebski G, Prior N, Reshef A, Riedl M, Ritchie B, Rafique Sheikh F, Smith WR, Spaeth PJ, Stobiecki M, Toubi E, Varga LA, Weller K, Zanichelli A, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema-The 2021 revision and update. Allergy 2022; 77:1961-1990. [PMID: 35006617 DOI: 10.1111/all.15214] [Citation(s) in RCA: 164] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 12/11/2022]
Abstract
Hereditary angioedema (HAE) is a rare and disabling disease for which early diagnosis and effective therapy are critical. This revision and update of the global WAO/EAACI guideline on the diagnosis and management of HAE provides up-to-date guidance for the management of HAE. For this update and revision of the guideline, an international panel of experts reviewed the existing evidence, developed 28 recommendations, and established consensus by an online DELPHI process. The goal of these recommendations and guideline is to help physicians and their patients in making rational decisions in the management of HAE with deficient C1 inhibitor (type 1) and HAE with dysfunctional C1 inhibitor (type 2), by providing guidance on common and important clinical issues, such as: (1) How should HAE be diagnosed? (2) When should HAE patients receive prophylactic on top of on-demand treatment and what treatments should be used? (3) What are the goals of treatment? (4) Should HAE management be different for special HAE patient groups such as children or pregnant/breast-feeding women? and (5) How should HAE patients monitor their disease activity, impact, and control? It is also the intention of this guideline to help establish global standards for the management of HAE and to encourage and facilitate the use of recommended diagnostics and therapies for all patients.
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Affiliation(s)
- Marcus Maurer
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | - Markus Magerl
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | | | - Werner Aberer
- Department of Dermatology Medical University of Graz Graz Austria
| | | | - Emel Aygören‐Pürsün
- Center for Children and Adolescents University Hospital Frankfurt Frankfurt Germany
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology Massachusetts General Hospital Boston Massachusetts USA
| | - Noémi‐Anna Bara
- Romanian Hereditary Angioedema Expertise CentreMediquest Clinical Research Center Sangeorgiu de Mures Romania
| | - Isabelle Boccon‐Gibod
- National Reference Center for Angioedema (CREAK) Angioedema Center of Reference and Excellence (ACARE) Grenoble Alpes University Hospital Grenoble France
| | - Konrad Bork
- Department of Dermatology University Medical CenterJohannes Gutenberg University Mainz Germany
| | - Laurence Bouillet
- National Reference Center for Angioedema (CREAK) Angioedema Center of Reference and Excellence (ACARE) Grenoble Alpes University Hospital Grenoble France
| | | | - Nicholas Brodszki
- Department of Pediatric Immunology Childrens HospitalSkåne University Hospital Lund Sweden
| | | | - Anette Bygum
- Clinical Institute University of Southern Denmark Odense Denmark
- Department of Clinical Genetics Odense University Hospital Odense Denmark
| | - Teresa Caballero
- Allergy Department Hospital Universitario La PazIdiPaz, CIBERER U754 Madrid Spain
| | - Mauro Cancian
- Department of Systems Medicine University Hospital of Padua Padua Italy
| | | | - Danny M. Cohn
- Department of Vascular Medicine Amsterdam UMC/University of Amsterdam Amsterdam The Netherlands
| | - Dorottya Csuka
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Henriette Farkas
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Mark Gompels
- Clinical Immunology North Bristol NHS Trust Bristol UK
| | - Richard Gower
- Marycliff Clinical ResearchPrinciple Research Solutions Spokane Washington USA
| | | | | | - Michihiro Hide
- Department of Dermatology Hiroshima Citizens Hospital Hiroshima Japan
- Department of Dermatology Hiroshima University Hiroshima Japan
| | - Hye‐Ryun Kang
- Department of Internal Medicine Seoul National University College of Medicine Seoul Korea
| | - Allen Phillip Kaplan
- Division of Pulmonary, Critical Care, Allergy and Immunology Medical university of South Carolina Charleston South Carolina USA
| | - Constance Katelaris
- Department of Medicine Campbelltown Hospital and Western Sydney University Sydney NSW Australia
| | | | - Wei‐Te Lei
- Division of Allergy, Immunology, and Rheumatology Department of Pediatrics Mackay Memorial Hospital Hsinchu Taiwan
| | - Richard Lockey
- Division of Allergy and Immunology Department of Internal Medicine Morsani College of MedicineUniversity of South Florida Tampa Florida USA
| | - Hilary Longhurst
- Department of Immunology Auckland District Health Board and Department of MedicineUniversity of Auckland Auckland New Zealand
| | - William B. Lumry
- Internal Medicine Allergy Division University of Texas Health Science Center Dallas Texas USA
| | - Andrew MacGinnitie
- Division of Immunology Department of Pediatrics Boston Children's HospitalHarvard Medical School Boston Massachusetts USA
| | - Alejandro Malbran
- Unidad de Alergia, Asma e Inmunología Clínica Buenos Aires Argentina
| | | | | | - Alexander Nast
- Department of Dermatology, Venereology and Allergology Division of Evidence‐Based Medicine Charité ‐ Universitätsmedizin Berlincorporate member of Free University of BerlinHumboldt University of Berlin, and Berlin Institute of Health Berlin Germany
| | - Dinh Nguyen
- Respiratory, Allergy and Clinical Immunology Unit Internal Medicine Department Vinmec Healthcare System College of Health SciencesVinUniversity Hanoi Vietnam
| | | | - Ruby Pawankar
- Department of Pediatrics Nippon Medical School Tokyo Japan
| | - Jonathan Peter
- Division of Allergy and Clinical Immunology University of Cape Town Cape Town South Africa
- Allergy and Immunology Unit University of Cape Town Lung Institute Cape Town South Africa
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology Jagiellonian University Medical College Krakow Poland
| | - Nieves Prior
- Allergy Hospital Universitario Severo Ochoa Madrid Spain
| | - Avner Reshef
- Angioderma CenterBarzilai University Medical Center Ashkelon Israel
| | - Marc Riedl
- Division of Rheumatology, Allergy and Immunology University of California San Diego La Jolla California USA
| | - Bruce Ritchie
- Departments of Medicine and Medical Oncology University of Alberta Edmonton AB Canada
| | - Farrukh Rafique Sheikh
- Section of Adult Allergy & Immunology Department of Medicine King Faisal Specialist Hospital & Research Centre Riyadh Saudi Arabia
| | - William R. Smith
- Clinical Immunology and Allergy Royal Adelaide Hospital Adelaide SA Australia
| | - Peter J. Spaeth
- Institute of PharmacologyUniversity of Bern Bern Switzerland
| | - Marcin Stobiecki
- Department of Clinical and Environmental Allergology Jagiellonian University Medical College Krakow Poland
| | - Elias Toubi
- Division of Allergy and Clinical Immunology Bnai Zion Medical CenterAffiliated with Rappaport Faculty of MedicineTechnion‐Israel Institute of Technology Haifa Israel
| | - Lilian Agnes Varga
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Karsten Weller
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | - Andrea Zanichelli
- Department of Internal Medicine ASST Fatebenefratelli Sacco Ospedale Luigi Sacco‐University of Milan Milan Italy
| | - Yuxiang Zhi
- Department of Allergy and Clinical Immunology Bejing Union Medical College Hospital & Chinese Academy of Medical Sciences Bejing China
| | - Bruce Zuraw
- University of California, San Diego San Diego California USA
| | - Timothy Craig
- Departments of Medicine and Pediatrics Penn State University Hershey Pennsylvania USA
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Bang YS, Cho J, Park C. An anesthetic experience of hereditary angioedema type I patient undertook total laparoscopic hysterectomy - A case report. Anesth Pain Med (Seoul) 2022; 17:235-238. [PMID: 34991189 PMCID: PMC9091676 DOI: 10.17085/apm.21088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background Hereditary angioedema (HAE) is an autosomal dominant disorder. The characteristic of HAE is recurrent angioedema episodes due to low C1 esterase inhibitor (C1-INH) level. HAE symptoms, especially those affecting oropharynx or larynx may develop respiratory distress syndrome due to impaired airway, which can be potentially fatal. Case We report a clinical case of a 57 year-old female patient, with type I HAE, scheduled for total laparoscopic hysterectomy under general endotracheal anesthesia, which was done successfully without inducing airway edema. Danazol, which increases liver synthesis of C1- INH, was administered and fresh frozen plasma (FFP), which contained C1-INH, was transfused after induction. Conclusions For HAE patients, the greatest concern is that general anesthesia can induces upper airway edema by direct mucosal irritation by the endotracheal tube. The perioperative management should include both prophylactic increase of C1-INH production and on-demand administration of C1-INH or FFP.
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Affiliation(s)
- Yun-Sic Bang
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jaeho Cho
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Chunghyun Park
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Jung JW, Park SY, Yoon SY, Kim GW, Sohn KH, Kang SY, Park HJ, Kang MK, Kim JH, Park KH, Suh DI, Lee DH, Kim SH, Kwon HS, Kang HR. Diagnosis and treatment of hereditary angioedema: An expert opinion. ALLERGY ASTHMA & RESPIRATORY DISEASE 2022. [DOI: 10.4168/aard.2022.10.2.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - So-Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sun Young Yoon
- Division of Pulmonology and Allergy, Department of Internal Medicine, Chungnam National University Sejong Hospital, Sejong, Korea
| | - Gun-Woo Kim
- Department of Internal Medicine, St. Carollo General Hospital, Suncheon, Korea
| | - Kyoung-Hee Sohn
- Division of Pulmonology and Allergy, Department of Internal Medicine, KyungHee University Medical Center, Seoul, Korea
| | - Sung-Yoon Kang
- Division of Pulmonology and Allergy, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hye Jung Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min-Kyu Kang
- Departmemt of Internal Medicine, Chungbuk National University Hospital, Chungbuk National College of Medicine, Cheongju, Korea
| | - Joo-Hee Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kyung Hee Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute for Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hun Lee
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Jindal AK, Bishnoi A, Dogra S. Hereditary Angioedema: Diagnostic Algorithm and Current Treatment Concepts. Indian Dermatol Online J 2021; 12:796-804. [PMID: 34934714 PMCID: PMC8653746 DOI: 10.4103/idoj.idoj_398_21] [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: 06/21/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/23/2022] Open
Abstract
Hereditary angioedema (HAE) is an uncommon disorder with a global prevalence of approximately 1 in 10,000 to 1 in 50,000 population. This disease is grossly underrecognized in India because of lack of awareness and/or lack of diagnostic facilities. Clinical manifestations include swelling over face, eyes, lips, hands, feet, and genitals, abdominal pain, and life-threatening laryngeal edema. HAE should be suspected in all patients who present with angioedema without wheals and who do not respond to antihistamines and/or steroids. C1 levels, C1-INH levels, and C1-INH function should be checked in all patients suspected to have HAE. C1q levels should be assessed in patients with suspected autoimmune-mediated acquired angioedema. Management of HAE constitutes the treatment of acute attack and short-term and long-term prophylaxis. Because of lack of all first-line recommended medications, the management of HAE in India is a challenging task. Patients are managed using fresh frozen plasma (acute treatment), tranexamic acid, and attenuated androgens (prophylaxis). Even though attenuated androgens have been shown to be effective in the prevention of attacks of HAE, the side effect profile especially in children and in females is a serious concern. Hence, the treatment needs to be individualized considering the risk-benefit ratio of long-term prophylaxis. In this review, we provide an overview of diagnostic strategy for patients with HAE and the current treatment concepts with emphasis on currently available treatment options in resource-constrained settings.
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Affiliation(s)
| | - Anuradha Bishnoi
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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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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Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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19
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Manning ME, Kashkin JM. Berotralstat (BCX7353) is a novel oral prophylactic treatment for hereditary angioedema: Review of phase II and III studies. Allergy Asthma Proc 2021; 42:274-282. [PMID: 34127176 DOI: 10.2500/aap.2021.42.210034] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Hereditary angioedema (HAE) is a rare genetic disorder characterized by unpredictable and potentially life-threatening episodes of swelling in various parts of the body. These attacks can be painful and debilitating, and affect a patient's quality of life. Every patient who experiences an attack should be treated with on-demand medication to mitigate attack severity and duration. Many patients with HAE also receive long-term prophylaxis to reduce the frequency and severity of edema episodes. Although long-term prophylaxis reduces the disease burden for patients with HAE, available intravenous and subcutaneous treatments are accompanied by a significant treatment burden because of the logistical, emotional, and physical challenges posed by their long-term parenteral nature. Androgens are an effective oral prophylactic treatment; however, they are associated with significant adverse events and are not suitable for all patients. Thus, the HAE community has expressed interest in the development of alternative oral prophylactic therapies for preventing HAE attacks. Objective: Here, we review the phase II and III clinical data of berotralstat (BCX7353), which was approved by the U.S. Food and Drug Administration in December 2020. Results: Berotralstat is an oral, second-generation, synthetic, small-molecule plasma kallikrein inhibitor taken once daily for the prevention of HAE attacks in patients ages ≥ 12 years. Results from the APeX studies (APeX-1 NCT02870972, APeX-2 NCT03485911, APeX-S NCT03472040, APex-J NCT03873116) demonstrated the efficacy of berotralstat as long-term prophylaxis for patients with HAE, which showed a reduction in the attack rate and on-demand medication usage. Berotralstat was well tolerated, and gastrointestinal treatment-emergent adverse events were generally mild and self-limited. Conclusion: Oral berotralstat is an effective and safe long-term prophylactic treatment for patients with HAE that will provide patients unable to tolerate parenteral therapies with the option of disease control. Berotralstat may be associated with reduced treatment burden compared with injectable therapies, highlighting the importance of patient preference with regard to the administration route of their HAE prophylactic treatment.
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Affiliation(s)
- Michael E. Manning
- From the Allergy, Asthma and Immunology Associates, Ltd., Scottsdale, Arizona; and
| | - Jay M. Kashkin
- Kashkin Allergy, Asthma and Immunology Center, Fair Lawn, New Jersey
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20
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Rosi‐Schumacher M, Shah SJ, Craig T, Goyal N. Clinical manifestations of hereditary angioedema and a systematic review of treatment options. Laryngoscope Investig Otolaryngol 2021; 6:394-403. [PMID: 34195359 PMCID: PMC8223449 DOI: 10.1002/lio2.555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/28/2021] [Accepted: 03/22/2021] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE This study systematically reviews the existing literature on the management of hereditary angioedema (HAE) and provides an update on the clinical presentation and specific therapies. METHODS A literature search of PubMed and Embase databases was conducted from start of the database to February 2021. Inclusion criteria included relevant systematic reviews, randomized control clinical trials, prospective and retrospective cohort studies, and outcomes research published in English and available in full-text. Out of 310 candidate articles, a total of 55 articles were included in our study. RESULTS The most common genetic form of HAE in up to 85% of cases is caused by low levels of C1 esterase inhibitor (C1-INH) protein, leading to a bradykinin-mediated increase in vascular permeability. During an attack of HAE, abortive treatment with C1-INH replacement is most commonly described, however, icatibant, ecallantide, or fresh frozen plasma are also used. Long-term prophylaxis in the form of C1-INH replacement (subcutaneous or intravenous), monoclonal antibodies targeting plasma kallikrein, attenuated androgens, and transexemic acid should be considered for those who suffer from frequent, severe attacks. CONCLUSION Progressively distal involvement of the upper airway, especially the larynx, has been shown to pose an increased risk of asphyxiation and death in the acute presentation of HAE. Evaluation by an otolaryngologist is often sought during the emergent clinical management of HAE; therefore, it is prudent that the consulting physician is well-versed in the prompt recognition, triage of patients, and appropriate treatment modalities. LEVEL OF EVIDENCE 1A.
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Affiliation(s)
- Mattie Rosi‐Schumacher
- Department of Otolaryngology‐Head and Neck SurgeryJacobs School of Medicine and Biomedical Sciences at The State University of New York at BuffaloBuffaloNew YorkUSA
| | - Sejal J. Shah
- Department of SurgeryPenn State College of Medicine, Penn State UniversityHersheyPennsylvaniaUSA
| | - Timothy Craig
- Department of Medicine and PediatricsPenn State College of Medicine, Penn State UniversityHersheyPennsylvaniaUSA
| | - Neerav Goyal
- Department of Otolaryngology‐Head and Neck SurgeryPenn State College of Medicine, Penn State University500 University DriveHersheyPennsylvaniaMC H091USA
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21
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Mitigating Disparity in Health-care Resources Between Countries for Management of Hereditary Angioedema. Clin Rev Allergy Immunol 2021; 61:84-97. [PMID: 34003432 PMCID: PMC8282575 DOI: 10.1007/s12016-021-08854-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 12/28/2022]
Abstract
Hereditary angioedema (HAE) is a rare genetic disorder characterized by recurrent episodes of skin and mucosal edema. The main treatment goal is to enable a “normal life” for all patients. However, due to high costs, there are limited options for the management of HAE in most developing and low-income countries. As a result, most of the recommended first-line treatments are not available. In this review, we attempt to highlight the disparities in health-care resources for the management of patients with HAE amongst different countries. Data was collected from HAE experts in countries who provide tabulated information regarding management and availability of HAE treatments in their countries. We reviewed the two most recent international HAE guidelines. Using India, the world’s second most populous country, as a paradigm for HAE management in lower-income countries, we reviewed the evidence for second-line and non-recommended practices reported by HAE experts. Results suggest significant inequities in provision of HAE services and treatments. HAE patients in low-income countries do not have access to life-saving acute drugs or recently developed highly effective prophylactic medications. Most low-income countries do not have specialized HAE services or diagnostic facilities, resulting in consequent long delays in diagnosis. Suggestions for optimizing the use of limited resources as a basis for future discussion and reaching a global consensus are provided. There is an urgent need to improve HAE services, diagnostics and treatments currently available to lower-income countries. We recommend that all HAE stakeholders support the need for global equity and access to these essential measures.
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22
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Jindal AK, Rawat A, Kaur A, Sharma D, Suri D, Gupta A, Garg R, Dogra S, Saikia B, Minz RW, Singh S. Novel SERPING1 gene mutations and clinical experience of type 1 hereditary angioedema from North India. Pediatr Allergy Immunol 2021; 32:599-611. [PMID: 33220126 DOI: 10.1111/pai.13420] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND There is paucity of literature on long-term follow-up of patients with hereditary angioedema (HAE) from developing countries. OBJECTIVE This study was carried out to analyze the clinical manifestations, laboratory features, and genetic profile of 32 patients (21 male and 11 female) from 23 families diagnosed with HAE between January 1996 and December 2019. METHODS Data were retrieved from medical records of Paediatric Immunodeficiency Clinic, Postgraduate Institute of Medical Education and Research, Chandigarh, India. RESULTS Median age at onset of symptoms was 6.25 years (range 1-25 years), and median age at diagnosis was 12 years (range 2-43 years). Serum complement C4 level was decreased in all patients. All patients had low C1-esterase inhibitor (C1-INH) quantitative level (type 1 HAE). SERPING1 gene sequencing could be carried out in 20 families. Of these, 11 were identified to have a pathogenic disease-causing variant in the SERPING1 gene. While 2 of these families had a previously reported mutation, remaining 9 families had novel pathogenic variants in SERPING1 gene. Because of non-availability of C1-INH therapy in India, all patients were given long-term prophylaxis (attenuated androgens or tranexamic acid (TA) or a combination of the 2). Life-threatening episodes of laryngeal edema were managed with fresh-frozen plasma (FPP) infusions. We recorded one disease-related mortality in our cohort. This happened in spite of long-term prophylaxis with stanozolol and TA. CONCLUSIONS We report largest single-center cohort of patients with HAE from India. Attenuated androgens, fibrinolytic agents, and FPP may be used for management of HAE in resource-limited settings.
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Affiliation(s)
- Ankur K Jindal
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anit Kaur
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dhrubajyoti Sharma
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anju Gupta
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravinder Garg
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Biman Saikia
- Department of Immunopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ranjana W Minz
- Department of Immunopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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23
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Christiansen SC, Zuraw BL. Hereditary angioedema: On-demand treatment of angioedema attacks. Allergy Asthma Proc 2020; 41:S26-S29. [PMID: 33109322 DOI: 10.2500/aap.2020.41.200066] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The availability of effective acute treatment for angioedema has been fundamental in reducing the burden of illness for patients with hereditary angioedema (HAE). In building on the foundation of scientific advances that elucidate the pathomechanism(s) of attacks related to vascular permeability, novel targeted on-demand treatments have been developed and approved. These therapies have provided the means to arrest episodes of swelling, which, in the past, had the potential to inexorably lead to morbidity, and even mortality, for patients with HAE. Access to these medications, along with an emphasis on early administration and guidance that all attacks are candidates for treatment, has shifted the management paradigm for HAE. Although unmet needs remain, these acute therapies, coupled with advances in prophylactic treatment, have furthered the goal for all patients with HAE to live a normal life.
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Affiliation(s)
| | - Bruce L. Zuraw
- From the University of California San Diego, La Jolla, California; and
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24
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Busse PJ, Christiansen SC, Riedl MA, Banerji A, Bernstein JA, Castaldo AJ, Craig T, Davis-Lorton M, Frank MM, Li HH, Lumry WR, Zuraw BL. US HAEA Medical Advisory Board 2020 Guidelines for the Management of Hereditary Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:132-150.e3. [PMID: 32898710 DOI: 10.1016/j.jaip.2020.08.046] [Citation(s) in RCA: 165] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 08/28/2020] [Accepted: 08/29/2020] [Indexed: 01/29/2023]
Abstract
Scientific and clinical progress together with the development of effective novel therapeutic options has engendered multiple important changes in the diagnosis and management of hereditary angioedema (HAE). We now update and extend the 2013 United States Hereditary Angioedema Association Medical Advisory Board guidelines for the treatment and management of HAE. The guidelines are based on a comprehensive literature review with recommendations indicating both the strength of our recommendation and the quality of the underlying evidence. Guidelines are provided regarding the classification, diagnosis, on-demand treatment, prophylactic treatment, special considerations for women and children, development of a comprehensive management and monitoring plan, and assessment of burden of illness for both HAE due to C1 inhibitor deficiency and HAE with normal C1 inhibitor. Advances in HAE treatment now allow the development of management plans that can help many patients with HAE lead a normal life. Achieving this goal requires that physicians be familiar with the diagnostic and therapeutic transformations that have occurred in recent years.
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Affiliation(s)
- Paula J Busse
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Sandra C Christiansen
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, Calif
| | - Marc A Riedl
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, Calif
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Harvard Medical School, Boston, Mass
| | - Jonathan A Bernstein
- Division of Immunology, Rheumatology, and Allergy, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Timothy Craig
- Division of Allergy, Asthma, and Immunology, Department of Medicine, Pediatrics, and Graduate Studies, Pennsylvania State University, Hershey, Pa
| | - Mark Davis-Lorton
- Division of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, NYU Winthrop Hospital, Mineola, NY
| | - Michael M Frank
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - H Henry Li
- Medicine Service, Institute for Asthma and Allergy, Chevy Chase, Md
| | - William R Lumry
- Allergy and Asthma Research Associates Research Center, Dallas, Tex
| | - Bruce L Zuraw
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, Calif; San Diego Veterans Administration Healthcare, San Diego, Calif.
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25
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Sabeen Ahmed A, Fayyaz S. Novel Use of Fresh Frozen Plasma in Treating Hereditary Angioedema: A Success Story From Pakistan. Cureus 2020; 12:e9669. [PMID: 32923264 PMCID: PMC7485914 DOI: 10.7759/cureus.9669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Hereditary angioedema (HAE) due to a C1-esterase inhibitor(C1-INH) deficiency is a rare and potentially life-threatening disorder. It is characterized by an episodic and self-limiting increase in vascular permeability. The condition manifests itself as recurrent attacks of swelling in any part of the body. The angioedema can cause the involvement of the respiratory tract, skin, and gastrointestinal tract. Laryngeal involvement can make the condition life-threatening. It does not respond well to conventional angioedema therapy of steroids, adrenaline, and antihistamines. The targeted therapy for HAE consists of plasma-derived or recombinant C1-INH, ecallantide, and icatibant or bradykinin receptor antagonist. In the absence of these therapies, it becomes difficult to manage this condition effectively. We present a case of hereditary angioedema, who presented with life-threatening laryngeal edema, causing asphyxia, leading to cardiac arrest. Due to a lack of availability of C1-INH concentrate, he was given fresh frozen plasma (FFP). His condition gradually improved, and he was successfully extubated after three days. This is the first time we are reporting a case from Pakistan in which the patient was successfully treated with FFP for an acute attack of hereditary angioedema.
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Affiliation(s)
| | - Sidra Fayyaz
- Pulmonology, Aga Khan University Hospital, Karachi, PAK
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