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Ding L, Zhang MJ, Rao GW. Summary and future of medicine for hereditary angioedema. Drug Discov Today 2024; 29:103890. [PMID: 38246415 DOI: 10.1016/j.drudis.2024.103890] [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] [Received: 07/16/2023] [Revised: 12/24/2023] [Accepted: 01/16/2024] [Indexed: 01/23/2024]
Abstract
Hereditary angioedema (HAE) is a rare autosomal genetic disease for which there are currently nine FDA-approved drugs. This review summarizes drug treatments for HAE based on four therapeutic pathways: inhibiting the contact system, inhibiting bradykinin binding to B2 receptors, supplying missing C1 inhibitors, and inhibiting plasminogen conversion. The review generalizes the clinical use, pharmacological effects and mechanisms of HAE drugs, and it also discusses possible development directions and targets to enhance understanding of HAE and help researchers.
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Affiliation(s)
- Lei Ding
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou 310014, PR China; Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, PR China
| | - Meng-Jiao Zhang
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou 310014, PR China; Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, PR China
| | - Guo-Wu Rao
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou 310014, PR China; Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, PR China.
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Hsu FI, Lumry W, Riedl M, Tachdjian R. Considerations in the management of hereditary angioedema due to C1-INH deficiency in women of childbearing age. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:64. [PMID: 35831891 PMCID: PMC9281160 DOI: 10.1186/s13223-022-00689-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/22/2022] [Indexed: 02/06/2023]
Abstract
Hereditary angioedema (HAE) is a rare, autosomal disorder that manifests with unpredictable episodes of severe swelling of the skin and mucous membranes. These attacks can be highly disfiguring and range in severity from mild to-in cases of airway swelling-life-threatening. Fluctuations in female sex hormones-such as the changes that occur during puberty, menses, contraceptive use, pregnancy, and menopause-can all affect the frequency and severity of HAE attacks. Disease management decisions for women of childbearing age may be more complex and require additional considerations since they could develop complications related to contraception, pregnancy, labor, delivery, and lactation. In addition, some HAE treatment options are contraindicated during pregnancy. Discussions about medications used to treat HAE should include a risk-benefit assessment of the woman's health status, her preferences, and other factors that are relevant to the choice of therapy. Planning prophylactic therapies that are effective and safe before, during, and after pregnancy can prevent gaps in treatment, ensure continuity of care, and reduce both disease burden and risk of adverse fetal outcomes. The 2020 US Hereditary Angioedema Association (HAEA) Medical Advisory Board and 2021 World Allergy Organization/European Academy of Allergy and Immunology (WAO/EAACI) Guidelines outline key considerations for managing HAE in females of childbearing age (15-45 years), with the goal of improving treatment efficacy and safety for this cohort of patients. Treatment decisions made in a collaborative manner involving the patient, HAE specialist and obstetric/gynecologic specialist, is the best approach to ensure optimal HAE management and safety in this patient population.
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Affiliation(s)
| | | | - Marc Riedl
- University of California - San Diego, La Jolla, CA, USA
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Greve J, Strassen U, Gorczyza M, Dominas N, Frahm UM, Mühlberg H, Wiednig M, Zampeli V, Magerl M. Prophylaxis in hereditary angioedema (HAE) with C1 inhibitor deficiency. J Dtsch Dermatol Ges 2016; 14:266-75. [PMID: 26972189 DOI: 10.1111/ddg.12856] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hereditary angioedema (HAE) is a rare congenital disorder characterized by recurrent episodes of subcutaneous or submucosal edema. Laryngeal manifestations can be life-threatening. In the majority of cases, the disease can be adequately treated with an on-demand approach--in some cases, however, short- or long-term prophylaxis is indicated. Attenuated androgens used to be the drugs of choice, but they are associated with considerable side effects and no longer commercially available in the German-speaking countries of the EU. They are currently being replaced by more effective and more tolerable agents such C1-inhibitors, the kallikrein inhibitor ecallantide, and the B2 receptor antagonist icatibant, which have recently obtained market authorization. These new drugs have had a major impact, especially on the indications and procedures for long-term prophylaxis. According to the most recent international consensus papers and our own experience, self-administered C1-inhibitors are now the first option for long-term prophylactic therapy. The decision for prophylaxis should no longer be based on single parameters such as the frequency of attacks but on adequate overall disease control including quality of life. More drugs are currently being developed, which may lead to further changes in the treatment algorithms of HAE.
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Affiliation(s)
- Jens Greve
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Ulrich Strassen
- Department of Otorhinolaryngology, Head and Neck Surgery, Technical University of Munich, Germany
| | - Marina Gorczyza
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité - Universitätsmedizin, Berlin, Germany
| | - Nina Dominas
- Department of Otorhinolaryngology, Head and Neck Surgery, University hospital, Essen, Germany
| | - Uta-Marie Frahm
- Department of Otorhinolaryngology, Head and Neck Surgery, University hospital, Essen, Germany
| | | | - Michaela Wiednig
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Vasiliki Zampeli
- Departments of Dermatology, Venereology, Allergology, and Immunology, Dessau Medical Center, Dessau, Weinheim, Germany
| | - Markus Magerl
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité - Universitätsmedizin, Berlin, Germany
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Greve J, Strassen U, Gorczyza M, Dominas N, Frahm UM, Mühlberg H, Wiednig M, Zampeli V, Magerl M. Prophylaxe beim hereditären Angioödem (HAE) mit C1-Inhibitormangel. J Dtsch Dermatol Ges 2016. [DOI: 10.1111/ddg.12856_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jens Greve
- Abteilung für Hals-Nasen- Ohrenheilkunde; Kopf- und Halschirurgie, Universitätsklinikum Ulm; Ulm Deutschland
| | - Ulrich Strassen
- Abteilung für Hals-Nasen-Ohrenheilkunde; Kopf- und Halschirurgie, Technische Universität München; München Deutschland
| | - Marina Gorczyza
- Abteilung für Dermatologie und Allergologie; Allergiezentrum Charité, Charité-Universitätsmedizin Berlin; Deutschland
| | - Nina Dominas
- Abteilung für Hals-Nasen-Ohrenheilkunde; Kopf- und Halschirurgie, Universität klinikum; Essen Deutschland
| | - Uta-Marie Frahm
- Abteilung für Hals-Nasen-Ohrenheilkunde; Kopf- und Halschirurgie, Universität klinikum; Essen Deutschland
| | - Heike Mühlberg
- Healthcare at Home Deutschland GmbH; Weinheim Deutschland
| | - Michaela Wiednig
- Abteilung für Dermatologie; Medizinische Universität Graz; Graz Österreich
| | - Vasiliki Zampeli
- Abteilungen für Dermatologie, Venerologie, Allergologie und Immunologie; Städtisches Klinikum Dessau; Dessau Deutschland
| | - Markus Magerl
- Abteilung für Dermatologie und Allergologie; Allergiezentrum Charité, Charité-Universitätsmedizin Berlin; Deutschland
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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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Wu MA, Zanichelli A, Mansi M, Cicardi M. Current treatment options for hereditary angioedema due to C1 inhibitor deficiency. Expert Opin Pharmacother 2015; 17:27-40. [DOI: 10.1517/14656566.2016.1104300] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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MacGinnitie AJ. Future Therapy for Pediatric Hereditary Angioedema. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2014; 27:177-180. [DOI: 10.1089/ped.2014.0390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Andrew J. MacGinnitie
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Abstract
Hereditary angioedema (HAE) is a lifelong illness characterized by recurrent swelling of the skin, intestinal tract, and, ominously, the upper airway. It is caused by inadequate activity of the protein C1-inhibitor, with dysfunction in the kallikrein/bradykinin pathway underlying the clinical symptoms. In addition to the physical symptoms, patients experience significant decrements in vocational and school achievement as well as in overall quality of life. Symptoms often begin in childhood and occur by age 20 in most patients, but life-threatening attacks are uncommon in the pediatric population. The availability of new therapies has transformed the management of HAE.
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Affiliation(s)
- Andrew J MacGinnitie
- Division of Immunology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Chyung Y, Vince B, Iarrobino R, Sexton D, Kenniston J, Faucette R, TenHoor C, Stolz LE, Stevens C, Biedenkapp J, Adelman B. A phase 1 study investigating DX-2930 in healthy subjects. Ann Allergy Asthma Immunol 2014; 113:460-6.e2. [PMID: 24980392 DOI: 10.1016/j.anai.2014.05.028] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 05/23/2014] [Accepted: 05/29/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND DX-2930 is a human monoclonal antibody inhibitor of plasma kallikrein under investigation for long-term prophylaxis of hereditary angioedema. OBJECTIVE To assess the safety, tolerability, pharmacokinetics, and pharmacodynamics of DX-2930 in healthy subjects. METHODS A single-center, double-blinded study was performed in 32 healthy subjects randomized 3:1 to receive a single subcutaneous administration of DX-2930 or placebo within 1 of 4 sequential, ascending dose cohorts (n = 8 each): 0.1, 0.3, 1.0, or 3.0 mg/kg. RESULTS No dose-limiting toxicity was observed. Headache was the most commonly reported treatment emergent adverse event (AE), occurring at a rate of 25% in the DX-2930- and placebo-treated groups; none were severe and all resolved. There were no serious AEs, discontinuations owing to an AE, or deaths. Two subjects had a severe AE reported as related to treatment by the blinded investigator; the 2 AEs were asymptomatic creatinine phosphokinase elevations of 902 U/L in 1 subject receiving 0.1 mg/kg DX-2930 and 1,967 U/L in 1 subject receiving placebo. For the 0.1-, 0.3-, 1.0-, and 3.0-mg/kg dose groups, respectively, mean maximum plasma concentrations were 0.6, 1.4, 5.6, and 14.5 μg/mL and mean elimination half-lives were 20.6, 16.8, 17.6, and 21.2 days. Exploratory biomarker assays, involving ex vivo activation of the kallikrein pathway, showed dose- and time-dependent inhibition of plasma kallikrein, with evidence of sustained bioactivity consistent with the pharmacokinetics profile. CONCLUSION A single administration of DX-2930 in healthy subjects up to doses of 3.0 mg/kg was well tolerated without dose-limiting toxicity. Pharmacokinetic and pharmacodynamic data provide evidence for a long-acting biological effect relevant to long-term prophylaxis for hereditary angioedema with C1-inhibitor deficiency. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01923207.
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Affiliation(s)
| | - Bradley Vince
- Vince & Associates Clinical Research, Overland Park, Kansas
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Kenniston JA, Faucette RR, Martik D, Comeau SR, Lindberg AP, Kopacz KJ, Conley GP, Chen J, Viswanathan M, Kastrapeli N, Cosic J, Mason S, DiLeo M, Abendroth J, Kuzmic P, Ladner RC, Edwards TE, TenHoor C, Adelman BA, Nixon AE, Sexton DJ. Inhibition of plasma kallikrein by a highly specific active site blocking antibody. J Biol Chem 2014; 289:23596-608. [PMID: 24970892 PMCID: PMC4156074 DOI: 10.1074/jbc.m114.569061] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Plasma kallikrein (pKal) proteolytically cleaves high molecular weight kininogen to generate the potent vasodilator and the pro-inflammatory peptide, bradykinin. pKal activity is tightly regulated in healthy individuals by the serpin C1-inhibitor, but individuals with hereditary angioedema (HAE) are deficient in C1-inhibitor and consequently exhibit excessive bradykinin generation that in turn causes debilitating and potentially fatal swelling attacks. To develop a potential therapeutic agent for HAE and other pKal-mediated disorders, we used phage display to discover a fully human IgG1 monoclonal antibody (DX-2930) against pKal. In vitro experiments demonstrated that DX-2930 potently inhibits active pKal (Ki = 0.120 ± 0.005 nm) but does not target either the zymogen (prekallikrein) or any other serine protease tested. These findings are supported by a 2.1-Å resolution crystal structure of pKal complexed to a DX-2930 Fab construct, which establishes that the pKal active site is fully occluded by the antibody. DX-2930 injected subcutaneously into cynomolgus monkeys exhibited a long half-life (t½ ∼12.5 days) and blocked high molecular weight kininogen proteolysis in activated plasma in a dose- and time-dependent manner. Furthermore, subcutaneous DX-2930 reduced carrageenan-induced paw edema in rats. A potent and long acting inhibitor of pKal activity could be an effective treatment option for pKal-mediated diseases, such as HAE.
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Affiliation(s)
| | | | - Diana Martik
- From the Dyax Corp., Burlington, Massachusetts 01803
| | | | | | - Kris J Kopacz
- From the Dyax Corp., Burlington, Massachusetts 01803
| | | | - Jie Chen
- From the Dyax Corp., Burlington, Massachusetts 01803
| | | | | | - Janja Cosic
- From the Dyax Corp., Burlington, Massachusetts 01803
| | - Shauna Mason
- From the Dyax Corp., Burlington, Massachusetts 01803
| | - Mike DiLeo
- From the Dyax Corp., Burlington, Massachusetts 01803
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Rubinstein E, Stolz LE, Sheffer AL, Stevens C, Bousvaros A. Abdominal attacks and treatment in hereditary angioedema with C1-inhibitor deficiency. BMC Gastroenterol 2014; 14:71. [PMID: 24712435 PMCID: PMC4101849 DOI: 10.1186/1471-230x-14-71] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 03/28/2014] [Indexed: 11/24/2022] Open
Abstract
Background Hereditary angioedema (HAE) is characterized by unpredictable attacks of debilitating subcutaneous and mucosal edema. Gastrointestinal attacks are painful, of sudden onset and often mistaken for acute abdomen leading to unnecessary surgery. The purpose of this study was to analyze symptom presentation of gastrointestinal angioedema in pediatric and adult HAE patients. Methods Information collected during the clinical development of ecallantide for treatment of acute HAE attacks included affected anatomic location, accompanying symptoms, medical history, and pain assessments. Efficacy endpoints included Treatment Outcome Score (TOS, maximum score = 100; minimally important difference = 30), a point-in-time measure of treatment response, and time to treatment response. Results Forty-nine percent of 521 HAE attacks only involved abdominal symptoms. The most commonly reported abdominal symptoms were distension (77%), cramping (73%) and nausea (67%). The most common pain descriptors were tender, tiring-exhausting, aching, cramping and sickening. White blood cell counts were elevated (>10 × 109/L) in 23% of attacks (mean ± SD: 15.1 ± 11.27 × 109/L). A high proportion of patients reported a history of abdominal surgery, including appendectomy (23%), cholecystectomy (16.4%), and hysterectomy (8.2%). Mean TOS at 4 hours post ecallantide was 77±33 versus 29±65 for placebo. Median time to significant symptom resolution was 165 minutes (95% CI 136, 167) for ecallantide versus >4 hours (95% CI 161, >4 hours) for placebo. Anaphylactic reactions occurred in 6 of the 149 treated patients. Conclusions HAE should be considered in the differential diagnosis of patients with recurrent discrete episodes of severe, unexplained crampy abdominal pain associated with nausea. Trials registration The data used in the analysis were gathered across multiple clinical trials conducted during the clinical development program for ecallantide. All of the studies were conducted using Good Clinical Practices (GCP) and in accordance with the ethical principles that have their origins in the Declaration of Helsinki. Each site that participated in the clinical trials obtained the appropriate IRB or Ethics Committee approval prior to enrolling any patients. All patients provided written informed consent prior to undergoing any study-related procedures. Pediatric patients provided written assent and their parents or guardians gave written informed consent. The following trials have been registered at http://www.clinicaltrials.gov: EDEMA2 (identifier NCT01826916); EDEMA3 (identifier NCT00262080); EDEMA4 (identifier NCT00457015); and DX-88/19 (identifier NCT00456508).
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Affiliation(s)
- Eitan Rubinstein
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, 300 Longwood Ave, Fegan 5th Floor, Boston, MA 02115, USA.
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Ecallantide for the treatment of acute attacks of hereditary angioedema due to C1-inhibitor deficiency. ACTA ACUST UNITED AC 2013. [DOI: 10.4155/cli.13.76] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hereditary angioedema therapy: kallikrein inhibition and bradykinin receptor antagonism. World Allergy Organ J 2013; 3:S34-8. [PMID: 23282868 PMCID: PMC3666151 DOI: 10.1097/wox.0b013e3181f20dbc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Current strategies for the treatment of hereditary angioedema (HAE) include targeted inhibition or antagonism of the contact system, which is dysregulated in HAE patients by a C1 esterase inhibitor deficiency. Ecallantide, a plasma kallikrein inhibitor, and icatibant, a selective bradykinin-2 receptor antagonist, have recently been evaluated in clinical studies for the treatment of acute HAE attacks. Both drugs have demonstrated evidence of efficacy and safety in treating acute HAE episodes, with ecallantide approved for use in the United States and icatibant approved for use in Europe. As therapeutic options for HAE expand for both for prophylactic and acute treatment strategies, a number of patient-specific and drug-specific factors have emerged as important considerations when developing individualized HAE management plans. Optimization of HAE therapy will require further integration of new therapies into the current treatment paradigm.
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Maurer M, Parish LC. The dermatology view of hereditary angio-oedema: practical diagnostic and management considerations. J Eur Acad Dermatol Venereol 2012; 27:133-41. [PMID: 22568407 DOI: 10.1111/j.1468-3083.2012.04562.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hereditary angio-oedema (HAE) is characterized by recurrent, localized, non-pitting, non-pruritic, non-urticarial oedema. Nearly all patients experience skin swelling as a feature of HAE. There may be painful abdominal attacks, accompanied by nausea and vomiting. The disease is life-threatening should laryngeal oedema occur. HAE results from a deficiency or dysfunction of C1 inhibitor, a plasma protein with an important role in regulating the contact, complement and fibrinolytic systems. Effective management of HAE should include a plan for treatment of attacks, as well as routine and preprocedure prevention. Acute and prophylactic therapy with C1 inhibitor therapy for correcting the underlying deficiency in HAE is a valuable option.
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Affiliation(s)
- M Maurer
- Department of Dermatology, Venereology and Allergy, Charité - University Medicine, Berlin, Germany.
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Hofstra J, Budde IK, van Twuyver E, Choi G, Levi M, Leebeek F, de Monchy J, Ypma P, Keizer R, Huitema A, Strengers P. Treatment of hereditary angioedema with nanofiltered C1-esterase inhibitor concentrate (Cetor®): Multi-center phase II and III studies to assess pharmacokinetics, clinical efficacy and safety. Clin Immunol 2012; 142:280-90. [DOI: 10.1016/j.clim.2011.11.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 11/03/2011] [Accepted: 11/04/2011] [Indexed: 11/29/2022]
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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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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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Parish LC. Hereditary angioedema: Diagnosis and management–a perspective for the dermatologist. J Am Acad Dermatol 2011; 65:843-850. [DOI: 10.1016/j.jaad.2010.09.715] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 07/21/2010] [Accepted: 09/12/2010] [Indexed: 10/18/2022]
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Davis B, Bernstein JA. Conestat alfa for the treatment of angioedema attacks. Ther Clin Risk Manag 2011; 7:265-73. [PMID: 21753889 PMCID: PMC3132097 DOI: 10.2147/tcrm.s15544] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Indexed: 12/20/2022] Open
Abstract
Recently, multiple C1 inhibitor (C1-INH) replacement products have been approved for the treatment of hereditary angioedema (HAE). This review summarizes HAE and its current treatment modalities and focuses on findings from bench to bedside trials of a new C1-INH replacement, conestat alfa. Conestat alfa is unique among the other C1-INH replacement products because it is produced from transgenic rabbits rather than derived from human plasma donors, which can potentially allow an unlimited source of drug without any concern of infectious transmission. The clinical trial data generated to date indicate that conestat alfa is safe and effective for the treatment of acute HAE attacks.
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Affiliation(s)
- Benjamin Davis
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section, Cincinnati, OH, USA
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Floccard B, Crozon J, Rimmelé T, Vulliez A, Coppere B, Chamouard V, Boccon-Gibod I, Bouillet L, Allaouchiche B. Prise en charge en urgence de l’angiœdème à bradykinine. ACTA ACUST UNITED AC 2011; 30:578-88. [DOI: 10.1016/j.annfar.2011.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 01/25/2011] [Indexed: 11/30/2022]
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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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Füst G, Farkas H, Csuka D, Varga L, Bork K. Long-term efficacy of danazol treatment in hereditary angioedema. Eur J Clin Invest 2011; 41:256-62. [PMID: 20955212 DOI: 10.1111/j.1365-2362.2010.02402.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND No systematic study has been published yet on the long-term efficacy of attenuated androgens in hereditary angioedema (HAE). Our aim was to conduct a follow-up study in two (German and Hungarian) cohorts of HAE patients (45 and 39 patients, respectively) undergoing uninterrupted treatment for 6 years with similar (starting dose 128 ± 78 mg per day and 136 ± 70 mg per day, respectively) and constant doses of danazol. DESIGN The frequencies of subcutaneous, abdominal and laryngeal attacks were recorded each year. RESULTS The annual frequency of all the three types of attacks was significantly lower during the first year of danazol treatment, compared to the last year before baseline. During subsequent years in Hungarian patients, the frequency of both subcutaneous and abdominal attacks - but not that of laryngeal attacks - increased significantly. In the case of abdominal attacks, a significant increase in the attack frequency was observed only in female patients. In the German cohort, by contrast, no change in the frequency of either type of attack was found during the 6-year study period. CONCLUSIONS The differences observed between these cohorts cannot be related to drug dose, the age or gender distribution of subjects or the age at the onset of symptoms or the length of diagnostic delay in the patients. There were, however, marked differences in the baseline pattern of attacks: significantly - 3 times - more abdominal attacks were recorded in German patients. Further studies are necessary to clarify the mechanism of these findings.
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Affiliation(s)
- George Füst
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
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Abstract
Hereditary angioedema (HAE) is a relatively rare genetic disorder that is usually characterized by either low levels of C1 esterase inhibitor (C1-INH) or the presence of dysfunctional C1-INH. It can present with relatively mild and self-limiting symptoms, but it is also potentially fatal; the most common cause of death is asphyxiation secondary to edema of the upper airway. The diagnosis of HAE, especially in the emergency situation, is not straightforward. HAE must be distinguished from several other types of angioedema that require different management approaches. Management approaches include trigger avoidance and pharmacologic therapy; the latter has traditionally involved the administration of attenuated androgens and antifibrinolytics. Recently, a new class of agent—C1-INH—has been introduced in the United States. This article provides an update on the pathophysiology, clinical picture, diagnosis, prophylaxis, and acute treatment of HAE. We must keep HAE in mind as a possible diagnosis whenever we are faced with a case of unexplained angioedema if we are to take advantage of the effective and more specific therapies that are becoming available.
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Affiliation(s)
- Jack B. Anon
- From the Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh
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Giavina-Bianchi P, França AT, Grumach AS, Motta AA, Fernandes FR, Campos RA, Valle SO, Rosário NA, Sole D. Brazilian guidelines for the diagnosis and treatment of hereditary angioedema. Clinics (Sao Paulo) 2011; 66:1627-36. [PMID: 22179171 PMCID: PMC3164416 DOI: 10.1590/s1807-59322011000900021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 05/01/2011] [Indexed: 01/16/2023] Open
Abstract
Hereditary angioedema is an autosomal dominant disease characterized by edema attacks with multiple organ involvement. It is caused by a quantitative or functional deficiency of the C1 inhibitor, which is a member of the serine protease inhibitor family. Hereditary angioedema is unknown to many health professionals and is therefore an underdiagnosed disease. The causes of death from hereditary angioedema include laryngeal edema with asphyxia. The estimated mortality rate in patients in whom the disease goes undetected and who are therefore incorrectly treated is 25-40%. In addition to edema of the glottis, hereditary angioedema often results in edema of the gastrointestinal tract, which can be incapacitating. Patients with hereditary angioedema may undergo unnecessary surgical interventions because the digestive tract can be the primary or only organ system involved, thus mimicking acute surgical abdomen. It is estimated that patients with hereditary angioedema experience some degree of disability 20-100 days per year. The Experts in Clinical Immunology and Allergy of the "Associação Brasileira de Alergia e Imunopatologia -ASBAI" developed these guidelines for the diagnosis, therapy, and management of hereditary angioedema.
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Maurer M, Magerl M. Long-term prophylaxis of hereditary angioedema with androgen derivates: a critical appraisal and potential alternatives. J Dtsch Dermatol Ges 2010; 9:99-107. [PMID: 20946572 DOI: 10.1111/j.1610-0387.2010.07546.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Androgen derivatives are regarded as standard in the long-term prophylaxis of swelling attacks in patients with hereditary angioedema (HAE). Because of their relatively slow onset of action, they are not suitable for acute therapy. Long-term prophylaxis with androgen derivatives must be regarded critically, especially on account of their androgenic and anabolic effects, some of which are severe. The risk of adverse events increases with the daily dose and the duration of treatment. Thus, treatment always calls for close monitoring of patients with regard to potential adverse events. In addition, androgens are subject to numerous contraindications and they show interactions with a large number of other drugs. Off-label use, doping issues, clarification of reimbursement and the need to import the androgen derivatives, which are no longer marketed in Germany, result in additional effort for the treating physician in terms of logistics and time involved. In symptomatic treatment of acute attacks the intravenous substitution of C1-INH and - since 2008 - subcutaneous administration of icatibant are available. The two substances are well tolerated and their effect occurs rapidly and, when the diagnosis has been confirmed, reliably. In the light of these two treatment options for controlling acute attacks, prophylactic treatment of HAE patients with androgen derivatives such as danazol should be reassessed. Patients might benefit from a dose reduction or the withdrawal of androgen prophylaxis and attacks can be controlled with demand-oriented acute treatment using C1-INH or icatibant.
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Affiliation(s)
- Marcus Maurer
- Department of Dermatology, Venerology and Allergology, Charité - Universitätsmedizin Berlin, Germany.
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Krassilnikova S, Craig ET, Craig TJ. Summary of the International Multicenter Prospective Angioedema C1-inhibitor Trials 1 and 2 (IMPACT1 and 2). Expert Rev Clin Immunol 2010; 6:327-34. [PMID: 20441418 DOI: 10.1586/eci.10.19] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Hereditary angioedema (HAE) is an autosomal dominant disease characterized by deficiency of C1 inhibitor (C1-INH) that commonly presents with recurrent swelling affecting different parts of the body. Supplementation with C1-INH is successfully used to treat HAE in selected countries, mostly in Europe. Berinert P (CSL Behring, Marburg, Germany), a human plasma-derived C1-INH, was studied in the International Multicenter Prospective Angioedema C1-inhibitor Trial 1 (IMPACT1) that was completed in 2007. It was the first safety and dose-finding study of C1-INH in patients with acute abdominal and facial angioedema. IMPACT2 was the extension of the first trial to study C1-INH efficacy and safety in multiple treatments of acute HAE attacks in various areas of the body. Berinert P has excellent potential to become a first-line therapy for treating patients with acute HAE attacks in the USA and other countries involved in the IMPACT trials. While final data from the IMPACT2 trial are not yet released, this article reviews currently available data from previous reports and abstract presentations.
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Farkas H. Pediatric hereditary angioedema due to C1-inhibitor deficiency. Allergy Asthma Clin Immunol 2010; 6:18. [PMID: 20667121 PMCID: PMC2920237 DOI: 10.1186/1710-1492-6-18] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Accepted: 07/28/2010] [Indexed: 12/03/2022] Open
Abstract
Hereditary angioedema (HAE) resulting from the deficiency of the C1 inhibitor (C1-INH) is a rare, life-threatening disorder. It is characterized by attacks of angioedema involving the skin and/or the mucosa of the upper airways, as well as the intestinal mucosa. In approximately 50 per cent of cases, clinical manifestations may appear during childhood. The complex management of HAE in pediatric patients is in many respects different from the management of adults. Establishing the diagnosis early, preferably before the onset of clinical symptoms, is essential in cases with a positive family history. Complement studies usually afford accurate diagnosis, whereas molecular genetics tests may prove helpful in uncertain cases. Appropriate therapy, supported by counselling, suitable modification of lifestyle, and avoidance of triggering factors (which primarily include mechanical trauma, mental stress and airway infections in children) may spare the patient unnecessary surgery and may prevent mortality. Prompt control of edematous attacks, short-term prophylaxis and intermittent therapy are recommended as the primary means for the management of pediatric cases. Medicinal products currently used for the treatment of children with hereditary angioedema include antifibrinolytics, attenuated androgens, and C1-INH replacement therapy. Current guidelines favour antifibrinolytics for long-term prophylaxis because of their favorable safety profile but efficacy may be lacking. Attenuated androgens administered in the lowest effective dose are another option. C1-INH replacement therapy is also an effective and safe agent for children. Regular monitoring and follow-up of patients are necessary.
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Affiliation(s)
- Henriette Farkas
- 3rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, H-1125 Budapest, Kútvölgyi út 4, Hungary.
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Bouillet L. Hereditary angioedema in women. Allergy Asthma Clin Immunol 2010; 6:17. [PMID: 20667120 PMCID: PMC2918592 DOI: 10.1186/1710-1492-6-17] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 07/28/2010] [Indexed: 11/19/2022] Open
Abstract
Women with hereditary angioedema (HAE) are more likely to be symptomatic that men. Hormonal factors (puberty, contraception, pregnancy,....) play a significant role in the precipitation or worsening of the condition in women. So, combined contraceptive pills are not indicated and progestogen pill must be preferred. During pregnancy, attack rate can increase (38-48% of women). C1Inhibitor concentrate and tranexamic acid can be used during pregnancy. Attenuated androgens for long term prophylaxis are effective but side effects appear more often in female patients. These side effects are dose dependant and can be attenuated by titrating the dose down the lowest effective level.
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Affiliation(s)
- Laurence Bouillet
- National French Reference Centre of Angioedema, Internal Medicine Department, Grenoble University Hospital, France.
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Farkas H. Management of upper airway edema caused by hereditary angioedema. Allergy Asthma Clin Immunol 2010; 6:19. [PMID: 20667122 PMCID: PMC2920238 DOI: 10.1186/1710-1492-6-19] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 07/28/2010] [Indexed: 11/10/2022] Open
Abstract
Hereditary angioedema is a rare disorder with a genetic background involving mutations in the genes encoding C1-INH and of factor XII. Its etiology is unknown in a proportion of cases. Recurrent edema formation may involve the subcutis and the submucosa - the latter can produce obstruction in the upper airways and thereby lead to life-threatening asphyxia. This is the reason for the high, 30-to 50-per-cent mortality of undiagnosed or improperly managed cases. Airway obstruction can be prevented through early diagnosis, meaningful patient information, timely recognition of initial symptoms, state-of-the-art emergency therapy, and close monitoring of the patient. Prophylaxis can substantially mitigate the risk of upper airway edema and also improve the patients' quality of life. Notwithstanding the foregoing, any form of upper airway edema should be regarded as a potentially life-threatening condition. None of the currently available prophylactic modalities is capable of preventing UAE with absolute certainty.
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Affiliation(s)
- Henriette Farkas
- 3rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, H-1125 Budapest, Kútvölgyi út 4, Hungary.
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30
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Bowen T, Cicardi M, Farkas H, Bork K, Longhurst HJ, Zuraw B, Aygoeren-Pürsün E, Craig T, Binkley K, Hebert J, Ritchie B, Bouillet L, Betschel S, Cogar D, Dean J, Devaraj R, Hamed A, Kamra P, Keith PK, Lacuesta G, Leith E, Lyons H, Mace S, Mako B, Neurath D, Poon MC, Rivard GE, Schellenberg R, Rowan D, Rowe A, Stark D, Sur S, Tsai E, Warrington R, Waserman S, Ameratunga R, Bernstein J, Björkander J, Brosz K, Brosz J, Bygum A, Caballero T, Frank M, Fust G, Harmat G, Kanani A, Kreuz W, Levi M, Li H, Martinez-Saguer I, Moldovan D, Nagy I, Nielsen EW, Nordenfelt P, Reshef A, Rusicke E, Smith-Foltz S, Späth P, Varga L, Xiang ZY. 2010 International consensus algorithm for the diagnosis, therapy and management of hereditary angioedema. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2010; 6:24. [PMID: 20667127 PMCID: PMC2921362 DOI: 10.1186/1710-1492-6-24] [Citation(s) in RCA: 326] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 07/28/2010] [Indexed: 01/13/2023]
Abstract
BACKGROUND We published the Canadian 2003 International Consensus Algorithm for the Diagnosis, Therapy, and Management of Hereditary Angioedema (HAE; C1 inhibitor [C1-INH] deficiency) and updated this as Hereditary angioedema: a current state-of-the-art review: Canadian Hungarian 2007 International Consensus Algorithm for the Diagnosis, Therapy, and Management of Hereditary Angioedema. OBJECTIVE To update the International Consensus Algorithm for the Diagnosis, Therapy and Management of Hereditary Angioedema (circa 2010). METHODS The Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH) http://www.haecanada.com and cosponsors University of Calgary and the Canadian Society of Allergy and Clinical Immunology (with an unrestricted educational grant from CSL Behring) held our third Conference May 15th to 16th, 2010 in Toronto Canada to update our consensus approach. The Consensus document was reviewed at the meeting and then circulated for review. RESULTS This manuscript is the 2010 International Consensus Algorithm for the Diagnosis, Therapy and Management of Hereditary Angioedema that resulted from that conference. CONCLUSIONS Consensus approach is only an interim guide to a complex disorder such as HAE and should be replaced as soon as possible with large phase III and IV clinical trials, meta analyses, and using data base registry validation of approaches including quality of life and cost benefit analyses, followed by large head-to-head clinical trials and then evidence-based guidelines and standards for HAE disease management.
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Affiliation(s)
- Tom Bowen
- Departments of Medicine and Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Marco Cicardi
- Department of Internal Medicine, Universita degli Studi di Milano, Ospedale L. Sacco, Milan, Italy
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Konrad Bork
- Department of Dermatology, University Hospital of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Hilary J Longhurst
- Department of Immunology, Barts and the London NHS Trust, London, England, UK
| | - Bruce Zuraw
- University of California, San Diego, San Diego, California, USA
| | | | - Timothy Craig
- Departments of Medicine and Pediatrics, Penn State University, Hershey, Pennsylvania, USA
| | - Karen Binkley
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Jacques Hebert
- Department of Medicine, Laval University, Quebec City, Quebec, Canada
| | - Bruce Ritchie
- Departments of Medicine and Medical Oncology, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Della Cogar
- Member, Patient Advisory Committee, Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH). 705 South Tower, 3031 Hospital Dr. NW, Calgary, Alberta, Canada
- Portage La Prairie, Manitoba, Canada
| | - John Dean
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Azza Hamed
- Memorial University and Janeway Child Health Centre, St. John's, Newfoundland, Canada
| | - Palinder Kamra
- Memorial University and Janeway Child Health Centre, St. John's, Newfoundland, Canada
| | - Paul K Keith
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gina Lacuesta
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Eric Leith
- Department of Medicine, University of Toronto, Oakville, Ontario, Canada
| | - Harriet Lyons
- Member, Patient Advisory Committee, Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH). 705 South Tower, 3031 Hospital Dr. NW, Calgary, Alberta, Canada
- Ancaster, Ontario, Canada
| | - Sean Mace
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Barbara Mako
- Member, Patient Advisory Committee, Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH). 705 South Tower, 3031 Hospital Dr. NW, Calgary, Alberta, Canada
- St. Catharines, Ontario, Canada; Member and Chair, Patient Advisory Committee, Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH
| | - Doris Neurath
- Transfusion Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Man-Chiu Poon
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Georges-Etienne Rivard
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Robert Schellenberg
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dereth Rowan
- Member, Patient Advisory Committee, Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH). 705 South Tower, 3031 Hospital Dr. NW, Calgary, Alberta, Canada
- Ancaster, Ontario, Canada
| | - Anne Rowe
- Member, Patient Advisory Committee, Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH). 705 South Tower, 3031 Hospital Dr. NW, Calgary, Alberta, Canada
- Halifax, Nova Scotia, Canada
| | - Donald Stark
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ellie Tsai
- Queen's University, Kingston, Ontario, Canada
| | - Richard Warrington
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Jonathan Bernstein
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Janne Björkander
- Department of Clinical and Experimental Medicine, County Hospital Ryhov, Jönköping, Sweden
| | - Kristylea Brosz
- Member, Patient Advisory Committee, Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH). 705 South Tower, 3031 Hospital Dr. NW, Calgary, Alberta, Canada
- Calgary, Alberta, Canada
| | - John Brosz
- Member, Patient Advisory Committee, Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH). 705 South Tower, 3031 Hospital Dr. NW, Calgary, Alberta, Canada
- Calgary, Alberta, Canada
| | - Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Denmark
| | | | - Mike Frank
- Duke University Medical Center, Durham, North Carolina, USA
| | - George Fust
- 3rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | | | - Amin Kanani
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wolfhart Kreuz
- Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - Marcel Levi
- Dept of Medicine, Academic Medical Center, Amsterdam Area, Netherlands
| | - Henry Li
- Institute for Asthma & Allergy, Wheaton and Chevy Chase, Maryland, USA
| | | | - Dumitru Moldovan
- 4th Medical Clinic, University of Medicine and Pharmacy, Tirgu Mures, Romania
| | - Istvan Nagy
- Hungarian Association of Angioedema Patients, Budapest, Hungary
| | | | | | - Avner Reshef
- Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Eva Rusicke
- Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - Sarah Smith-Foltz
- Asociación Española de Angioedema Familiar por Deficiencia del inhibidor de C1 (AEDAF), Madrid, Spain
| | - Peter Späth
- Institute of Pharmacology, University of Bern, Switzerland
| | - Lilian Varga
- 3rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Zhi Yu Xiang
- Peking Union Medical College Hospital, Beijing, China
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Abstract
There is no cure for hereditary angioedema (HAE). Therapeutic approaches consist of symptomatic therapy for acute attacks, short-term prophylaxis before surgery, and long-term prophylaxis for those with frequent and severe attacks. In Germany, C1-INH concentrate and icatibant are licensed for acute therapy. C1-INH concentrate, which is obtained from human plasma, is administered intravenously to restore the deficient C1-INH activity. This therapy, which has been available for decades, is effective and well-tolerated. Batch documentation is required by German law. The synthetic decapeptide icatibant is administered subcutaneously. It competes with bradykinin, the responsible inducer of edema formation, for binding to the bradykinin B2 receptor. Icatibant is also effective and well-tolerated, even on repeated administration. An additional human C1-inhibitor, a recombinant human C1-inhibitor and the recombinant inhibitor of kallikrein ecallantide are currently under development. There are no licensed treatment options available in Germany for long- and short-term prophylaxis. Androgen derivatives are established in long-term prophylaxis. However, they are associated with many adverse effects, some of which are severe. Many drug interactions also limit their use. They are contraindicated in pregnancy, lactation, for children and in cases of prostate cancer. Antifibrinolytics have fewer adverse effects but are also less effective than androgens. They are contraindicated in thromboembolic disease and impaired vision. If androgen therapy has too negative an effect on quality of life, it may be worth reducing the dose or discontinuing therapy entirely and treating attacks with acute therapy.
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Affiliation(s)
- Marcus Maurer
- Department of Dermatology, Venereology and Allergy, Charité- University Medicine Berlin, Germany.
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Varga L, Farkas H. Treatment of type I and II hereditary angioedema with Rhucin, a recombinant human C1 inhibitor. Expert Rev Clin Immunol 2010; 4:653-61. [PMID: 20477114 DOI: 10.1586/1744666x.4.6.653] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hereditary and acquired angioedema are of outstanding clinical importance, as edematous attacks associated with these conditions can thrust afflicted patients into mortal danger. Currently, C1 inhibitor concentrate - a human blood product - is available as a replacement therapy. In view of the limited number of donors, as well as the risk of transmission of blood-borne infections, it is a reasonable expectation to develop a therapeutic alternative based on recombinant technology, which would eliminate all these shortcomings. Pharming (Leiden, The Netherlands) has developed Rhucin, a recombinant human C1 inhibitor, as a proprietary product, which is currently being evaluated in Phase III clinical trials. Ongoing studies conducted within the framework of the development program are almost complete and their interim findings are reassuring. This should facilitate successful regulatory approval in the near future, which is indispensable in order to make Rhucin available for patients with hereditary angioedema or other disorders amenable to C1 inhibitor replacement.
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Affiliation(s)
- Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University Budapest, H-1125 Kútvölgyi Street 4, Budapest, Hungary.
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Abstract
PURPOSE OF REVIEW The purpose of the present review is to outline the clinical aspects and management of the upper airway involvement in the patients suffering from hereditary angioedema. RECENT FINDINGS Molecular mechanisms of hereditary angioedema reviewed in the literature conclude that it is an autosomal dominant disorder, characterized by the deficiency of C1 inhibitor due to mutations of its gene (SERPING). Hereditary angioedema manifests as episodes of localized swelling in any site of the body from skin, gastrointestinal tract to the upper airway, where it is severe and life-threatening. The age of onset, frequency of attacks and the factors triggering upper airway swelling in hereditary angioedema are variable among different patients. Acute laryngeal edema should be managed in emergency with monitoring of airway patency. To avoid airway obstruction, therapy should begin early either with current treatment (C1 inhibitor concentrate) or with new drugs developed recently. In patients with recurrent upper airway swelling attacks, long-term prophylaxis is recommended. CONCLUSION The use of old and new treatment in acute attacks as well as in prophylaxis (long and short-term) has changed the outcome of patients with hereditary angioedema who present upper airway swelling.
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Bernstein JA, Qazi M. Ecallantide: its pharmacology, pharmacokinetics, clinical efficacy and tolerability. Expert Rev Clin Immunol 2010; 6:29-39. [PMID: 20383888 DOI: 10.1586/eci.09.60] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ecallantide (Kalbitor, Dyax Corporation) is a highly specific recombinant plasma kallikrein inhibitor developed for treatment of hereditary angioedema (HAE). Advantages of this agent over plasma-derived treatments are that it poses no risk of viral contamination, is highly selective, has a quick onset of action and can be administered subcutaneously. In clinical trials, ecallantide appears to be a safe and effective drug useful for the treatment of HAE patients suffering from an acute attack. Ecallantide was found to be superior compared with placebo in relieving symptoms, decreasing the severity of attacks and shortening the duration of attacks. The primary safety concern appears to be related to hypersensitivity reactions. Phase IV postmarketing surveillance studies to monitor the incidence of these reactions will be implemented by the company now that the drug has been US FDA approved.
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Affiliation(s)
- Jonathan A Bernstein
- University of Cincinnati, Department of Internal Medicine, Division of Immunology/Allergy Section, 231 Albert Sabin Way ML#563, Cincinnati, OH 45267-0563, USA.
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35
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Sartorius GA, Handelsman DJ. Testicular Dysfunction in Systemic Diseases. Andrology 2010. [DOI: 10.1007/978-3-540-78355-8_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Riedl M. Hereditary Angioedema Therapy: Kallikrein Inhibition and Bradykinin Receptor Antagonism. World Allergy Organ J 2010. [DOI: 10.1186/1939-4551-3-s3-s34] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Farkas H, Czaller I, Csuka D, Vas A, Valentin S, Varga L, Széplaki G, Jakab L, Füst G, Prohászka Z, Harmat G, Visy B, Karádi I. The effect of long-term danazol prophylaxis on liver function in hereditary angioedema-a longitudinal study. Eur J Clin Pharmacol 2009; 66:419-26. [PMID: 20024535 DOI: 10.1007/s00228-009-0771-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 11/24/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Danazol is a drug most widely used for the prophylaxis of hereditary angioedema resulting from the deficiency of the C1-inhibitor. Potential hepatotoxic or liver tumor-inducing side effects of long-term danazol prophylaxis have been investigated during the follow-up of hereditary angioedema patients. METHODS Characteristic parameters of liver function (including bilirubin, GOT, GPT, gammaGT, total protein, ALP, LDH), as well as findings of viral serology screens and abdominal ultrasonography-determined during years 0 and 5 of follow-up of patient groups taking/not taking danazol-have been reviewed and analyzed comparatively. RESULTS From a population of 126 hereditary angioedema patients, 46 subjects taking danazol and another 46 not taking danazol fulfilled the inclusion criteria. Longitudinal follow-up did not reveal any clinically relevant difference between the liver function parameters determined in years 0 and 5 in the two groups. Abdominal ultrasound did not detect neoplastic or other potentially treatment-related alterations of the liver parenchyma. There were no discontinuations of treatment during the study. CONCLUSIONS Our results clearly suggest that, administered at the lowest effective dose, danazol does not induce liver injury in hereditary angioedema patients.
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Affiliation(s)
- Henriette Farkas
- Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
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Craig TJ, Levy RJ, Wasserman RL, Bewtra AK, Hurewitz D, Obtułowicz K, Reshef A, Ritchie B, Moldovan D, Shirov T, Grivcheva-Panovska V, Kiessling PC, Keinecke HO, Bernstein JA. Efficacy of human C1 esterase inhibitor concentrate compared with placebo in acute hereditary angioedema attacks. J Allergy Clin Immunol 2009; 124:801-8. [DOI: 10.1016/j.jaci.2009.07.017] [Citation(s) in RCA: 254] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 07/07/2009] [Accepted: 07/14/2009] [Indexed: 11/26/2022]
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Angioedema hereditario y adquirido: características clínicas de ocho pacientes y revisión de la literatura. Rev Clin Esp 2009; 209:332-6. [DOI: 10.1016/s0014-2565(09)71817-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Grigoriadou S, Longhurst HJ. Clinical Immunology Review Series: An approach to the patient with angio-oedema. Clin Exp Immunol 2009; 155:367-77. [PMID: 19220828 DOI: 10.1111/j.1365-2249.2008.03845.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Angio-oedema is a common reason for attendance at the accident and emergency department and for referral to immunology/allergy clinics. Causative factors should always be sought, but a large proportion of patients have the idiopathic form of the disease. A minority of patients represent a diagnostic and treatment challenge. Failure to identify the more unusual causes of angio-oedema may result in life-threatening situations. Common and rare causes of angio-oedema will be discussed in this article, as well as the diagnostic and treatment pathways for the management of these patients. A comprehensive history and close monitoring of response to treatment are the most cost-effective diagnostic and treatment tools.
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Affiliation(s)
- S Grigoriadou
- Barts and The London NHS Trust, Royal London Hospital, London, UK
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Epstein TG, Bernstein JA. Current and emerging management options for hereditary angioedema in the US. Drugs 2009; 68:2561-73. [PMID: 19093699 DOI: 10.2165/0003495-200868180-00003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Hereditary angioedema (HAE) is a rare disorder characterized by recurrent attacks of swelling that may involve multiple anatomical locations. In the majority of patients, it is caused by a functional or quantitative defect in the C1 inhibitor (C1-INH), which is an important regulator of the complement, fibrinolytic, kallikrein-kinin and coagulation systems. Standard treatments used for other types of angioedema are ineffective for HAE. Traditional therapies for HAE, including fresh frozen plasma, epsilon-aminocaproic acid and danazol, may be well tolerated and effective in some patients; however, there are limitations both in their safety and efficacy. Several novel therapies have completed phase III trials in the US, including: (i) plasma-derived C1-INH replacement therapies (Berinert P and Cinryze); (ii) a recombinant C1-INH replacement therapy (conestat alfa; Rhucin); (iii) a kallikrein inhibitor (ecallantide [DX-88]); and (iv) a bradykinin-2-receptor antagonist (icatibant). Both Berinert P and Cinryze are reported to have excellent efficacy and safety data from phase III trials. Currently, only Cinryze has been approved for prophylactic use in the US. US FDA approval for other novel agents to treat HAE and for the use of Cinryze in the treatment of acute attacks is pending.
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Affiliation(s)
- Tolly G Epstein
- Department of Internal Medicine, Division of Immunology/Allergy, University of Cincinnati Medical Center, Cincinnati, Ohio 45267-0563, USA
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C1-inhibitor deficiency and angioedema: molecular mechanisms and clinical progress. Trends Mol Med 2009; 15:69-78. [DOI: 10.1016/j.molmed.2008.12.001] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 12/04/2008] [Accepted: 12/04/2008] [Indexed: 11/21/2022]
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