1
|
Rupar N, Šelb J, Košnik M, Zidarn M, Andrejević S, Čulav L, Grivčeva-Panovska V, Korošec P, Rijavec M. The CC2D2B is a novel genetic modifier of the clinical phenotype in patients with hereditary angioedema due to C1 inhibitor deficiency. Gene 2024; 919:148496. [PMID: 38679185 DOI: 10.1016/j.gene.2024.148496] [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: 02/18/2024] [Revised: 04/10/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
Hereditary angioedema due to C1 inhibitor deficiency (HAE-C1-INH) is a rare genetic disorder caused by pathogenic variants in the SERPING1 gene and characterised by swelling and a highly variable clinical phenotype. We aimed to identify novel modifying genetic factors predisposing to the clinical symptoms. We performed whole exome sequencing (WES) and comprehensive bioinformatic analysis in symptomatic and asymptomatic (three duos) family members with HAE-C1-INH. Selected variants identified using WES (present in all asymptomatic and absent in symptomatic patients) were determined using Sanger sequencing. We included 88 clinically well-characterised HAE-C1-INH patients from south-eastern Europe (nine asymptomatic) from 42 unrelated families. We identified 39 variants in 23 genes (ANKRD36C, ARGFX, CC2D2B, IL5RA, IRF2BP2, LGR6, MRPL45, MUC3A, NPIPA1, NRG1, OR5M1, OR5M3, OR5M10, OR8U3, PLCL1, PRSS3, PSKH2, PTPRA, RTP4, SEZ6, SLC25A5, VWA3A, and ZNF790). We selected variants in CC2D2B and PLCL1, which were analysed using Sanger sequencing in the entire group of HAE-C1-INH. We found significant differences in the frequencies of the CC2D2B c.190A>G (rs17383738) variant between symptomatic and asymptomatic patients, where heterozygotes were more common in asymptomatic HAE-C1-INH patients in comparison to symptomatic patients (55 % vs 23%; P = 0.049, OR = 4.24, 95% CI 1.07-14.69). Our study identified novel genetic factors that modify the clinical variability of HAE-C1-INH. We further demonstrated, in a large cohort, the importance of the CC2D2B gene as a disease-modifying factor. Based on linkage disequilibrium analysis, the CCNJ and ZNF518A genes might also be involved in the clinical variability of HAE-C1-INH.
Collapse
Affiliation(s)
- Nina Rupar
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia
| | - Julij Šelb
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Mihaela Zidarn
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Slađana Andrejević
- Clinic of Allergology and Immunology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ljerka Čulav
- General Hospital Šibenik, 22000 Šibenik, Croatia
| | - Vesna Grivčeva-Panovska
- Dermatology Clinic, School of Medicine, Ss. Cyril and Methodius University, 1000 Skopje, Republic of Macedonia
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia; Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; Biotechnical Faculty, University of Ljubljana, 1000 Ljubljana, Slovenia.
| |
Collapse
|
2
|
Christiansen SC, Zuraw BL. Contact System Activation and Bradykinin Generation in Angioedema: Laboratory Assessment and Biomarker Utilization. Immunol Allergy Clin North Am 2024; 44:543-560. [PMID: 38937015 DOI: 10.1016/j.iac.2024.03.011] [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
The role of contact system activation has been clearly established in the pathogenesis of hereditary angioedema due to C1 inhibitor deficiency (HAE-C1INH). C1 inhibitor (C1INH)-protease complexes, levels of functional C1INH, plasma kallikrein activation, and cleavage of high-molecular-weight kininogen have each been associated with disease activity. More recently, HAE with normal levels of C1INH (HAE-nl-C1INH) has been recognized. Six genetic mutations have been identified which are linked to HAE-nl-C1INH phenotypes. The majority of individuals with HAE-nl-C1INH fall into the unknown category. There is substantial evidence that bradykinin generation underlies the recurrent attacks of swelling in some of these cohorts.
Collapse
Affiliation(s)
- Sandra C Christiansen
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mail Code 0732, La Jolla, CA 92093, USA
| | - Bruce L Zuraw
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mail Code 0732, La Jolla, CA 92093, USA; Medicine Service, San Diego Veterans Administration Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
| |
Collapse
|
3
|
Zuraw BL, Christiansen SC. Classification, Diagnosis, and Pathology of Angioedema Without Hives. Immunol Allergy Clin North Am 2024; 44:529-541. [PMID: 38937014 DOI: 10.1016/j.iac.2024.03.010] [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
A clear disease classification schema coupled with an understanding of the specific mechanisms involved in the different types of angioedema without hives informs the diagnostic assessment. The recommended approach involves several key steps. Foremost is the recognizing of the clinical clues which allow for the differentiation of mast cell-mediated disorders from bradykinin-mediated angioedema. Enhanced vascular permeability related to bradykinin is of critical importance to identify given the implications for disease morbidity and risk of mortality. The ability to efficiently categorize and diagnose all forms of angioedema results in improved patient outcomes.
Collapse
Affiliation(s)
- Bruce L Zuraw
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mail Code 0732, La Jolla, CA 92093, USA; Medicine Service, San Diego Veterans Administration Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
| | - Sandra C Christiansen
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mail Code 0732, La Jolla, CA 92093, USA
| |
Collapse
|
4
|
Guan X, Sheng Y, Liu S, He M, Chen T, Zhi Y. Epidemiology, economic, and humanistic burden of hereditary angioedema: a systematic review. Orphanet J Rare Dis 2024; 19:256. [PMID: 38978028 PMCID: PMC11229247 DOI: 10.1186/s13023-024-03265-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 06/25/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND This systematic study aims to assess the global epidemiologic, economic, and humanistic burden of illness associated with all types of hereditary angioedema. METHODS A systematic search for articles reporting the epidemiologic, economic, and humanistic burden associated with patients with HAE was conducted using English and Chinese literature databases from the inception to May 23, 2022. The selected studies were assessed for their quality and risk of bias. The study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022352377). RESULTS In total, 65 articles that met the search inclusion criteria reported 10,310 patients with HAE, of whom 5861 were female patients. Altogether, 4312 patients (81%) and 479 patients (9%) had type 1 and type 2 HAE, respectively, whereas 422 patients (8%) had HAE-normal C1-INH. The overall prevalence of all types of HAE was between 0.13 and 1.6 cases per 100,000. The mean or median delay from the first onset of a symptom of HAE to confirmed diagnosis ranged from 3.9 to 26 years. The estimated risk of death from asphyxiation was 8.6% for patients with HAE. Hospitalization, medication, unnecessary surgeries, doctor visits, specialist services, and nursing costs are direct expenses that contribute to the growing economic burden. The indirect cost accounted mostly due to missing work ($3402/year) and loss of productivity ($5750/year). Furthermore, impairment of QoL as reported by patient-reported outcomes was observed. QoL measures identified depression, anxiety, and stress to be the most common symptoms for adult patients and children. CONCLUSION This study highlights the importance of early diagnosis and the need for improving awareness among health care professionals to reduce the burden of HAE on patients and society.
Collapse
Affiliation(s)
- Xin Guan
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
| | - Yanan Sheng
- Medical Affairs, Takeda (China) International Trading Company, Beijing, 100006, China
| | - Shuang Liu
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Miao He
- Medical Affairs, Takeda (China) International Trading Company, Beijing, 100006, China
| | - Tianxiang Chen
- Medical Affairs, Takeda (China) International Trading Company, Beijing, 100006, China
| | - Yuxiang Zhi
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| |
Collapse
|
5
|
Lu Q, Tang L, Yang J. Recurrent Abdominal Pain Associated With Small Intestinal Edema. Gastroenterology 2024; 167:218-222. [PMID: 38302006 DOI: 10.1053/j.gastro.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 02/03/2024]
Affiliation(s)
- Qing Lu
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China; Department of Gastroenterology and Hepatology, Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Li Tang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jinlin Yang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan, China; Department of Gastroenterology and Hepatology, Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| |
Collapse
|
6
|
Taori K, Kirnake V, Junare P, Padwale V. Navigating the swells: A case report of hereditary angioedema. J Family Med Prim Care 2024; 13:2784-2786. [PMID: 39071003 PMCID: PMC11272023 DOI: 10.4103/jfmpc.jfmpc_1254_23] [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: 07/31/2023] [Revised: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 07/30/2024] Open
Abstract
Hereditary angioedema (HAE) is a rare genetic disorder characterized by recurrent episodes of localized edema caused by a deficiency or dysfunction of C1 inhibitor (C1-INH). This case report presents the clinical features, diagnostic evaluation, and management of a 23-year-old man with HAE. We discuss the challenges of diagnosing and treating this condition, emphasizing the importance of early recognition and appropriate therapeutic interventions.
Collapse
Affiliation(s)
- Kamlesh Taori
- Department of Gastroenterology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra, India
| | - Vijendra Kirnake
- Department of Gastroenterology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra, India
| | - Parmeshwar Junare
- Department of Gastroenterology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra, India
| | - Vishal Padwale
- Department of Gastroenterology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra, India
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Craig TJ, Levy DS, Reshef A, Lumry WR, Martinez-Saguer I, Jacobs JS, Yang WH, Ritchie B, Aygören-Pürsün E, Keith PK, Busse P, Feuersenger H, Alexandru Bica M, Jacobs I, Pragst I, Magerl M. Garadacimab for hereditary angioedema attack prevention: long-term efficacy, quality of life, and safety data from a phase 2, randomised, open-label extension study. Lancet Haematol 2024; 11:e436-e447. [PMID: 38710185 DOI: 10.1016/s2352-3026(24)00081-4] [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: 01/09/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Garadacimab is a fully human immunoglobulin G4 monoclonal antibody targeting activated factor XII. This study evaluated long-term efficacy, health-related quality of life (HRQoL), and safety data for garadacimab in adults with hereditary angioedema. METHODS This global phase 2 study comprised a treatment period 1 (TP1: 12 weeks, double-blind, placebo-controlled) and a treatment period 2 (TP2: ≥44-week open-label extension). Patients aged 18-65 years with clinically confirmed hereditary angioedema were eligible. In TP1, 32 patients were randomly assigned (1:1:1:1) to receive subcutaneous garadacimab (75 mg, 200 mg, or 600 mg) or placebo every 4 weeks (once monthly). Randomisation was done using interactive response technology via block randomisation (block sizes 1-4). Subsequently, six additional patients in TP1 were assigned to open-label garadacimab 400 mg every 2 weeks. At the start of TP2, patients were re-randomised (if receiving placebo, garadacimab 75 mg, or garadacimab 400 mg) or continued to receive garadacimab 200 mg or garadacimab 600 mg once monthly. After a protocol amendment on March 20, 2020, patients originally assigned to the 600 mg dose were down-titrated to 200 mg at their next visit. The primary endpoint (published previously) was monthly attack rate for patients receiving 200 mg or 600 mg garadacimab in TP1 in the intention-to-treat population. Here, we assessed the impact of garadacimab on patient-reported and investigator-reported outcomes and HRQoL as well as long-term efficacy and safety. This trial is registered with ClinicalTrials.gov, NCT03712228, and is completed. FINDINGS Of 54 patients screened between Oct 29, 2018, and Aug 28, 2019, 32 randomised and six open-label patients completed TP1 and entered TP2 (20 in the garadacimab 200 mg group; 18 in the garadacimab 600 mg group; total 38 patients). Median age was 39·0 years (IQR 27·0-53·0), and 21 patients (55%) were female and 17 (45%) were male. In TP2, the median garadacimab exposure was 87·9 weeks (IQR 50·0-106·6) in the garadacimab 200 mg group and 44·1 weeks (24·1-56·1) in the garadacimab 600 mg group. Median monthly attack rates were 0·0 (IQR 0·0-0·1) in the garadacimab 200 mg group and 0·1 (0·0-0·4) in the garadacimb 600 mg group. Median reduction in monthly attack rate versus run-in was 100% (IQR 98-100) with garadacimab 200 mg. HRQoL improvements observed during TP1 with garadacimab were sustained throughout TP2. TP2 safety signals were consistent with TP1. Two patients experienced serious adverse events of diverticular perforation and asthma (not garadacimab-related). Treatment-emergent adverse events were mostly mild or moderate in severity. The most common adverse events were headache (nine of 38, 24%) and abdominal pain (seven of 38, 18%). There were no treatment-related deaths. INTERPRETATION Once-monthly garadacimab for more than 2 years in patients with hereditary angioedema was well tolerated and efficacious in reducing monthly attack rate and improving HRQoL. These results reveal the potential of long-term prophylactic treatment with 200 mg once-monthly garadacimab towards complete disease control of patients with hereditary angioedema. FUNDING CSL Behring.
Collapse
Affiliation(s)
- Timothy J Craig
- Allergy, Asthma and Immunology, Department of Medicine, Pediatrics and Biomedical Sciences, Penn State University, Hershey, PA, USA; Vinmec International Hospital, Hanoi, Vietnam.
| | - Donald S Levy
- Division of Allergy and Immunology, University of California, Irvine, CA, USA
| | - Avner Reshef
- Allergy, Immunology and Angioedema Center, Barzilai University Hospital, Ashkelon, Israel
| | | | | | | | - William H Yang
- Ottawa Allergy Research Corporation, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Bruce Ritchie
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Emel Aygören-Pürsün
- Department of Pediatrics, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Paul K Keith
- McMaster University Medical Centre Site, Hamilton, ON, Canada
| | | | | | | | | | - Ingo Pragst
- CSL Behring Innovation GmbH, Marburg, Germany
| | - Markus Magerl
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Berlin, Germany; Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| |
Collapse
|
9
|
D'Apolito M, Santacroce R, Vazquez DO, Cordisco G, Fantini CA, D'Andrea G, Leccese A, Colia AL, Martinez P, Zanichelli A, Josviack D, Margaglione M. DAB2IP associates with hereditary angioedema: Insights into the role of VEGF signaling in HAE pathophysiology. J Allergy Clin Immunol 2024:S0091-6749(24)00558-X. [PMID: 38823490 DOI: 10.1016/j.jaci.2024.05.017] [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: 01/21/2024] [Revised: 05/09/2024] [Accepted: 05/24/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND In the recent years, there was an important improvement in the understanding of the pathogenesis of hereditary angioedema (HAE). Notwithstanding, in a large portion of patients with unknown mutation (HAE-UNK) the genetic cause remains to be identified. OBJECTIVES To identify new genetic targets associated with HAE, a large Argentine family with HAE-UNK spanning 3 generations was studied. METHODS Whole exome sequencing was performed on affected family members to identify potential genetic variants associated with HAE-UNK. In silico analyses and experimental studies were applied to assess the role of the identified gene variant. RESULTS A missense variant (p.D239N) in DAB2IP was identified. The variant occurred in the C2-domain, the region interacting with vascular endothelial growth factor receptor 2 (VEGFR2). It was found to be rare, and predicted to have a detrimental effect on the functionality of DAB2IP. Protein structure modeling predicted changes in the mutant p.D239N protein structure, impacting protein stability. The p.D239N variant affected the subcellular localization of VEGFR2. Cells transfected with the DAB2IP-239N transcript exhibited an intracellular distribution, and VEGFR2 remained associated with the cell membrane. The altered localization pattern indicated reduced colocalization of the mutant protein with VEGFR2, suggesting a diminished ability of VEGFR2 binding. CONCLUSIONS The study identified a novel missense variant (p.D239N) in DAB2IP in a family with HAE-UNK and highlighted the role of dysregulated VEGF-mediated signaling in altered endothelial permeability. DAB2IP loss-of-function pathogenic variants lead to the impairment of the endothelial VEGF/VEGFR2 ligand system and represent a new pathophysiologic cause of HAE-UNK.
Collapse
Affiliation(s)
- Maria D'Apolito
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Rosa Santacroce
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | | | - Giorgia Cordisco
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | | | - Giovanna D'Andrea
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Angelica Leccese
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Anna Laura Colia
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Pablo Martinez
- Universidad Nacional del Sur, Argentina Hospital Penna de Bahia Blanca, Bahia Blanca, Argentina
| | - Andrea Zanichelli
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy; Operative Unit of Medicine, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Darío Josviack
- Instituto de Medicina Respiratoria, Rafaela, Santa Fe, Argentina
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy.
| |
Collapse
|
10
|
Riedl MA, Bordone L, Revenko A, Newman KB, Cohn DM. Clinical Progress in Hepatic Targeting for Novel Prophylactic Therapies in Hereditary Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:911-918. [PMID: 38142864 DOI: 10.1016/j.jaip.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/09/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023]
Abstract
Hereditary angioedema (HAE) is typically caused by a deficiency of the protease inhibitor C1 inhibitor (C1INH). The absence of C1INH activity on plasma kallikrein and factor XIIa leads to overproduction of the vasoactive peptide bradykinin, with resulting angioedema. As the primary site of C1INH and prekallikrein production, the liver is recognized as an important therapeutic target in HAE, leading to the development of hepatic-focused treatment strategies such as GalNAc-conjugated antisense technology and gene modification. This report reviews currently available data on hepatic-focused interventions for HAE that have advanced into human trials. Donidalorsen is an investigational GalNAc3-conjugated antisense oligonucleotide that binds to prekallikrein mRNA in the liver and reduces the expression of prekallikrein. Phase 2 data with subcutaneous donidalorsen demonstrated a significant reduction in HAE attack rate compared with placebo. Phase 3 trials are underway. ADX-324 is a GalNAc3-conjugated short-interfering RNA being investigated in HAE. BMN 331 is an investigational AAV5-based gene therapy vector that expresses wild-type human C1INH and is targeted to hepatocytes. A single intravenous dose of BMN 331 is intended to replace the defective SERPING1 gene and enable patients to produce functional C1INH. A first-in-human phase 1/2 study is ongoing with BMN 331. NTLA-2002 is an investigational in vivo clustered regularly interspaced short palindromic repeats/Cas9-based therapy designed to knock out the prekallikrein-coding KLKB1 gene in hepatocytes; a phase 1/2 study is ongoing. Findings from these and other ongoing studies are highly anticipated with the expectation of expanding the array of treatment options in HAE.
Collapse
Affiliation(s)
- Marc A Riedl
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif.
| | | | | | | | - Danny M Cohn
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
11
|
Yong PFK, Guilarte M. Prodromal symptoms of hereditary angioedema (HAE) attacks: A patient survey in UK and Spain. Allergy 2024. [PMID: 38462815 DOI: 10.1111/all.16099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 02/22/2024] [Accepted: 02/29/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Patrick F K Yong
- Clinical Immunology and Allergy, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Mar Guilarte
- Allergy Department, National Reference Hereditary Angioedema Center (CSUR), Hospital universitari Vall d'Hebron, Barcelona, Spain
- Allergy Research Unit, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| |
Collapse
|
12
|
Tsutsui E, Gomez-Hernandez C, Nguyen D, Yang Y, Ma S. Recurrent Isolated Uvular Angioedema Associated With Intranasal Cocaine Use: A Case Report. Cureus 2024; 16:e56818. [PMID: 38654800 PMCID: PMC11036027 DOI: 10.7759/cureus.56818] [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] [Accepted: 03/24/2024] [Indexed: 04/26/2024] Open
Abstract
Isolated uvular angioedema, or Quincke's disease, is a rare manifestation with various potential causes. This article presents the first documented case of recurrent isolated uvular angioedema associated with intranasal cocaine use. The patient, a 43-year-old man, exhibited acute symptoms of sore throat, throat swelling, and difficulty breathing, with a history of a similar episode a few years prior. Both episodes occurred following intranasal cocaine use. Examination revealed an enlarged uvula obstructing the airway. The patient was treated with epinephrine, antihistamines, and corticosteroids with resolution of the uvular edema. This case highlights the importance of considering cocaine as a potential causative agent in isolated uvular angioedema and emphasizes the need for patient education to avoid further cocaine use.
Collapse
Affiliation(s)
- Erika Tsutsui
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Destiny Nguyen
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Yuhong Yang
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Songhui Ma
- Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, USA
| |
Collapse
|
13
|
Piotrowicz-Wójcik K, Bulanda M, Czarnobilska E, Porebski G. Clinical Characteristics and Quality of Life in a Cohort of Polish Pediatric Patients with Hereditary Angioedema. CHILDREN (BASEL, SWITZERLAND) 2024; 11:237. [PMID: 38397349 PMCID: PMC10887984 DOI: 10.3390/children11020237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/25/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024]
Abstract
Hereditary angioedema (HAE) is a rare genetic disease. It is characterized by recurrent attacks of angioedema. Evidence to what extent it affects patient functioning is limited in the pediatric population. We aimed to determine the clinical characteristics and management of Polish children with HAE and to measure the health-related quality of life (HRQoL) of these patients. This cross-sectional study was conducted among 21 pediatric patients and their caregivers, as well as 21 respective controls randomly selected from the general population. During routine follow-up visits, standardized pediatric quality of life questionnaires (PedsQLTM 4.0) were administered to all caregivers and adolescents (≥13 years). Caregivers also completed a structured medical interview regarding the clinical characteristics and treatment of children with HAE during the previous six months. During this period, 57% of patients had low (group I), 24% moderate (group II), and 19% high (group III) HAE activity, corresponding to ≥10 attacks per 6 months. None of the patients received long-term prophylaxis. The children in group III had a lower HRQoL than other groups and controls on all dimensions of the PedsQLTM 4.0. The lowest scores in all groups were observed in the emotional functioning domain. Our data demonstrate that the burden of HAE on the quality of life of pediatric patients and their families encompasses a wide range of daily functioning.
Collapse
Affiliation(s)
| | | | | | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland; (K.P.-W.); (M.B.); (E.C.)
| |
Collapse
|
14
|
Ghebrehiwet B, Joseph K, Kaplan AP. The bradykinin-forming cascade in anaphylaxis and ACE-inhibitor induced angioedema/airway obstruction. FRONTIERS IN ALLERGY 2024; 5:1302605. [PMID: 38332896 PMCID: PMC10850323 DOI: 10.3389/falgy.2024.1302605] [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: 09/26/2023] [Accepted: 01/15/2024] [Indexed: 02/10/2024] Open
Abstract
Anaphylaxis is a potentially life-threatening multi-system allergic reaction to a biological trigger resulting in the release of potent inflammatory mediators from mast cells and basophils and causing symptoms in at least two organ systems that generally include skin, lungs, heart, or gastrointestinal tract in any combination. One exception is profound hypotension as an isolated symptom. There are two types of triggers of anaphylaxis: immunologic and non-Immunologic. Immunologic anaphylaxis is initiated when a foreign antigen directly binds to IgE expressed on mast cells or basophils and induces the release of histamine and other inflammatory substances resulting in vasodilation, vascular leakage, decreased peripheral vascular resistance, and heart muscle depression. If left untreated, death by shock (profound hypotension) or asphyxiation (airway obstruction) can occur. The non-immunologic pathway, on the other hand, can be initiated in many ways. A foreign substance can directly bind to receptors of mast cells and basophils leading to degranulation. There can be immune complex activation of the classical complement cascade with the release of anaphylatoxins C3a and C5a with subsequent recruitment of mast cells and basophils. Finally, hyperosmolar contrast agents can cause blood cell lysis, enzyme release, and complement activation, resulting in anaphylactoid (anaphylactic-like) symptoms. In this report we emphasize the recruitment of the bradykinin-forming cascade in mast cell dependent anaphylactic reactions as a potential mediator of severe hypotension, or airway compromise (asthma, laryngeal edema). We also consider airway obstruction due to inhibition of angiotensin converting enzyme with a diminished rate of endogenous bradykinin metabolism, leading not only to laryngeal edema, but massive tongue swelling with aspiration of secretions.
Collapse
Affiliation(s)
- Berhane Ghebrehiwet
- Division of Rheumatology, Allergy, and Clinical Immunology, SUNY-Stony Brook, Stony Brook, NY, United States
| | | | - Allen P. Kaplan
- Division of Pulmonary and Critical Care Medicine, The Medical University of South Carolina, Charleston, SC, United States
| |
Collapse
|
15
|
Beaini H, Bjorkman C, Johnson K, Araj FG. Sirolimus potentiated angioedema: A case report and review of the literature. Open Med (Wars) 2024; 19:20230884. [PMID: 38205154 PMCID: PMC10775924 DOI: 10.1515/med-2023-0884] [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: 10/18/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024] Open
Abstract
Introduction In the realm of organ transplantation, particularly heart transplantation, angioedema presents a significant challenge. This clinical condition ranges from minor facial edema to life-threatening swelling of vital structures. Its multifactorial etiology involves various factors and mechanisms, including C1 esterase inhibitor deficiency, food allergen hypersensitivity, and adverse drug reactions, notably involving angiotensin-converting enzyme (ACE) inhibitors and mechanistic target of rapamycin inhibitors (mTOR-Is). We present a rare case of sirolimus potentiated angioedema in a patient with long-standing ACE inhibitor therapy. Case A 52-year-old male with a history of heart transplant developed severe upper and lower lip edema. The patient had been on Lisinopril without any adverse events. However, sirolimus was recently added to his drug regimen. Sirolimus potentiated angioedema was suspected. Intervention Intravenous methylprednisolone, famotidine, and diphenhydramine were initiated, and both lisinopril and sirolimus were discontinued. The patient showed improvement and was discharged with oral antihistamines. Lessons Transplant physicians should be aware of the life-threatening interaction between ACE inhibitors and mTOR-Is like sirolimus. Consideration should be given to switching from an ACE inhibitor to an angiotensin-receptor blocker when initiating patients on mTOR-Is.
Collapse
Affiliation(s)
- Hadi Beaini
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, United States
| | - Carol Bjorkman
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, United States
| | - Kelly Johnson
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, United States
| | - Faris G. Araj
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Professional Office Bldg. 2 Suite 600, 5939 Harry Hines Blvd.Dallas, TX, 75390-9252, United States
| |
Collapse
|
16
|
Christiansen SC, Wilmot J, Castaldo AJ, Zuraw BL. The US Hereditary Angioedema Association Scientific Registry: hereditary angioedema demographics, disease severity, and comorbidities. Ann Allergy Asthma Immunol 2023; 131:766-774.e8. [PMID: 37619776 DOI: 10.1016/j.anai.2023.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) and idiopathic nonhistaminergic angioedema (INHA) are ultra-rare diseases whose natural histories and comorbidities are incompletely understood. OBJECTIVE To develop a national patient-centric registry to address these deficiencies in our knowledge and improve our ability to assess the real-world impact of therapeutic interventions. METHODS Data from members of the US HAE Association were collected into an online registry between 2009 and April 7, 2021. Cohorts were categorized by reported physician diagnosis. Patient reported data were collected using a series of questionnaires. Demographic, natural history, and family history outcomes of the HAE due to C1 inhibitor deficiency (HAE-C1INH) participants were compared with those of the combined HAE with normal C1 inhibitor (HAE-nl-C1INH) plus INHA group. The prevalence of comorbid conditions in the HAE-C1INH group was compared with the general US population. RESULTS A total of 485 HAE-C1INH, 26 HAE-nl-C1INH, and 70 INHA participants were included in the analysis. Delay to diagnosis was shorter in HAE-C1INH (5 vs 11 years), but both had decreasing delays over time. Differences in attack frequency and location were found between the groups. Morbidity surrogates including emergency department visits, hospitalizations, unnecessary abdominal surgeries, and intubations were strikingly high as was mortality with 36.9% of HAE-C1INH and 15.4% of HAE-nl-C1INH participants reporting family members who died from a HAE attack. Females with HAE-C1INH had a significant increase in the prevalence of depression, sleep disorders, kidney disease, anemia, and hepatitis. Cardiovascular comorbidities were significantly reduced in the HAE-C1INH group. CONCLUSION The US HAEA Scientific Registry provides a mechanism to enhance our knowledge of HAE and INHA.
Collapse
Affiliation(s)
| | - Joyce Wilmot
- US Hereditary Angioedema Association, Fairfax, Virginia
| | | | - Bruce L Zuraw
- Department of Medicine, University of California San Diego, La Jolla, California; Medicine Service, Veterans Administration Healthcare, San Diego, California.
| |
Collapse
|
17
|
Prenzel F, Abraham S, Hirche C, Müller G, Kaiser S, Serdani‐Neuhaus L, Zingel R, Martinez‐Saguer I. Epidemiology and treatment of children with hereditary angioedema in Germany: A retrospective database study. Clin Transl Allergy 2023; 13:e12313. [PMID: 38006382 PMCID: PMC10642561 DOI: 10.1002/clt2.12313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/11/2023] [Accepted: 10/26/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Hereditary angioedema (HAE) is a potentially life-threatening inherited disease that causes recurrent, serious, and debilitating episodes of swelling. While evidence has improved in adult patients, data on the epidemiology and treatment of pediatric patients with HAE remain very limited. The aim of this study was to determine the incidence and prevalence of pediatric patients with HAE aged <12 years, as well as treatment patterns, co-medication, and specialties involved. METHODS In this retrospective study (2016-2021), the German IQVIATM pharmacy claims (LRx) database was used to analyze prescriptions of HAE-specific treatments and co-medications. RESULTS We found an HAE prevalence in pediatric patients aged <12 years of 2.51:100,000 and a 12-month prevalence of up to 1.02:100,000 between 2016 and 2021. Most HAE treatments were prescribed by outpatient clinics and pediatricians, with an increasing proportion of icatibant as an on-demand treatment and low rates of long-term prophylaxis (LTP). The prescription rate of analgesics as the most common co-medication decreased notably after HAE diagnosis. CONCLUSION Our findings provide insights into the epidemiology and current pediatric HAE treatment landscape in Germany. The obtained HAE prevalence in pediatric patients aged <12 years was even higher than the previously reported average of overall cohorts, whereas the LTP rate was low, which might indicate an unmet need for newer LTP treatment options in pediatric patients.
Collapse
Affiliation(s)
- Freerk Prenzel
- Department of PediatricsUniversity of Leipzig Medical CenterLeipzigGermany
| | - Susanne Abraham
- Department of DermatologyUniversity Allergy CenterUniversity Hospital Carl Gustav CarusTU DresdenGermany
| | | | | | | | | | | | | |
Collapse
|
18
|
Landry L, Witten T, Anwar AI, Jackson CN, Talbot NC, Ahmadzadeh S, Varrassi G, Shekoohi S, Kaye AD. Angiotensin-Converting Enzyme Inhibitors and Other Medications Associated With Angioedema. Cureus 2023; 15:e49306. [PMID: 38957198 PMCID: PMC11218608 DOI: 10.7759/cureus.49306] [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: 11/10/2023] [Accepted: 11/23/2023] [Indexed: 07/04/2024] Open
Abstract
Angioedema is a localized swelling of the dermis, subcutaneous tissues, and/or submucosal tissues caused by fluid extravasation into these tissues. Angioedema is associated with certain vasoactive molecules and is typically mediated by histamine or bradykinin. It manifests clinically as facial edema, swelling of the extremities and urogenital area, and potential involvement of the larynx, leading to dyspnea and inspiratory stridor, which can become life-threatening. Histamine-mediated angioedema is associated with urticaria and pruritus and will show classic signs of allergic (type 1 hypersensitivity) reactions. Bradykinin-mediated angioedema is often familial (hereditary angioedema) and is more often associated with gastrointestinal symptoms (abdominal pain, nausea, vomiting, diarrhea), edema of the extremities and trunk, and a lack of urticaria and pruritus. Angiotensin-converting enzyme inhibitors (ACEIs) are a class of medications commonly prescribed for hypertension, heart failure, and diabetic nephropathy. ACEIs are associated with an increased risk of angioedema, which can range from a mild reaction to severe and life-threatening. ACEI-induced angioedema is a bradykinin-mediated reaction that can occur in individuals with a genetic predisposition. Other medications, such as angiotensin receptor blockers, nonsteroidal anti-inflammatory drugs, and certain antibiotics, most notably those in the beta-lactam class, can also cause drug-induced angioedema. The present investigation describes current knowledge of the pathophysiology, epidemiology, clinical manifestations, predisposing factors, and management of drug-induced angioedema.
Collapse
Affiliation(s)
- Layne Landry
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Taylor Witten
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Corrie N Jackson
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Norris C Talbot
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| |
Collapse
|
19
|
Lima H, Zheng J, Wong D, Waserman S, Sussman GL. Pathophysiology of bradykinin and histamine mediated angioedema. FRONTIERS IN ALLERGY 2023; 4:1263432. [PMID: 37920409 PMCID: PMC10619149 DOI: 10.3389/falgy.2023.1263432] [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: 07/19/2023] [Accepted: 09/26/2023] [Indexed: 11/04/2023] Open
Abstract
Angioedema is characterized by swelling localized to the subcutaneous and submucosal tissues. This review provides an overview of angioedema, including the different types, triggers, and underlying pathophysiologic mechanisms. Hereditary and acquired angioedema are caused by dysregulation of the complement and kinin pathways. In contrast, drug-induced and allergic angioedema involve the activation of the immune system and release of vasoactive mediators. Recent advances in the understanding of the pathophysiology of angioedema have led to the development of targeted therapies, such as monoclonal antibodies, bradykinin receptor antagonists, and complement inhibitors, which promise to improve clinical outcomes in patients with this challenging condition. To accurately diagnose and manage angioedema, an understanding of this condition's complex and varied pathophysiology is both necessary and critical.
Collapse
Affiliation(s)
- Hermenio Lima
- LEADER Research Inc., Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Dennis Wong
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gordon L. Sussman
- Department of Medicine and Division of Clinical Immunology & Allergy, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
20
|
Santos GM, Andrade FM, Marrana C, Gouveia S. The Importance of Patient Empowerment: A Clinical Case of Hereditary Angioedem. Cureus 2023; 15:e47644. [PMID: 38021619 PMCID: PMC10668623 DOI: 10.7759/cureus.47644] [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] [Accepted: 10/22/2023] [Indexed: 12/01/2023] Open
Abstract
Hereditary angioedema (HAE) is a rare condition characterized by recurrent episodes of angioedema without urticaria or pruritus. Untreated angioedema can cause significant work absenteeism and, in rare cases, be lethal due to laryngeal involvement and suffocation. The authors report a case of a patient with laryngeal involvement who was unaware of the severity of their condition. Effective medical training in patient empowerment is essential, and it is an irreplaceable element in healthcare, as it contributes to therapeutic success.
Collapse
Affiliation(s)
| | | | | | - Sara Gouveia
- Family Medicine, SESARAM EPERAM, Madeira Island, PRT
| |
Collapse
|
21
|
Tachdjian R, Kaplan AP. A Comprehensive Management Approach in Pediatric and Adolescent Patients With Hereditary Angioedema. Clin Pediatr (Phila) 2023; 62:973-980. [PMID: 36908071 PMCID: PMC10478326 DOI: 10.1177/00099228231155703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Hereditary angioedema (HAE) is a rare autosomal-dominant disorder; most cases are characterized by low plasma levels of C1 esterase inhibitor (C1-INH). Clinical manifestations of HAE due to C1-INH deficiency include unpredictable, acute, recurrent episodes of nonpruritic swelling that can affect the face, trunk, limbs, and the respiratory, gastrointestinal, and genitourinary tracts. Attacks can be disfiguring, disabling, painful, and even life-threatening if laryngeal swelling occurs. Symptoms of HAE generally manifest in childhood. Effective medications are available and approved to treat HAE in children. However, evidence informing use of these medications in pediatric clinical practice is limited. Hereditary angioedema management plans are critical to optimize outcomes and should address on-demand treatment for acute attacks and plans to prevent potentially fatal laryngeal attacks. The plan should also comprise a holistic approach to address nonclinical aspects of HAE, including quality of life (QoL) and psychological issues. This article provides an overview of HAE management principles that health care providers can apply to treat pediatric patients to improve their QoL.
Collapse
Affiliation(s)
- Raffi Tachdjian
- UCLA School of Medicine, Los Angeles, CA, USA
- Division of Allergy and Immunology, Providence St. John Medical Center, Santa Monica, CA, USA
| | - Allen P. Kaplan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
22
|
Pagovich OE, Crystal RG. Gene Therapy for Immunoglobulin E, Complement-Mediated, and Eosinophilic Disorders. Hum Gene Ther 2023; 34:986-1002. [PMID: 37672523 PMCID: PMC10616964 DOI: 10.1089/hum.2023.039] [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: 03/10/2023] [Accepted: 06/30/2023] [Indexed: 09/08/2023] Open
Abstract
Immunoglobulin E, complement, and eosinophils play an important role in host defense, but dysfunction of each of these components can lead to a variety of human disorders. In this review, we summarize how investigators have adapted gene therapy and antisense technology to modulate immunoglobulin E, complement, and/or eosinophil levels to treat these disorders.
Collapse
Affiliation(s)
- Odelya E. Pagovich
- Department of Genetic Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Ronald G. Crystal
- Department of Genetic Medicine, Weill Cornell Medical College, New York, New York, USA
| |
Collapse
|
23
|
Nieto S, Madrigal I, Contreras F, Vargas ME. Real-world experience of hereditary angioedema (HAE) in Mexico: A mixed-methods approach to describe epidemiology, diagnosis, and treatment patterns. World Allergy Organ J 2023; 16:100812. [PMID: 37727628 PMCID: PMC10506135 DOI: 10.1016/j.waojou.2023.100812] [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: 03/17/2023] [Revised: 08/03/2023] [Accepted: 08/17/2023] [Indexed: 09/21/2023] Open
Abstract
Introduction and objectives Due to the lack of structured and systematic information available, the aim of this study was to describe the epidemiology, diagnosis, healthcare processes, and treatment patterns of hereditary angioedema (HAE) in Mexico. To achieve this, different data sources were consulted regarding medical literature, structured health system databases, and angioedema-specialized physicians (AEP) opinion regarding HAE. Material and methods A mixed methods approach was conducted in 4 phases: I) systematic literature review (SLR) and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; II) review of national health system (NHS) databases and systematic reports; III) physician survey; and IV) an epidemiologic model. ICD 10 D84.1 encoded records from the NHS were used to estimate the number of patients with HAE attended and treated during 2019. A survey was implemented to increase understanding of the clinical profile and treatments used. Results A prevalence rate of 0.9/50 000 inhabitants was estimated for 2019. In the same year, an estimated 317 HAE type 1 patients were recorded in the NHS, aged ≥11 years old. The most frequent clinical symptoms were cutaneous edema (67.5%) and abdominal pain (47.9%). A severe episode with laryngeal edema appeared in 27.5% of cases. Acute episodes were mainly moderate to severe (77.0%), with an annual per capita frequency of emergency visits of 7.6 patient-year (range 1-12/patient-year). The main reasons for hospitalization corresponded to laryngeal facial, tongue, and abdominal edemas, representing 73.3% of annual ICD 10 D84.1 reported hospitalizations. The main treatments that patients with HAE received were fresh frozen plasma for acute attacks and danazol for short-term prophylaxis (STP). Conclusions Despite efforts to make HAE visible, according to this study, cases recognized and treated in the NHS represent only 16.6% of the estimated prevalence.
Collapse
Affiliation(s)
- Sandra Nieto
- Specialty in Pediatrics and Pediatric Hematology. Genetics of Nutrition Unit, Instituto Nacional de Pediatría, CDMX, Mexico
| | - Ileana Madrigal
- Specialty in Allergy and Immunology. High Specialty Medical Unit (UMAE), Centro Médico Nacional de Occidente, IMSS, Guadalajara, Mexico
| | - Francisco Contreras
- Specialty in Pediatrics and Allergy and Clinical Immunology. Allergy and Immunology Department, Instituto Nacional de Pediatría, CDMX, Mexico
| | - María Eugenia Vargas
- Specialty in Internal Medicine, Allergy and Clinical Immunology Master's Degree in History. Allergy and Immunology Department, Centro Médico Nacional 20 de Noviembre, ISSSTE, CDMX, Mexico
| |
Collapse
|
24
|
Betschel SD, Banerji A, Busse PJ, Cohn DM, Magerl M. Hereditary Angioedema: A Review of the Current and Evolving Treatment Landscape. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2315-2325. [PMID: 37116793 DOI: 10.1016/j.jaip.2023.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/30/2023]
Abstract
Hereditary angioedema (HAE) is a rare disease characterized by sudden and often unprovoked episodes of swelling that can be potentially life-threatening when it involves the upper airway. The treatment options for both acute episodes of HAE and LTP, used to minimize the frequency and severity of angioedema attacks, were limited historically to very few options, had considerable side effects, and/or had considerable burden of treatment. Fortunately, through the elucidation of the pathophysiology of HAE, the development of newer targeted therapies has been possible both for acute therapy and long-term prophylaxis and even more are on the horizon. Because of the rapid development of these therapies, it can be challenging for clinicians to keep abreast of newer and developing treatments for HAE. This review article will outline the current and potential future treatments for HAE. It will also highlight important considerations when treating special HAE patient populations including women and pediatric patients.
Collapse
Affiliation(s)
- Stephen D Betschel
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Aleena Banerji
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Mass.
| | - Paula J Busse
- Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Danny M Cohn
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Markus Magerl
- Institute of Allergology, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin), Berlin, Germany; Department of Immunology and Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany
| |
Collapse
|
25
|
Lyons JJ, Farkas H, Germenis AE, Rijavec M, Smith TD, Valent P. Genetic Variants Leading to Urticaria and Angioedema and Associated Biomarkers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2286-2301. [PMID: 37263349 DOI: 10.1016/j.jaip.2023.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/20/2023] [Accepted: 05/15/2023] [Indexed: 06/03/2023]
Abstract
Advances in next generation sequencing technologies, as well as their expanded accessibility and clinical use over the past 2 decades, have led to an exponential increase in the number of identified single gene disorders. Among these are primary atopic disorders-inborn errors of immunity resulting in severe allergic phenotypes as a primary presenting feature. Two cardinal aspects of type I immediate hypersensitivity allergic reactions are hives and angioedema. Mast cells (MCs) are frequent primary drivers of these symptoms, but other cells have also been implicated. Even where MC degranulation is believed to be the cause, mediator-induced symptoms may greatly vary among individuals. Angioedema-particularly in the absence of hives-may also be caused by hereditary angioedema conditions resulting from aberrant regulation of contact system activation and excessive bradykinin generation or impairment of vascular integrity. In these patients, swelling can affect unpredictable locations and fail to respond to MC-directed therapies. Genetic variants have helped delineate key pathways in the etiology of urticaria and nonatopic angioedema and led to the development of targeted therapies. Herein, we describe the currently known inherited and acquired genetic causes for these conditions, highlight specific features in their clinical presentations, and discuss the benefits and limitations of biomarkers that can help distinguish them.
Collapse
Affiliation(s)
- Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Anastasios E Germenis
- Department of Immunology and Histocompatibility, School of Medicine, University of Thessaly, Larissa, Greece
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia; Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Tukisa D Smith
- Division of Rheumatology, Allergy and Immunology, University of California San Diego, La Jolla, Calif
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
26
|
Ren Z, Zhao S, Li T, Wedner HJ, Atkinson JP. Insights into the pathogenesis of hereditary angioedema using genetic sequencing and recombinant protein expression analyses. J Allergy Clin Immunol 2023; 151:1040-1049.e5. [PMID: 36587848 PMCID: PMC10449387 DOI: 10.1016/j.jaci.2022.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/09/2022] [Accepted: 11/29/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The pathogenesis of hereditary angioedema (HAE) type I and type II is linked to defective C1 esterase inhibitor (C1-INH) encoded by the SERPING1 gene. There are substantial variabilities in the clinical presentations of patients with HAE that are not directly correlated to the serum levels of C1-INH. The impact of SERPING1 variants on C1-INH expression, structure, and function is incompletely understood. OBJECTIVE To investigate the influence of SERPING1 variants on the C1-INH expression, structure, and function of 20 patients with HAE from 14 families with no prior genetic diagnosis. METHODS Patients underwent whole-exome sequencing (WES). If no variants were identified, whole-genome sequencing (WGS) was performed. Except for the frameshift and large deletions, each C1-INH variant was recombinantly produced and, if synthesized and secreted, was subjected to structural, oligosaccharide, and functional analyses. RESULTS We identified 11 heterozygous variants in the SERPING1 gene, of which 5 were classified as pathogenic (E85Dfs∗63, N166Qfs∗91, K201Qfs∗56, P399A, and R466H) and 6 as variants of uncertain significance (C130W, I224S, N272del, K273del, L349F, and F471C). Three large heterozygous deletions were discovered through WGS. Our data indicate that C130W, N272del, P399A, and F471C are poorly synthesized, I224S prevents proper C1-INH folding, and K273del impairs C1-INH function by adding an additional oligosaccharide. Further evaluation suggests that compound variant P399A/L349F contributes to a more severe clinical phenotype. CONCLUSIONS Our combined approach of WES and WGS uncovered SERPING1 gene alternations in each patient. The recombinant protein production followed by systematic antigenic, structural, and functional assessment facilitates the identification of underlying pathogenic mechanisms in HAE.
Collapse
Affiliation(s)
- Zhen Ren
- Division of Allergy and Immunology, Department of Medicine, Washington University School of Medicine, St Louis, Mo.
| | - Shuangxia Zhao
- Department of Molecular Diagnostics and Endocrinology, The Core Laboratory in Medical Center of Clinical Research, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tiandao Li
- Department of Developmental Biology, Washington University School of Medicine, St Louis, Mo
| | - H James Wedner
- Division of Allergy and Immunology, Department of Medicine, Washington University School of Medicine, St Louis, Mo
| | - John P Atkinson
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St Louis, Mo
| |
Collapse
|
27
|
Launay D, Bouillet L, Boccon-Gibod I, Trumbic B, Gobert D, Fain O. [Hereditary angioedema and its new treatments: An update]. Rev Med Interne 2023:S0248-8663(23)00061-9. [PMID: 36872215 DOI: 10.1016/j.revmed.2023.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/20/2023] [Accepted: 01/30/2023] [Indexed: 03/06/2023]
Abstract
Hereditary angioedema, with or without deficient C1 inhibitor level or function, is a rare disease characterized by recurrent attacks of noninflammatory subcutaneous and/or submucosal edema. It may be life-threatening and substantially affects quality of life. Attacks may be spontaneous or induced, in a setting of emotional stress, by infections or physical trauma, in particular. As the key mediator is bradykinin, this angioedema does not respond to the usual treatments of mast cell-mediated angioedema (antihistamines, corticosteroids, adrenaline), which is much more frequent. Therapeutic management of hereditary angioedema first consists in treating severe attacks with a selective B2 bradykinin receptor antagonist or a C1 inhibitor concentrate. The latter or an attenuated androgen (danazol) can be used for short-term prophylaxis. Therapeutic solutions conventionally proposed for long-term prophylaxis (danazol, antifibrinolytics [tranexamic acid], C1 inhibitor concentrate) vary in efficacy and/or pose problems of safety or ease of use. Kallikrein inhibitors (subcutaneous lanadelumab, oral berotralstat) recently made available as disease-modifying treatment constitute an important advance in long-term prophylaxis of hereditary angioedema attacks. The advent of these new drugs is accompanied by a new ambition for patients: optimize control of the disease and thereby minimize its impact on quality of life.
Collapse
Affiliation(s)
- D Launay
- University Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, service de médecine interne et immunologie clinique, centre de référence angioedèmes à kinine (CREAK), 59000 Lille, France.
| | - L Bouillet
- CHU Grenoble Alpes, service de médecine interne, centre de référence des angioedèmes (CREAK), 38000 Grenoble, France; University Grenoble Alpes, UMR 5525 TIMC-IMAG, laboratoire T-Raig, 38000 Grenoble, France
| | - I Boccon-Gibod
- Service de médecine interne et immunologie clinique, centre hospitalo-universitaire de Grenoble, CHUGA, centre de référence des angioedèmes national (CREAK) et international (ACARE), Grenoble, France
| | | | - D Gobert
- Sorbonne université, AP-HP, service de médecine interne, hôpital Saint-Antoine, 75012 Paris, France
| | - O Fain
- Sorbonne université, AP-HP, service de médecine interne, hôpital Saint-Antoine, 75012 Paris, France
| |
Collapse
|
28
|
Chong-Neto HJ. A narrative review of recent literature of the quality of life in hereditary angioedema patients. World Allergy Organ J 2023; 16:100758. [PMID: 36994443 PMCID: PMC10040818 DOI: 10.1016/j.waojou.2023.100758] [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: 06/02/2022] [Revised: 01/30/2023] [Accepted: 03/03/2023] [Indexed: 03/31/2023] Open
Abstract
Hereditary angioedema (HAE) is a rare disorder that causes unpredictable and debilitating cutaneous and submucosal edema and can lead to death. HAE can impair patients' ability to perform daily activities, proportional to pain severity, with patients reporting lower productivity, missed time from work or school and potentially resulting in missed career and educational opportunities. Many patients with HAE experience a significant psychological burden, including anxiety and depression. Available treatment aims to prevent and/or treat HAE attacks as they occur, to reduce morbidity and mortality and, finally, to improve health-related quality of life. Two different validated specific angioedema instruments are available to assess patients' quality of life. The Angioedema Quality of Life Questionnaire (AE-QoL) examines diagnosed patients' quality of life but is not specific for HAE. The disease-specific questionnaire is the Hereditary Angioedema Quality of Life (HAE-QoL), and the first used for hereditary angioedema with C1 inhibitors (C1-INH) deficiency. These quality-of-life instruments are helpful to the HAE patients' assessment and to the development of better therapeutic strategies as clinical tools, as defined by international guidelines. Considering this context, this review was conducted to compare the effects of acute vs. long-term prophylaxis on HAE patients' health-related quality of life. In addition, the prevalence of anxiety and depression among these individuals was also reviewed.
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Sheikh F, Alajlan H, Albanyan M, Alruwaili H, Alawami F, Sumayli S, Al Gazlan S, Abu Awwad S, Al-Dhekri H, Al-Saud B, Arnaout R, Alrayes H, Sayes N, Al-Hamed MH, Al-Mousa H, AlShareef S, Alazami AM. Phenotypic and Genotypic Characterization of Hereditary Angioedema in Saudi Arabia. J Clin Immunol 2023; 43:479-484. [PMID: 36348183 DOI: 10.1007/s10875-022-01399-y] [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: 06/06/2021] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
Abstract
Hereditary angioedema (HAE) is a potentially life-threatening autosomal dominant disorder affecting roughly 1:50,000 individuals. It is commonly characterized by swelling of the larynx, gastrointestinal tract, extremities, and skin. There is growing genetic heterogeneity associated with this disease but more than 95% of mutations are found in SERPING1, the gene which encodes complement 1 inhibitor (C1-INH). HAE cohorts from several populations have been published but no large scale study has been reported from the Arab world to date. Here we document the clinical and genetic findings of HAE patients from a single Saudi institution, which is a major referral center at the national level. A total of 51 patients across 17 unrelated families were recruited including two large multi-generational families, of which one contained an in-frame exonic deletion that was resolved through MLPA. Two cases were negative for all the genes we tested (including F12, PLG, ANGPT1, MYOF, KNG1, and HS3ST6). The predominant HAE subtype in our cohort was type I, at 76%. We were able to uncover a mutation in 49 patients (96%). No type III (normal C1-INH) patients were encountered in the clinic, suggesting that this subtype does not play a major role in HAE pathogenesis in Saudi Arabia. Additionally, the existence of four patients with consistently normal complement 4 (C4) levels alongside abnormal C1-INH profiles highlights the utility of dual screening for both proteins in suspected patients.
Collapse
Affiliation(s)
- Farrukh Sheikh
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Huda Alajlan
- Translational Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital & Research Centre, MBC 3, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Maram Albanyan
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hibah Alruwaili
- Translational Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital & Research Centre, MBC 3, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Fatimah Alawami
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Safia Sumayli
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sulaiman Al Gazlan
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sawsan Abu Awwad
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
| | - Hasan Al-Dhekri
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
| | - Bandar Al-Saud
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Rand Arnaout
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hassan Alrayes
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Najla Sayes
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Mohamed H Al-Hamed
- Clinical Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hamoud Al-Mousa
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
| | - Saad AlShareef
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Anas M Alazami
- Translational Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital & Research Centre, MBC 3, P.O. Box 3354, Riyadh, 11211, Saudi Arabia.
- Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia.
| |
Collapse
|
31
|
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.
Collapse
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
| |
Collapse
|
32
|
Yamamoto B, Honda D, Ohsawa I, Iwamoto K, Horiuchi T, Fukunaga A, Maehara J, Yamashita K, Hide M. Burden of illness seen in hereditary angioedema in Japanese patients: Results from a patient reported outcome survey. Intractable Rare Dis Res 2023; 12:35-44. [PMID: 36873666 PMCID: PMC9976089 DOI: 10.5582/irdr.2022.01130] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/14/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
Hereditary angioedema (HAE) is a potentially life-threatening rare disease, which is mainly caused by the deficiency or dysfunction of C1-esterase inhibitor, and characterized by spontaneous, recurrent episodes of edema in various parts of the body including internal organs and the laryngeal area. Delayed diagnosis and treatment increase the burdens and risks of this condition. The current study aimed to understand the burden of illness for HAE patients in Japan before and after diagnosis through a patient reported outcome survey. A survey instrument was distributed to 121 adult patients with HAE by a patient organization via HAE treating physicians between July and November in 2016. Seventy patients (57.9%) returned the questionnaire. Patients reported high levels of medical resource utilization, including emergency procedures and services. Episodes of receiving laparotomy were somewhat less after diagnosis with HAE than before, but no apparent difference in episodes of tracheotomy between before and after the diagnosis. The economic burden, including direct and indirect medical costs, was highest before diagnosis, but still perceived as substantial after diagnosis. Patients reported disruption of work and school life, with 40% reporting that they miss 10 or more days from work or education per year. Sixty percent of patients reported that HAE affected their daily activities. We concluded that HAE is associated with considerable physical, social, economic and psycho-social burdens even after diagnosis, and that higher attack frequency is associated with a heavy disease burden for patients in Japan.
Collapse
Affiliation(s)
- Beverley Yamamoto
- Graduate School of Human Sciences, Osaka University, Osaka, Japan
- HAEJ registered NPO, Japan
- HAEi Registered Charity, USA
| | - Daisuke Honda
- HAEJ registered NPO, Japan
- Department of Nephrology, Chiba University Hospital, Chiba, Japan
- Address correspondence to:Daisuke Honda, Department of Nephrology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba 260-8677, Japan. E-mail:
| | - Isao Ohsawa
- HAEJ registered NPO, Japan
- Department of Nephrology, Internal Medicine, Saiyu Soka Hospital, Saitama, Japan
| | - Kazumasa Iwamoto
- HAEJ registered NPO, Japan
- Iwamoto Dermatology & Allergology Clinic, Hiroshima, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyusyu University Beppu Hospital, Oita, Japan
| | - Atsushi Fukunaga
- Department of Dermatology, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
| | - Junichi Maehara
- Department of Acute Care & General Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kouhei Yamashita
- Department of Hematology, Kyoto University Hospital, Kyoto, Japan
| | - Michihiro Hide
- HAEJ registered NPO, Japan
- Department of Dermatology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Dermatology, Hiroshima Citizens Hospital, Hiroshima, Japan
| |
Collapse
|
33
|
Cancian M, Triggianese P, Modica S, Arcoleo F, Bignardi D, Brussino L, Colangelo C, Di Agosta E, Firinu D, Guarino MD, Giardino F, Giliberti M, Montinaro V, Senter R. The impact of puberty on the onset, frequency, location, and severity of attacks in hereditary angioedema due to C1-inhibitor deficiency: A survey from the Italian Network for Hereditary and Acquired Angioedema (ITACA). Front Pediatr 2023; 11:1141073. [PMID: 37144145 PMCID: PMC10152551 DOI: 10.3389/fped.2023.1141073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/08/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction Hereditary angioedema due to C1-inhibitor deficiency is influenced by hormonal factors, with a more severe course of disease in women. Our study aims to deepen the impact of puberty on onset, frequency, location and severity of attacks. Methods Retrospective data were collected through a semi-structured questionnaire and shared by 10 Italian reference centers of the Italian Network for Hereditary and Acquired Angioedema (ITACA). Results The proportion of symptomatic patients increased significantly after puberty (98.2% vs 83.9%, p=0.002 in males; 96.3% vs 68,4%, p<0.001 in females); the monthly mean of acute attacks was significantly higher after puberty, and this occurred both in females (median (IQR) = 0.41(2) in the three years before puberty vs 2(2.17) in the three years after, p<0.001) and in males (1(1.92) vs 1.25(1.56) respectively, p<0.001). The increase was greater in females. No significant differences were detected in attack location before and after puberty. Discussion Overall, our study confirms previous reports on a more severe phenotype in the female gender. Puberty predisposes to increased numbers of angioedema attacks, in particular in female patients.
Collapse
Affiliation(s)
- Mauro Cancian
- UOSD Allergologia, University Hospital of Padua, Padua, Italy
- Correspondence: Mauro Cancian
| | | | | | - Francesco Arcoleo
- UOC di Patologia Clinica e Immunologia, AOR Villa Sofia-Cervello, Palermo, Italy
| | | | - Luisa Brussino
- University Hospital Ordine Mauriziano di Torino, Turin, Italy
| | | | - Ester Di Agosta
- Immunoallergology unit, Careggi University Hospital, Florence, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Francesco Giardino
- Azienda Ospedaliero-Universitaria Policlinico “G.Rodolico-San Marco”, Catania, Italy
| | - Marica Giliberti
- Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | | | - Riccardo Senter
- UOSD Allergologia, University Hospital of Padua, Padua, Italy
| |
Collapse
|
34
|
Maurer M, Abuzakouk M, Al-Ahmad M, Al-Herz W, Alrayes H, Al-Tamemi S, Arnaout R, Binghadeer H, Gutta R, Irani C, Mobayed H, Nasr I, Shendi H, Zaitoun F. Consensus on diagnosis and management of Hereditary Angioedema in the Middle East: A Delphi initiative. World Allergy Organ J 2022; 16:100729. [PMID: 36601261 PMCID: PMC9803817 DOI: 10.1016/j.waojou.2022.100729] [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: 08/01/2022] [Revised: 10/10/2022] [Accepted: 11/23/2022] [Indexed: 12/25/2022] Open
Abstract
Background Hereditary angioedema (HAE), a potentially life-threatening genetic disorder due to C1 inhibitor deficiency in most cases, is characterized by sudden and/or recurrent attacks of angioedema (subcutaneous/submucosal swellings). The global World Allergy Organization (WAO)/European Academy of Allergy and Clinical Immunology (EAACI) International guideline for HAE management is comprehensive, but the implementation of this guideline may require regional adaptation considering the diversity in disease awareness, type of medical care systems, and access to diagnostics and treatment. The aim of this Delphi initiative was to build on the global guideline and provide regional adaptation to address the concerns and specific needs in the Middle East. Methods The Consensus panel comprised 13 experts from the Middle East (3 from the United Arab Emirates, 3 from Saudi Arabia, 2 from Lebanon, 2 from Kuwait, 2 from Oman and 1 from Qatar) who have more than 2 decades of experience in allergy and immunology and are actively involved in managing HAE patients. The process that was carried out to reach the consensus recommendation included: 1.) A systematic literature review for articles related to HAE management using Ovid MEDLINE. 2.) The development of a questionnaire by an internationally acclaimed expert, with 10 questions specific to HAE management in the Middle East. 3.) Experts received the questionnaire via email individually and their answers were recorded (email/interview). 4.) A virtual consensus meeting was organized to discuss the questionnaire, make amends if needed, vote, and achieve consensus. Results The questionnaire comprised 10 questions, each with 2 or more statements/recommendations on which the regional experts voted. A consensus was reached based on a 70% agreement between the participants. The key highlights include: 1) HAE experts in the Middle East emphasized the importance of a positive family history for arriving at a diagnosis of HAE. 2) The number of episodes per month or per 6-month period and severity should be used, together with other markers, to determine the need for prophylaxis. 3) Disease status should be monitored by periodic visits and the use of patient-reported outcome measures such as the angioedema activity score and the angioedema control test. 4) Attenuated androgens and tranexamic acid may be considered for long-term prophylaxis, if lanadelumab, C1-Inhibitor or berotralstat are not available. Conclusion This consensus recommendation may help to educate healthcare practitioners in the Middle East and unify their approach to the diagnosis and management of HAE.
Collapse
Affiliation(s)
- Marcus Maurer
- Institute of Allergology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany,Corresponding author. Prof. Marcus Maurer Charité – Universitätsmedizin Berlin
- Institute of Allergology
| | | | - Mona Al-Ahmad
- Al-Rashed Allergy Center, Ministry of Health, Kuwait,Microbiology department, College of Medicine, Kuwait University, Kuwait
| | - Waleed Al-Herz
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Kuwait
| | - Hassan Alrayes
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Rand Arnaout
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hend Binghadeer
- King Abdulaziz Medical City-Riyadh, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Ravi Gutta
- Adult and Pediatric Allergy and Immunology Department, Mediclinic City Hospital, DHCC, Dubai
| | - Carla Irani
- Hotel Dieu de France Hospital, St Joseph University, Beirut, Lebanon
| | - Hassan Mobayed
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Hiba Shendi
- Tawam Hospital, Abu Dhabi, United Arab Emirates
| | - Fares Zaitoun
- Clemenceau Medical Center, Dubai, United Arab Emirates
| |
Collapse
|
35
|
Abstract
Hereditary angioedema is a rare and commonly misdiagnosed disease characterized by recurrent, painful, nonurticarial, and nonpruritic deep tissue swelling attacks, including potentially life-threatening asphyxiation. Nurses can assist in identifying disease hallmarks and provide emergency care, patient support, and education about injectable or infused medications. Hereditary angioedema is a rare and commonly misdiagnosed disease. This article discusses how nurses can assist in identifying disease hallmarks and provide emergency care, patient support, and education.
Collapse
|
36
|
Non-alcoholic fatty liver disease and liver secretome. Arch Pharm Res 2022; 45:938-963. [PMCID: PMC9703441 DOI: 10.1007/s12272-022-01419-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/15/2022] [Indexed: 11/29/2022]
|
37
|
Beard N, Frese M, Smertina E, Mere P, Katelaris C, Mills K. Interventions for the long-term prevention of hereditary angioedema attacks. Cochrane Database Syst Rev 2022; 11:CD013403. [PMID: 36326435 PMCID: PMC9632406 DOI: 10.1002/14651858.cd013403.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a serious and potentially life-threatening condition that causes acute attacks of swelling, pain and reduced quality of life. People with Type I HAE (approximately 80% of all HAE cases) have insufficient amounts of C1 esterase inhibitor (C1-INH) protein; people with Type II HAE (approximately 20% of all cases) may have normal C1-INH concentrations, but, due to genetic mutations, these do not function properly. A few people, predominantly females, experience HAE despite having normal C1-INH levels and C1-INH function (rare Type III HAE). Several new drugs have been developed to treat acute attacks and prevent recurrence of attacks. There is currently no systematic review and meta-analysis that included all preventive medications for HAE. OBJECTIVES To assess the benefits and harms of interventions for the long-term prevention of HAE attacks in people with Type I, Type II or Type III HAE. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 3 August 2021. SELECTION CRITERIA We included randomised controlled trials in children or adults with HAE that used medications to prevent HAE attacks. The comparators could be placebo or active comparator, or both; approved and experimental drug trials were eligible for inclusion. There were no restrictions on dose, frequency or intensity of treatment. The minimum length of four weeks of treatment was required for inclusion; this criterion excluded the acute treatment of HAE attacks. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. HAE attacks (number of attacks per person, per population) and change in number of HAE attacks; 2. mortality and 3. serious adverse events (e.g. hepatic dysfunction, hepatic toxicity and deleterious changes in blood tests). Our secondary outcomes were 4. quality of life; 5. severity of breakthrough attacks; 6. disability and 7. adverse events (e.g. weight gain, mild psychological changes and body hair). We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We identified 15 studies (912 participants) that met the inclusion criteria. The studies included people with Type I and II HAE. The studies investigated avoralstat, berotralstat, subcutaneous C1-INH, plasma-derived C1-INH, nanofiltered C1-INH, recombinant human C1-INH, danazol, and lanadelumab for the prevention of HAE attacks. We did not find any studies on the use of tranexamic acid for prevention of HAE attacks. All drugs except avoralstat reduced the number of HAE attacks compared with placebo. For breakthrough attacks that occurred despite prophylactic treatment, intravenous and subcutaneous forms of C1-INH and lanadelumab reduced attack severity. It is not known whether other drugs have a similar effect, as the severity of breakthrough attacks in people taking drugs other than C1-INH and lanadelumab was not reported. For quality of life, avoralstat, berotralstat, C1-INH (all forms) and lanadelumab increased quality of life compared with placebo; there were no data for danazol. Four studies reported on changes in disability during treatment with C1-INH, berotralstat and lanadelumab; all three drugs decreased disability compared with placebo. Adverse events, including serious adverse events, did not occur at a rate higher than placebo. However, serious adverse event data and other adverse event data were not available for danazol, which prevented us from drawing conclusions about the absolute or relative safety of this drug. No deaths were reported in the included studies. The analysis was limited by the small number of studies, the small number of participants in each study and the lack of data on older drugs, therefore the certainty of the evidence is low. Given the rarity of HAE, it is not surprising that drugs were rarely directly compared, which does not allow conclusions on the comparative efficacy of the various drugs for people with HAE. Finally, we did not identify any studies that included people with Type III HAE. Therefore, we cannot draw any conclusions about the efficacy or safety of any drug in people with this form of HAE. AUTHORS' CONCLUSIONS The available data suggest that berotralstat, C1-INH (subcutaneous, plasma-derived, nanofiltered and recombinant), danazol and lanadelumab are effective in lowering the risk or incidence (or both) of HAE attacks. In addition, C1-INH and lanadelumab decrease the severity of breakthrough attacks (data for other drugs were not available). Avoralstat, berotralstat, C1-INH (all forms) and lanadelumab increase quality of life and do not increase the risk of adverse events, including serious adverse events. It is possible that danazol, subcutaneous C1-INH and recombinant human C1-INH are more effective than berotralstat and lanadelumab in reducing the risk of breakthrough attacks, but the small number of studies and the small size of the studies means that the certainty of the evidence is low. This and the lack of head-to-head trials prevented us from drawing firm conclusions on the relative efficacy of the drugs.
Collapse
Affiliation(s)
- Nicole Beard
- Faculty of Science and Technology, University of Canberra, Bruce, Australia
| | - Michael Frese
- Faculty of Science and Technology, University of Canberra, Bruce, Australia
| | - Elena Smertina
- Faculty of Science and Technology, University of Canberra, Bruce, Australia
| | - Peter Mere
- Department of Mathematics and Statistics, Macquarie University, Macquarie Park, Australia
| | - Constance Katelaris
- Department of Medicine, Campbelltown Hospital and Western Sydney University, Campbelltown, Australia
| | - Kerry Mills
- Faculty of Science and Technology, University of Canberra, Bruce, Australia
| |
Collapse
|
38
|
Muacevic A, Adler JR, Prathiraja O, Jena R, Coffie-Pierre JA, Agyei J, Silva MS, Kayani AMA, Siddiqui OS. A Comprehensive Review of Bradykinin-Induced Angioedema Versus Histamine-Induced Angioedema in the Emergency Department. Cureus 2022; 14:e32075. [PMID: 36600855 PMCID: PMC9803396 DOI: 10.7759/cureus.32075] [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] [Accepted: 11/30/2022] [Indexed: 12/05/2022] Open
Abstract
Angioedema (AE) is a condition that is frequently encountered in the emergency department (ED). It is a rare condition with localized, asymmetrical swelling of the skin and/or mucosa that is frequently nonpruritic and primarily affects locations with loose connective tissue. Physicians must have a thorough understanding of this condition since it can cause fatal airway compromise, which might be the presenting symptom. Histamine-mediated AE is the most common type of AE seen in EDs. However, ED physicians must be on the lookout for the less common bradykinin-mediated types of AE as these do not respond to the same therapy as histamine-mediated AE. Hospitals may lack specialized drugs or protocols, and many ED staff may be unable to identify or treat bradykinin-mediated AE. It is crucial to understand the pathophysiology of the various kinds of AE in order to optimize treatment. The goal of this review paper is to provide an overview of the pathophysiology, clinical manifestations, and treatment options for bradykinin and histamine-induced AE in the ED.
Collapse
|
39
|
Muacevic A, Adler JR, Tahir H, Guan J. Angioedema as a Rare Presentation of Systemic Lupus Erythematosus. Cureus 2022; 14:e31763. [PMID: 36569666 PMCID: PMC9771844 DOI: 10.7759/cureus.31763] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 11/23/2022] Open
Abstract
Angioedema (AE) is an immune-mediated tissue swelling that can be life-threatening if it compromises the airway. This makes prompt diagnosis and management of the condition excruciatingly important. It can be hereditary or associated with infections, malignancies, and autoimmune diseases. There have been reported cases in the literature where Systemic lupus erythematosus (SLE) patients developed acquired angioedema raising suspicion of a possible association between the two conditions. We describe a case of a patient with no known medical issues, presenting with acute onset of her first episode of angioedema with airway compromise. Because of the rarity of awareness of the possible association of our conditions of interest, there was an inevitable delay in diagnosis and the patient was eventually diagnosed to have SLE and associated acquired angioedema as its first presentation. This case report highlights the importance of maintaining high suspicion for SLE in patients with an isolated first episode of AE and discusses mechanisms involved in the disease process to shed light on available treatment modalities.
Collapse
|
40
|
Wang X, Cao Y, Zhi Y. Throat microbiota alterations in patients with hereditary angioedema. World Allergy Organ J 2022; 15:100694. [PMID: 36254183 PMCID: PMC9526235 DOI: 10.1016/j.waojou.2022.100694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/19/2022] [Accepted: 08/17/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
- Xue Wang
- Department of Allergy & Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Beijing, China
| | - Yang Cao
- Department of Allergy & Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Beijing, China
- School of Clinical Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuxiang Zhi
- Department of Allergy & Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Beijing, China
- Corresponding author. Shuaifuyuan, Wangfujing, Beijing 100730, PR China.
| |
Collapse
|
41
|
Abstract
Health care providers are likely to encounter patients with recurrent unexplained abdominal pain. Because hereditary angioedema (HAE) is a rare disease, it may not be part of the differential diagnosis, especially for patients who do not have concurrent skin swelling in addition to abdominal symptoms. Abdominal pain is very common in patients with HAE, occurring in up to 93% of patients, with recurrent abdominal pain reported in up to 80% of patients. In 49% of HAE attacks with abdominal symptoms, isolated abdominal pain was the only symptom. Other abdominal symptoms that commonly present in patients with HAE include distension, cramping, nausea, vomiting, and diarrhea. The average time from onset of symptoms to diagnosis is 6 to 23 years. Under-recognition of HAE in patients presenting with predominant gastrointestinal symptoms is a key factor contributing to the delay in diagnosis, increasing the likelihood of unnecessary or exploratory surgeries or procedures and the potential risk of related complications. HAE should be considered in the differential diagnosis for patients with unexplained abdominal pain, nausea, vomiting, and/or diarrhea who have complete resolution of symptoms between episodes. As highly effective targeted therapies for HAE exist, recognition and diagnosis of HAE in patients presenting with isolated abdominal pain may significantly improve morbidity and mortality for these individuals.
Collapse
|
42
|
Mendoza-Alvarez A, Tosco-Herrera E, Muñoz-Barrera A, Rubio-Rodríguez LA, Alonso-Gonzalez A, Corrales A, Iñigo-Campos A, Almeida-Quintana L, Martin-Fernandez E, Martinez-Beltran D, Perez-Rodriguez E, Callero A, Garcia-Robaina JC, González-Montelongo R, Marcelino-Rodriguez I, Lorenzo-Salazar JM, Flores C. A catalog of the genetic causes of hereditary angioedema in the Canary Islands (Spain). Front Immunol 2022; 13:997148. [PMID: 36203598 PMCID: PMC9531158 DOI: 10.3389/fimmu.2022.997148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare disease where known causes involve C1 inhibitor dysfunction or dysregulation of the kinin cascade. The updated HAE management guidelines recommend performing genetic tests to reach a precise diagnosis. Unfortunately, genetic tests are still uncommon in the diagnosis routine. Here, we characterized for the first time the genetic causes of HAE in affected families from the Canary Islands (Spain). Whole-exome sequencing data was obtained from 41 affected patients and unaffected relatives from 29 unrelated families identified in the archipelago. The Hereditary Angioedema Database Annotation (HADA) tool was used for pathogenicity classification and causal variant prioritization among the genes known to cause HAE. Manual reclassification of prioritized variants was used in those families lacking known causal variants. We detected a total of eight different variants causing HAE in this patient series, affecting essentially SERPING1 and F12 genes, one of them being a novel SERPING1 variant (c.686-12A>G) with a predicted splicing effect which was reclassified as likely pathogenic in one family. Altogether, the diagnostic yield by assessing previously reported causal genes and considering variant reclassifications according to the American College of Medical Genetics guidelines reached 66.7% (95% Confidence Interval [CI]: 30.1-91.0) in families with more than one affected member and 10.0% (95% CI: 1.8-33.1) among cases without family information for the disease. Despite the genetic causes of many patients remain to be identified, our results reinforce the need of genetic tests as first-tier diagnostic tool in this disease, as recommended by the international WAO/EAACI guidelines for the management of HAE.
Collapse
Affiliation(s)
| | - Eva Tosco-Herrera
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Adrian Muñoz-Barrera
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
| | - Luis A. Rubio-Rodríguez
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
| | - Aitana Alonso-Gonzalez
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Universidad de Santiago de Compostela, Santiago de Compostela, Spain
| | - Almudena Corrales
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Iñigo-Campos
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
| | - Lourdes Almeida-Quintana
- Allergy Service, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Elena Martin-Fernandez
- Allergy Service, Hospital Universitario Dr. Molina Orosa, Las Palmas de Gran Canaria, Spain
| | - Dara Martinez-Beltran
- Allergy Service, Hospital Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Eva Perez-Rodriguez
- Allergy Service, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Ariel Callero
- Allergy Service, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Jose C. Garcia-Robaina
- Allergy Service, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | - Itahisa Marcelino-Rodriguez
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Public Health and Preventive Medicine Area, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Jose M. Lorenzo-Salazar
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
| | - Carlos Flores
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Genomics Division, Instituto Tecnológico y de Energías Renovables, Santa Cruz de Tenerife, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Fernando Pessoa Canarias, Las Palmas de Gran Canaria, Spain
- *Correspondence: Carlos Flores,
| |
Collapse
|
43
|
Ushio Y, Wakiya R, Kameda T, Nakashima S, Shimada H, Mansour MMF, Kato M, Miyagi T, Sugihara K, Mino R, Mizusaki M, Ibuki E, Kadowaki N, Dobashi H. Systemic lupus erythematosus with various clinical manifestations in a patient with hereditary angioedema: a case report. ALLERGY, ASTHMA & CLINICAL IMMUNOLOGY 2022; 18:84. [PMID: 36117202 PMCID: PMC9484190 DOI: 10.1186/s13223-022-00725-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 09/04/2022] [Indexed: 12/03/2022]
Abstract
Background Hereditary angioedema (HAE) is an inherited disease characterized by recurrent angioedema without urticaria or pruritus. The most common types of HAE are caused by deficiency or dysfunction in C1 esterase inhibitor (C1-INH-HAE). The association between C1-INH-HAE and systemic lupus erythematosus (SLE) is known; however, variations in the underlying pathophysiology, disease course, and treatment in this population remain incompletely understood. Case presentation A 31-year-old Japanese woman with a prior diagnosis of HAE type 1 based on the episodes of recurrent angioedema, low C1 inhibitor antigen levels and function, and family history presented with new complaints of malar rash, alopecia, and arthralgias in her hands and elbows. She later developed fever, oral ulcers, lupus retinopathy, a discoid rash localized to her chest, and malar rash. Investigations revealed positive antinuclear antibody, leukopenia, thrombocytopenia, hypocomplementemia, and nephritis. Based on these findings, she was diagnosed with SLE according to the 2019 European League Against Rheumatism/American College of Rheumatology classification criteria. There did not appear to be a correlation between HAE disease activity and the timing of presentation with SLE, because HAE disease activity had been stable. The patient was able to achieve and maintain remission with immunosuppressive therapy including prednisolone, hydroxychloroquine, and tacrolimus. Conclusions Our patient presented with a variety of symptoms, including fever and cytopenia in addition to mucocutaneous, joint, ocular, and renal lesions. It is important to better characterize the clinical characteristics of SLE in patients with C1-INH-HAE, and to clarify the mechanisms of SLE in this population.
Collapse
|
44
|
Triggianese P, Senter R, Petraroli A, Zoli A, Lo Pizzo M, Bignardi D, Di Agosta E, Agolini S, Arcoleo F, Rossi O, Modica S, Greco E, Chimenti MS, Spadaro G, De Carolis C, Cancian M. Pregnancy in women with Hereditary Angioedema due to C1-inhibitor deficiency: Results from the ITACA cohort study on outcome of mothers and children with in utero exposure to plasma-derived C1-inhibitor. Front Med (Lausanne) 2022; 9:930403. [PMID: 36186797 PMCID: PMC9515414 DOI: 10.3389/fmed.2022.930403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background In women with Hereditary Angioedema (HAE) due to C1-inhibitor (C1INH) deficiency (C1INH-HAE), pregnancy counseling and treatment can be challenging. Despite the evidence of the immediate favorable outcome and safety of plasma-derived (pd)C1INH concentrate, there are no data regarding any difference among women who underwent or not pdC1INH during pregnancy or on children with in utero exposure to pdC1INH. The present interview study aimed at analyzing outcome of C1INH-HAE mothers and children according to pdC1INH-exposure during pregnancies. Methods C1INH-HAE women who experienced at least 1 pregnancy were included from seven centers of the Italian Network for Hereditary and Acquired Angioedema (ITACA). The interview study retrospectively analyzed pregnancies who underwent (group 1) or not (group 2) pdC1INH. The overall goals of the study included immediate and long-term outcomes, in terms of outcomes in the time interval between pregnancy and survey. Results A total of 168 pregnancies from 87 included women were analyzed. At term delivery (>37 gestation-week, GW) has been registered in 73.8% of cases, while spontaneous abortion (SA) occurred in 14.2% of cases with a mean GW 7 ± 2. The group 1 including pdC1INH-treated pregnancies comprised a third of the cohort (51/168, time interval 1.5 ± 10.4 yrs), while the group 2 represented 69.6% (117/168, time interval 32.8 ± 14 yrs). The same prevalence of SA occurred when comparing group 1 (11.7%) with group 2 (15.4%) with a similar GW at SA. The group 1 was older at the pregnancy time and younger at the interview than the group 2 (P < 0.01 for both); moreover, the group 1 showed a higher prevalence of cesarean delivery (P < 0.0001). The overall prevalence of obstetrical syndromes was similar between two groups: however, gestational diabetes was described only in pdC1INH-untreated pregnancies. In utero pdC1INH-exposed children (n = 45) did not show differences compared with unexposed ones (n = 99) in neonatal short-term outcomes. Conclusion Through appropriate management and counseling, most of C1INH-HAE women undergo successful pregnancy and delivery. For pregnant C1INH-HAE women being treated with pdC1INH, our findings are reassuring and might lead to an improvement of both the knowledge about treatments and the experience of HAE itself.
Collapse
Affiliation(s)
- P. Triggianese
- Rheumatology, Allergology and Clinical Immunology, Department of “Medicina dei Sistemi”, University of Rome Tor Vergata, Rome, Italy
- *Correspondence: P. Triggianese
| | - R. Senter
- Department of Systems Medicine, University Hospital of Padua, Padua, Italy
| | - A. Petraroli
- Centro Interdipartimentale di Ricerca in Scienze Immunologiche di Base e Cliniche (CISI) dell'Università degli Studi di Napoli Federico II, Naples, Italy
| | - A. Zoli
- Azienda Ospedaliera Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - M. Lo Pizzo
- Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - D. Bignardi
- Department of Medicine Integrated With the Territory, Ospedale Policlinico San Martino, IRCCS, Genoa, Italy
| | - E. Di Agosta
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - S. Agolini
- Azienda Ospedaliera Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - F. Arcoleo
- Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - O. Rossi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - S. Modica
- Rheumatology, Allergology and Clinical Immunology, Department of “Medicina dei Sistemi”, University of Rome Tor Vergata, Rome, Italy
| | - E. Greco
- Rheumatology, Allergology and Clinical Immunology, Department of “Medicina dei Sistemi”, University of Rome Tor Vergata, Rome, Italy
| | - M. S. Chimenti
- Rheumatology, Allergology and Clinical Immunology, Department of “Medicina dei Sistemi”, University of Rome Tor Vergata, Rome, Italy
| | - G. Spadaro
- Centro Interdipartimentale di Ricerca in Scienze Immunologiche di Base e Cliniche (CISI) dell'Università degli Studi di Napoli Federico II, Naples, Italy
| | - C. De Carolis
- Rheumatology, Allergology and Clinical Immunology, Department of “Medicina dei Sistemi”, University of Rome Tor Vergata, Rome, Italy
| | - M. Cancian
- Department of Systems Medicine, University Hospital of Padua, Padua, Italy
| |
Collapse
|
45
|
Valerieva A, Longhurst HJ. Treatment of hereditary angioedema—single or multiple pathways to the rescue. FRONTIERS IN ALLERGY 2022; 3:952233. [PMID: 36172291 PMCID: PMC9510393 DOI: 10.3389/falgy.2022.952233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/18/2022] [Indexed: 12/04/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare disease caused by mutations in the SERPING1 gene. This results in deficient or dysfunctional C1 esterase inhibitor (C1-INH) and affects multiple proteases involved in the complement, contact-system, coagulation, and fibrinolytic pathways. Current options for the treatment and prevention of HAE attacks include treating all affected pathways via direct C1-INH replacement therapy; or specifically targeting components of the contact activation system, in particular by blocking the bradykinin B2 receptor (B2R) or inhibiting plasma kallikrein, to prevent bradykinin generation. Intravenously administered plasma-derived C1-INH (pdC1-INH) and recombinant human C1-INH have demonstrated efficacy and safety for treatment of HAE attacks, although time to onset of symptom relief varied among trials, specific agents, and dosing regimens. Data from retrospective and observational analyses support that short-term prophylaxis with intravenous C1-INH products can help prevent HAE attacks in patients undergoing medical or dental procedures. Long-term prophylaxis with intravenous or subcutaneous pdC1-INH significantly decreased the HAE attack rate vs. placebo, although breakthrough attacks were observed. Pathway-specific therapies for the management of HAE include the B2R antagonist icatibant and plasma kallikrein inhibitors ecallantide, lanadelumab, and berotralstat. Icatibant, administered for treatment of angioedema attacks, reduced B2R-mediated vascular permeability and, compared with placebo, reduced the time to initial symptom improvement. Plasma kallikrein inhibitors, such as ecallantide, block the binding site of kallikrein to prevent cleavage of high molecular weight kininogen and subsequent bradykinin generation. Ecallantide was shown to be efficacious for HAE attacks and is licensed for this indication in the United States, but the labeling recommends that only health care providers administer treatment because of the risk of anaphylaxis. In addition to C1-INH replacement therapy, the plasma kallikrein inhibitors lanadelumab and berotralstat are recommended as first-line options for long-term prophylaxis and have demonstrated marked reductions in HAE attack rates. Investigational therapies, including the activated factor XII inhibitor garadacimab and an antisense oligonucleotide targeting plasma prekallikrein messenger RNA (donidalorsen), have shown promise as long-term prophylaxis. Given the requirement of lifelong management for HAE, further research is needed to determine how best to individualize optimal treatments for each patient.
Collapse
Affiliation(s)
- Anna Valerieva
- Department of Allergology, Medical University of Sofia, Sofia, Bulgaria
- Correspondence: Anna Valerieva
| | - Hilary J. Longhurst
- Department of Immunology, Auckland District Health Board, and Department of Medicine, University of Auckland, Auckland, New Zealand
| |
Collapse
|
46
|
Dyga W, Obtulowicz A, Mikolajczyk T, Bogdali A, Dubiela P, Obtulowicz K. The Role of Bradykinin Receptors in Hereditary Angioedema Due to C1-Inhibitor Deficiency. Int J Mol Sci 2022; 23:ijms231810332. [PMID: 36142237 PMCID: PMC9499460 DOI: 10.3390/ijms231810332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 09/04/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Hereditary angioedema (HAE) is a rare, genetic disease caused by the decreased level or function of the C1 inhibitor. The primary mediator of symptoms in HAE is bradykinin acting through its two receptors, namely receptors 1 (BR1) and 2 (BR2). Although BR2 is well characterized, the role of BR1 remains unclear. Objective: To study the role of bradykinin receptors 1 (BR1) in the etiopathogenesis of HAE. Methods: A total of 70 individuals, 40 patients with HAE, and 30 healthy subjects were recruited to the study. HAE was diagnosed in accordance with the international guideline. The level of bradykinin receptors was determined in populations of CD3+, CD4+, CD8+, and CD14++CD16−, CD14++CD16+ monocytes. In addition, the level of disease activity-specific markers was measured. Results: There were statistically significant differences in the subpopulation of lymphocytes and monocytes between patients with HAE compared to healthy subjects. The level of BR1 and BR2 on PBMCs was comparable in healthy subjects and HAE patients during remission with significant overexpression of both receptors, triggered by HAE attack. Moreover, a significant increase in TNF-alpha and IL-1 plasma levels was observed among HAE patients. Conclusions: BR1 expression may play an important role in the pathomechanism of HAE.
Collapse
Affiliation(s)
- Wojciech Dyga
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
| | - Aleksander Obtulowicz
- Department of Dermatology, Jagiellonian University Medical College, Kopernika 50, 31-501 Krakow, Poland
| | - Tomasz Mikolajczyk
- Department of Internal and Agricultural Medicine, Jagiellonian University Medical College, Skarbowa 1, 31-121 Krakow, Poland
| | - Anna Bogdali
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
| | - Pawel Dubiela
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
- Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Waszyngtona 13, 15-269 Bialystok, Poland
- Correspondence:
| | - Krystyna Obtulowicz
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
| |
Collapse
|
47
|
Kesh S, Bernstein JA. Isolated Angioedema: A Review of Classification and Update on Management. Ann Allergy Asthma Immunol 2022; 129:692-702. [PMID: 35988876 DOI: 10.1016/j.anai.2022.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this article is to review the various types of angioedema including diagnosis and treatment. DATA SOURCES PubMed search of articles in the English language various types of angioedema STUDY SELECTION: Articles on the subject matter were selected and reviewed. RESULTS Herein, a case based approach is presented for discussing the major types of angioedema including: hereditary angioedema (HAE) TypesI/II and normal complement, acquired angioedema, Angiotensin converting enzyme (ACE) induced angioedema, as well as histaminergic and non-histaminergic angioedema. Emerging treatments of HAE including targets of pre-kalikrein, DNA vector technology replacing C1INH protein, and CRIPSR technology targeting PKK among many others are explored. In addition, other causes as well as mimickers of angioedema are briefly reviewed. Finally, a novel algorithm is proposed to help guide the treating physician through the work up and management of patients with suspected idiopathic angioedema unresponsive to conventional therapy with antihistamines. CONCLUSION Over the years, many strides have been made in both understanding the pathophysiology of various types of angioedema as well as expansion of treatment options. It is important for clinicians to be aware of current and emerging treatment options. We provide a novel practical algorithm to guide clinicians in challenging cases of idiopathic angioedema refractory to antihistamines.
Collapse
Affiliation(s)
- Susamita Kesh
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Division of Immunology and Allergy
| | - Jonathan A Bernstein
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section; Bernstein Allergy Group.
| |
Collapse
|
48
|
Jean-Baptiste M, Itzler R, Prusty S, Supina D, Martin ML. The symptom experience of hereditary angioedema (HAE) patients beyond HAE attacks: literature review and clinician interviews. Orphanet J Rare Dis 2022; 17:232. [PMID: 35710442 PMCID: PMC9204898 DOI: 10.1186/s13023-022-02360-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hereditary angioedema (HAE) is a genetic disorder characterized by re-occurring swelling episodes called "attacks," usually in the limbs, face, airways, and intestinal tract. New prophylactic therapies have reduced the frequency of these attacks. This study describes results from a literature review and clinician interviews assessing patient HAE symptom experiences and timing, and then evaluates whether existing patient-reported outcome (PRO) tools adequately reflect this experience. METHODS A targeted literature review as well as interviews with key opinion leaders (KOLs), were conducted to capture information about the patient experience and their symptoms. An assessment of various PROs was then conducted to determine how well they each covered HAE symptoms and impacts. RESULTS Nineteen HAE symptoms were identified. KOLs reported that patients on prophylactic therapy experienced some symptoms indicating an attack was imminent, but then never experienced an attack. The comparison of the different PROs found that the Hereditary Angioedema Patient-Reported Outcome was the instrument that most thoroughly examined the symptoms of patients with HAE. CONCLUSIONS Given the introduction of new prophylactic therapies, further research is needed to determine the effect of being attack-free for longer periods of time on health-related quality of life.
Collapse
Affiliation(s)
| | | | | | - Dylan Supina
- Jazz Pharmaceuticals (Formerly CSL Behring), King of Prussia, PA, USA
| | - Mona L Martin
- Evidera, 615 2nd Ave Ste 500, Seattle, WA, 98104, USA.
| |
Collapse
|
49
|
Chou SC, Lin CY, Lin HY, Pai CH, Yu CY, Kuo SF, Lin JS, Lin PT, Hung MH, Hsieh HN, Liu HC, Shen MC. Characterization of congenital factor XII deficiency in Taiwanese patients: identification of one novel and one common mutation. Int J Hematol 2022; 116:528-533. [PMID: 35675023 PMCID: PMC9174919 DOI: 10.1007/s12185-022-03390-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/29/2022]
Abstract
Background Factor XII (FXII) deficiency is an interesting condition that causes prolonged activated partial thromboplastin time without bleeding diathesis. FXII may be not important in hemostasis, but still plays roles in thrombosis and inflammation. In order to raise clinical awareness about this condition, we studied patients with severe FXII deficiency and their relatives. Methods Consecutive severely FXII deficient patients presenting from 1995 to 2020 were recruited from two medical centers in Taiwan. Index patients and their families were tested for FXII function, antigen and F12 gene. F12 variants were constructed into the pIRES-hrGFP vector and expressed on human embryonic kidney cells (HEK293T). FXII antigen and activity were analyzed. Results We found five severely FXII deficient patients, three women and two men, aged 44–71 years. FXII antigen results ranged from undetectable to 43.7%. Three different mutations were identified: c.1681C>A (p.Gly542Ser), c.1561G>A (p.Glu502Lys), and a novel mutation c.1556T>A (p.Leu500Gln). HEK293T cells expressed consistently low FXII activity with all mutations. FXII antigen expression was similar to the wild type in c.1681C>A (p.Gly542Ser), but reduced in c.1556T>A (p.Leu500Gln) and c.1561G>A (p.Glu502Lys). Conclusions We report five unrelated patients with severe FXII deficiency, one of whom carried a novel, cross-reacting material negative mutation c.1556T>A (p.Leu500Gln).
Collapse
Affiliation(s)
- Sheng-Chieh Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Yeh Lin
- Department of Internal Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua, 500, Taiwan
| | - Hsuan-Yu Lin
- Department of Internal Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua, 500, Taiwan
| | - Chen-Hsueh Pai
- Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University, Taipei, Taiwan
| | - Cheng-Ye Yu
- Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University, Taipei, Taiwan
| | - Su-Feng Kuo
- Department of Laboratory Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Jen-Shiou Lin
- Department of Laboratory Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Po-Te Lin
- Department of Internal Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua, 500, Taiwan
| | - Mei-Hua Hung
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Ni Hsieh
- Department of Internal Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua, 500, Taiwan
| | - Hsiang-Chun Liu
- Department of Medical Research, E-DA Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Ming-Ching Shen
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan. .,Department of Internal Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua, 500, Taiwan.
| |
Collapse
|
50
|
Tranexamic acid – A narrative review for the emergency medicine clinician. Am J Emerg Med 2022; 56:33-44. [DOI: 10.1016/j.ajem.2022.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023] Open
|