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Anderson J, Soteres D, Mellor J, Connolly H, Wynne-Cattanach K, Earl L, Schultz BG, Juethner S. Physician- and patient-reported outcomes by hereditary angioedema type: Data from a real-world study. Allergy Asthma Proc 2024; 45:247-254. [PMID: 38982603 PMCID: PMC11231741 DOI: 10.2500/aap.2024.45.240021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
Background: Hereditary angioedema (HAE) is a rare genetic condition characterized by painful and often debilitating swelling attacks. Little is known about the differences in outcomes between patients with HAE types I or II (type I: HAE caused by C1 esterase inhibitor deficiency; type II: HAE caused by C1 esterase inhibitor dysfunction), with decreased or dysfunctional C1 esterase inhibitor (C1-INH), and those with normal C1-INH (nC1-INH-HAE). Objective: To compare physician- and patient-reported real-world outcomes in patients with HAE types I/II versus patients with nC1-INH-HAE. Methods: Data were drawn from the Adelphi HAE Disease Specific ProgrammeTM a real-world, cross-sectional survey of HAE-treating physicians and their patients in the United States conducted between July and November 2021. Physicians reported patient disease activity and severity, and recent attack history. Patient-reported outcomes were collected. Bivariate tests used were either the Student's t-test, the Fisher exact test, or Mann-Whitney U test. Results: Physicians (N = 67) provided data on 368 patients (92.4% HAE types I/II and 7.6% nC1-INH-HAE). Physicians reported that a higher proportion of patients with nC1-INH-HAE had moderate or high disease activity and moderate or severe disease severity both at diagnosis and at data collection versus those with HAE types I/II. Patients with nC1-INH-HAE versus patients with HAE types I/II experienced increased attack severity (34.6% versus 4.4%) and hospitalization rate during the most recent attack (39.3% versus 6.6%), and reported lower health status and quality of life, via the European Quality of Life 5 Dimension 5 Level (US tariff) and Angioedema Quality of Life, respectively. On average, 25% of the patients with nC1-INH-HAE reported absenteeism and work or activity impairment due to HAE compared with 2.7% of patients with HAE types I/II. Both patient groups reported improvements in disease activity and severity from diagnosis to the time of data collection. Conclusion: These real-world findings suggest that patients with nC1-INH-HAE have increased disease activity and severity, and experience greater impairment to their quality of life, work, and daily functioning than patients with HAE types I/II. Powered statistical analyses are required to confirm these findings.
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Affiliation(s)
- John Anderson
- From Clinical Research, AllerVie Health, Birmingham, Alabama
| | - Daniel Soteres
- Allergy/Immunology, Asthma and Allergy Associates, Colorado Springs, Colorado
| | - Jennifer Mellor
- Rare Disease Franchise, Adelphi Real World, Bollington, United Kingdom, and
| | - Hannah Connolly
- Rare Disease Franchise, Adelphi Real World, Bollington, United Kingdom, and
| | | | - Lucy Earl
- Rare Disease Franchise, Adelphi Real World, Bollington, United Kingdom, and
| | - Bob G Schultz
- Takeda Pharmaceuticals USA, Inc., Lexington, Massachusetts
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2
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Aberer W, Altrichter S, Cerpes U, Hawranek T, Schöffl C, Kinaciyan T. [Hereditary angioedema due to C1-inhibitor deficiency, a national disease management programme]. Wien Klin Wochenschr 2023; 135:785-798. [PMID: 38063938 PMCID: PMC10709250 DOI: 10.1007/s00508-023-02298-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 12/18/2023]
Abstract
Hereditary angioedema (HAE) is a rare, painful, disabling and potentially fatal disease, where early diagnosis and effective treatment are critical. These Austrian guidelines for the diagnosis and management of HAE provide instructions and advice on the state of the art management of HAE in Austria in contrast to global guidelines, where the situation of all countries worldwide must be taken into account. Our goal is to help Austrian physicians to consider HAE as a differential diagnosis with corresponding symptoms, to make rational decisions for the diagnosis and management of HAE with C1-inhibitor deficiency (type 1 or type 2). The guidelines provide information on common and important clinical symptoms, diagnostic methods, treatment modalities, available HAE-specific medications in Austria and last but not least to motivate physicians to refer patients to HAE centers for confirmation of the diagnosis and adequate treatment decisions.
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Affiliation(s)
- Werner Aberer
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Graz, 8036, Auenbruggerplatz 8, Graz, Österreich.
| | - Sabine Altrichter
- Universitätsklinik für Dermatologie und Venerologie, Kepler Uniklinikum, Linz, Österreich
| | - Urban Cerpes
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Graz, 8036, Auenbruggerplatz 8, Graz, Österreich
| | - Thomas Hawranek
- Universitätsklinik für Dermatologie und Allergologie, Uniklinikum Salzburg, Salzburg, Österreich
| | - Clemens Schöffl
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Graz, 8036, Auenbruggerplatz 8, Graz, Österreich
| | - Tamar Kinaciyan
- Universitätsklinik für Dermatologie, Medizinische Universität Wien, Wien, Österreich
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3
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Magerl M, Sala‐Cunill A, Weber‐Chrysochoou C, Trainotti S, Mormile I, Spadaro G. Could it be hereditary angioedema?-Perspectives from different medical specialties. Clin Transl Allergy 2023; 13:e12297. [PMID: 37746796 PMCID: PMC10509412 DOI: 10.1002/clt2.12297] [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: 01/19/2023] [Revised: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 09/26/2023] Open
Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant disease, with patients often suffering with associated symptoms for many years before receiving a correct diagnosis. The symptoms greatly impact a patient's quality of life (QoL) and include excruciating abdominal pain and angioedema of the skin and submucosa. Angioedema of the larynx represents a significant mortality risk in undiagnosed patients, and a large proportion of patients with HAE receive incorrect diagnoses and undergo unnecessary surgery. HAE-specific treatments can control and prevent acute life-threatening episodes, in addition to improving QoL, emphasizing the value of early diagnosis for patients. Diagnostic delay may be due to a lack of HAE awareness by healthcare professionals and the similarity of HAE symptoms with those of more common conditions, complicating differential diagnosis. The multifaceted nature of the condition may result in visits to one of many different medical settings, for example: the Emergency Room, pediatrics, general practice, otolaryngology, gastroenterology, and dermatology. Therefore, it is crucial that physicians in multiple healthcare specialties are aware of the disease to ensure that patients with HAE receive a timely diagnosis. Using patient cases from various medical specialties, this review highlights the necessity for cross-specialty awareness of HAE and outlines the essential information for the various healthcare professionals that may encounter a patient with HAE symptoms, in order to effectively treat and/or diagnose HAE.
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Affiliation(s)
- Markus Magerl
- Institute of Allergology IFACharité – Universitätsmedizin BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPAllergology and ImmunologyBerlinGermany
| | - Anna Sala‐Cunill
- Allergy SectionInternal Medicine DepartmentHospital Universitari Vall d’HebronBarcelonaSpain
| | | | - Susanne Trainotti
- Department of OtorhinolaryngologyKlinikum rechts der IsarTechnical University of MunichMunichGermany
| | - Ilaria Mormile
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI)University of Naples Federico IINaplesItaly
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI)University of Naples Federico IINaplesItaly
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Bork K, Wulff K, Witzke G, Staubach P, Hardt J, Meinke P. Gene Mutations Linked to Hereditary Angioedema in Solitary Angioedema Patients With Normal C1 Inhibitor. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2441-2449. [PMID: 36787826 DOI: 10.1016/j.jaip.2023.01.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Chronic recurrent angioedema without wheals (CRA) with normal C1 inhibitor (C1-INH) that is unresponsive to antihistamines may involve patients with recurrent angioedema of unknown cause (ie, so-called non-histaminergic idiopathic angioedema) as well as patients with hereditary angioedema with normal C1-INH (HAEnCI) when HAEnCI occurs in only one family member. OBJECTIVE To identify patients with one of type of HAEnCI in a group of patients with CRA with normal C1-INH that was unresponsive to antihistamines. METHODS A total of 132 patients with CRA and normal C1-INH that was unresponsive to antihistamines underwent mutational and clinical analysis. The presence of hereditary angioedema-specific mutations in Factor XII, plasminogen, ANGPT1, KNG1, MYOF, and HS3ST6 genes was tested by Sanger sequencing. When an HAEnCI-causing mutation was identified, available asymptomatic relatives were genetically tested. RESULTS In 116 of 132 solitary patients with CRA (87.9%), none of the six HAEnCI-linked mutations could be found. Ten patients (7.6%) had the Factor XII mutation c.983C>A (p.T328K) and six (4.5%) the plasminogen mutation c.988A>G (p.K330E). Other mutations linked to HAEnCI were not found in this patient series. In the 16 families with HAEnCI, 11 asymptomatic carriers of one of the HAEnCI-linked mutations were identified. CONCLUSIONS A search for HAEnCI-linked mutations in patients with solitary CRA may lead to the detection of patients and families with HAEnCI. This is important because family members can be identified who are at risk for developing potentially life-threatening angioedema, although they were previously asymptomatic. Without genetic investigation, the risk for an HAEnCI would have remained undetected in these patients and asymptomatic relatives.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany.
| | - Karin Wulff
- University Medicine, University, Greifswald, Germany
| | - Günther Witzke
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Petra Staubach
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Jochen Hardt
- Department of Medical Psychology and Medical Sociology, Johannes Gutenberg University, Mainz, Germany
| | - Peter Meinke
- Friedrich-Baur-Institute, Department of Neurology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
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5
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Sundler Björkman L, Thulin M, Ekström M, Nordenfelt P, Egesten A. Trends in Treatments With Disease-Specific and Interfering Drugs in Patients With Hereditary Angioedema in Sweden. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:621-628. [PMID: 36528292 DOI: 10.1016/j.jaip.2022.11.034] [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: 08/25/2022] [Revised: 10/31/2022] [Accepted: 11/17/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is caused by low levels of or defects in C1 inhibitor. Although disease activity may be modified by prophylaxis, emergency treatment, treatment for comorbidities, and oral contraceptives, the extent of their use is unclear. OBJECTIVE To investigate trends in the use of disease-specific and interfering drugs in patients with HAE compared with the general population in Sweden. METHODS In a nationwide, longitudinal study, 239 patients with HAE and 2 383 controls were compared with the Prescribed Drug Register (2005-2019). These data reflect rates of dispensed prescriptions from pharmacies in Sweden. RESULTS Attenuated androgens were used by approximately 10% of patients with HAE. The number of individuals treated with prophylactic plasma-derived C1 inhibitor increased during this period to reach almost 25% in men and 35% in women in 2019. Tranexamic acid was prescribed to 5% to 15% of patients, primarily children and young adults. Rates of prescriptions for icatibant, an emergency medication, showed a steady increase since its introduction in 2010, in particular among middle-aged women, suggesting poorly controlled disease. The use of diuretics, calcium channel blockers, and gestagens was more common in patients with HAE than in controls, whereas angiotensin-converting enzyme inhibitors were rarely collected. CONCLUSIONS Despite concerns regarding side effects, approximately 10% of patients with HAE received attenuated androgens for long-term prophylaxis. The common use of emergency medication also suggests poorly controlled disease in many patients, highlighting the need for increased focus on prophylactic treatment.
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Affiliation(s)
- Linda Sundler Björkman
- Respiratory Medicine, Allergology & Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden.
| | - Måns Thulin
- Department of Mathematics, Uppsala University and Statistikakademin, Uppsala, Sweden
| | - Magnus Ekström
- Respiratory Medicine, Allergology & Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Patrik Nordenfelt
- Respiratory Medicine & Allergology, Department of Internal Medicine, County Hospital of Ryhov, Jönköping, Sweden
| | - Arne Egesten
- Respiratory Medicine, Allergology & Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
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Jones D, Zafra H, Anderson J. Managing Diagnosis, Treatment, and Burden of Disease in Hereditary Angioedema Patients with Normal C1-Esterase Inhibitor. J Asthma Allergy 2023; 16:447-460. [PMID: 37124440 PMCID: PMC10132308 DOI: 10.2147/jaa.s398333] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/23/2023] [Indexed: 05/02/2023] Open
Abstract
Hereditary angioedema (HAE) is a rare, chronic, and debilitating genetic disorder characterized by recurrent and unpredictable swelling episodes that primarily affect the subcutaneous and/or submucosal tissues of the extremities, larynx, face, abdomen, and genitals. Most cases of HAE are caused by mutations in the serpin family G member 1 gene (SERPING1), which encodes C1-esterase inhibitor (C1-INH) protein. Mutations in SERPING1 lead to deficient (type I HAE-C1-INH) or dysfunctional (type II HAE-C1-INH) C1-INH protein and subsequent dysregulation of the kallikrein-bradykinin cascade. However, some patients present with a third type of HAE (HAE-nI-C1-INH), which was first described in the year 2000 and is characterized by an absence of mutations in SERPING1. Although mutations in the coagulation factor XII, angiopoietin-1, plasminogen, kininogen-1, myoferlin, and heparan sulfate-glucosamine 3-O-sulfotransferase-6 genes have been identified in some patients with HAE-nI-C1-INH, genetic cause is still unknown in many cases, hindering full elucidation of the pathology of this HAE subtype. Diagnosis of HAE-nI-C1-INH is also further complicated by the fact that patients typically demonstrate normal plasma levels of C1-INH and complement component 4 protein and normal C1-INH functionality during laboratory analysis. Therefore, we review the challenges associated with diagnosing, treating, and living with HAE-nI-C1-INH. We conclude that raising awareness of the presenting features of HAE-nI-C1-INH within the clinical setting and among the general public is critical to aid earlier suspicion and diagnosis of the disease. Furthermore, adopting an individualized approach to HAE-nI-C1-INH treatment is essential to help address the current and significant unmet needs in this patient population.
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Affiliation(s)
- Douglas Jones
- Rocky Mountain Allergy, Tanner Clinic, Layton, UT, USA
- Correspondence: Douglas Jones, Rocky Mountain Allergy, Tanner Clinic, 2121 North 1700 West, Layton, UT, 84041, USA, Tel +1 801 773 4840, Fax +1 801 525 8179, Email
| | - Heidi Zafra
- Division of Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, WI, USA
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7
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Hsu FI, Lumry W, Riedl M, Tachdjian R. Considerations in the management of hereditary angioedema due to C1-INH deficiency in women of childbearing age. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:64. [PMID: 35831891 PMCID: PMC9281160 DOI: 10.1186/s13223-022-00689-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/22/2022] [Indexed: 02/06/2023]
Abstract
Hereditary angioedema (HAE) is a rare, autosomal disorder that manifests with unpredictable episodes of severe swelling of the skin and mucous membranes. These attacks can be highly disfiguring and range in severity from mild to-in cases of airway swelling-life-threatening. Fluctuations in female sex hormones-such as the changes that occur during puberty, menses, contraceptive use, pregnancy, and menopause-can all affect the frequency and severity of HAE attacks. Disease management decisions for women of childbearing age may be more complex and require additional considerations since they could develop complications related to contraception, pregnancy, labor, delivery, and lactation. In addition, some HAE treatment options are contraindicated during pregnancy. Discussions about medications used to treat HAE should include a risk-benefit assessment of the woman's health status, her preferences, and other factors that are relevant to the choice of therapy. Planning prophylactic therapies that are effective and safe before, during, and after pregnancy can prevent gaps in treatment, ensure continuity of care, and reduce both disease burden and risk of adverse fetal outcomes. The 2020 US Hereditary Angioedema Association (HAEA) Medical Advisory Board and 2021 World Allergy Organization/European Academy of Allergy and Immunology (WAO/EAACI) Guidelines outline key considerations for managing HAE in females of childbearing age (15-45 years), with the goal of improving treatment efficacy and safety for this cohort of patients. Treatment decisions made in a collaborative manner involving the patient, HAE specialist and obstetric/gynecologic specialist, is the best approach to ensure optimal HAE management and safety in this patient population.
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Affiliation(s)
| | | | - Marc Riedl
- University of California - San Diego, La Jolla, CA, USA
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8
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Maurer M, Magerl M, Betschel S, Aberer W, Ansotegui IJ, Aygören-Pürsün E, Banerji A, Bara NA, Boccon-Gibod I, Bork K, Bouillet L, Boysen HB, Brodszki N, Busse PJ, Bygum A, Caballero T, Cancian M, Castaldo AJ, Cohn DM, Csuka D, Farkas H, Gompels M, Gower R, Grumach AS, Guidos-Fogelbach G, Hide M, Kang HR, Kaplan AP, Katelaris CH, Kiani-Alikhan S, Lei WT, Lockey RF, Longhurst H, Lumry W, MacGinnitie A, Malbran A, Martinez Saguer I, Matta Campos JJ, Nast A, Nguyen D, Nieto-Martinez SA, Pawankar R, Peter J, Porebski G, Prior N, Reshef A, Riedl M, Ritchie B, Sheikh FR, Smith WB, Spaeth PJ, Stobiecki M, Toubi E, Varga LA, Weller K, Zanichelli A, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema – The 2021 revision and update. World Allergy Organ J 2022; 15:100627. [PMID: 35497649 PMCID: PMC9023902 DOI: 10.1016/j.waojou.2022.100627] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/05/2021] [Accepted: 12/21/2021] [Indexed: 12/21/2022] Open
Abstract
Hereditary Angioedema (HAE) is a rare and disabling disease for which early diagnosis and effective therapy are critical. This revision and update of the global WAO/EAACI guideline on the diagnosis and management of HAE provides up-to-date guidance for the management of HAE. For this update and revision of the guideline, an international panel of experts reviewed the existing evidence, developed 28 recommendations, and established consensus by an online DELPHI process. The goal of these recommendations and guideline is to help physicians and their patients in making rational decisions in the management of HAE with deficient C1-inhibitor (type 1) and HAE with dysfunctional C1-inhibitor (type 2), by providing guidance on common and important clinical issues, such as: 1) How should HAE be diagnosed? 2) When should HAE patients receive prophylactic on top of on-demand treatment and what treatments should be used? 3) What are the goals of treatment? 4) Should HAE management be different for special HAE patient groups such as children or pregnant/breast feeding women? 5) How should HAE patients monitor their disease activity, impact, and control? It is also the intention of this guideline to help establish global standards for the management of HAE and to encourage and facilitate the use of recommended diagnostics and therapies for all patients.
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9
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Maurer M, Magerl M, Betschel S, Aberer W, Ansotegui IJ, Aygören‐Pürsün E, Banerji A, Bara N, Boccon‐Gibod I, Bork K, Bouillet L, Boysen HB, Brodszki N, Busse PJ, Bygum A, Caballero T, Cancian M, Castaldo A, Cohn DM, Csuka D, Farkas H, Gompels M, Gower R, Grumach AS, Guidos‐Fogelbach G, Hide M, Kang H, Kaplan AP, Katelaris C, Kiani‐Alikhan S, Lei W, Lockey R, Longhurst H, Lumry WB, MacGinnitie A, Malbran A, Martinez Saguer I, Matta JJ, Nast A, Nguyen D, Nieto‐Martinez SA, Pawankar R, Peter J, Porebski G, Prior N, Reshef A, Riedl M, Ritchie B, Rafique Sheikh F, Smith WR, Spaeth PJ, Stobiecki M, Toubi E, Varga LA, Weller K, Zanichelli A, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema-The 2021 revision and update. Allergy 2022; 77:1961-1990. [PMID: 35006617 DOI: 10.1111/all.15214] [Citation(s) in RCA: 137] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 12/11/2022]
Abstract
Hereditary angioedema (HAE) is a rare and disabling disease for which early diagnosis and effective therapy are critical. This revision and update of the global WAO/EAACI guideline on the diagnosis and management of HAE provides up-to-date guidance for the management of HAE. For this update and revision of the guideline, an international panel of experts reviewed the existing evidence, developed 28 recommendations, and established consensus by an online DELPHI process. The goal of these recommendations and guideline is to help physicians and their patients in making rational decisions in the management of HAE with deficient C1 inhibitor (type 1) and HAE with dysfunctional C1 inhibitor (type 2), by providing guidance on common and important clinical issues, such as: (1) How should HAE be diagnosed? (2) When should HAE patients receive prophylactic on top of on-demand treatment and what treatments should be used? (3) What are the goals of treatment? (4) Should HAE management be different for special HAE patient groups such as children or pregnant/breast-feeding women? and (5) How should HAE patients monitor their disease activity, impact, and control? It is also the intention of this guideline to help establish global standards for the management of HAE and to encourage and facilitate the use of recommended diagnostics and therapies for all patients.
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Affiliation(s)
- Marcus Maurer
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | - Markus Magerl
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | | | - Werner Aberer
- Department of Dermatology Medical University of Graz Graz Austria
| | | | - Emel Aygören‐Pürsün
- Center for Children and Adolescents University Hospital Frankfurt Frankfurt Germany
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology Massachusetts General Hospital Boston Massachusetts USA
| | - Noémi‐Anna Bara
- Romanian Hereditary Angioedema Expertise CentreMediquest Clinical Research Center Sangeorgiu de Mures Romania
| | - Isabelle Boccon‐Gibod
- National Reference Center for Angioedema (CREAK) Angioedema Center of Reference and Excellence (ACARE) Grenoble Alpes University Hospital Grenoble France
| | - Konrad Bork
- Department of Dermatology University Medical CenterJohannes Gutenberg University Mainz Germany
| | - Laurence Bouillet
- National Reference Center for Angioedema (CREAK) Angioedema Center of Reference and Excellence (ACARE) Grenoble Alpes University Hospital Grenoble France
| | | | - Nicholas Brodszki
- Department of Pediatric Immunology Childrens HospitalSkåne University Hospital Lund Sweden
| | | | - Anette Bygum
- Clinical Institute University of Southern Denmark Odense Denmark
- Department of Clinical Genetics Odense University Hospital Odense Denmark
| | - Teresa Caballero
- Allergy Department Hospital Universitario La PazIdiPaz, CIBERER U754 Madrid Spain
| | - Mauro Cancian
- Department of Systems Medicine University Hospital of Padua Padua Italy
| | | | - Danny M. Cohn
- Department of Vascular Medicine Amsterdam UMC/University of Amsterdam Amsterdam The Netherlands
| | - Dorottya Csuka
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Henriette Farkas
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Mark Gompels
- Clinical Immunology North Bristol NHS Trust Bristol UK
| | - Richard Gower
- Marycliff Clinical ResearchPrinciple Research Solutions Spokane Washington USA
| | | | | | - Michihiro Hide
- Department of Dermatology Hiroshima Citizens Hospital Hiroshima Japan
- Department of Dermatology Hiroshima University Hiroshima Japan
| | - Hye‐Ryun Kang
- Department of Internal Medicine Seoul National University College of Medicine Seoul Korea
| | - Allen Phillip Kaplan
- Division of Pulmonary, Critical Care, Allergy and Immunology Medical university of South Carolina Charleston South Carolina USA
| | - Constance Katelaris
- Department of Medicine Campbelltown Hospital and Western Sydney University Sydney NSW Australia
| | | | - Wei‐Te Lei
- Division of Allergy, Immunology, and Rheumatology Department of Pediatrics Mackay Memorial Hospital Hsinchu Taiwan
| | - Richard Lockey
- Division of Allergy and Immunology Department of Internal Medicine Morsani College of MedicineUniversity of South Florida Tampa Florida USA
| | - Hilary Longhurst
- Department of Immunology Auckland District Health Board and Department of MedicineUniversity of Auckland Auckland New Zealand
| | - William B. Lumry
- Internal Medicine Allergy Division University of Texas Health Science Center Dallas Texas USA
| | - Andrew MacGinnitie
- Division of Immunology Department of Pediatrics Boston Children's HospitalHarvard Medical School Boston Massachusetts USA
| | - Alejandro Malbran
- Unidad de Alergia, Asma e Inmunología Clínica Buenos Aires Argentina
| | | | | | - Alexander Nast
- Department of Dermatology, Venereology and Allergology Division of Evidence‐Based Medicine Charité ‐ Universitätsmedizin Berlincorporate member of Free University of BerlinHumboldt University of Berlin, and Berlin Institute of Health Berlin Germany
| | - Dinh Nguyen
- Respiratory, Allergy and Clinical Immunology Unit Internal Medicine Department Vinmec Healthcare System College of Health SciencesVinUniversity Hanoi Vietnam
| | | | - Ruby Pawankar
- Department of Pediatrics Nippon Medical School Tokyo Japan
| | - Jonathan Peter
- Division of Allergy and Clinical Immunology University of Cape Town Cape Town South Africa
- Allergy and Immunology Unit University of Cape Town Lung Institute Cape Town South Africa
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology Jagiellonian University Medical College Krakow Poland
| | - Nieves Prior
- Allergy Hospital Universitario Severo Ochoa Madrid Spain
| | - Avner Reshef
- Angioderma CenterBarzilai University Medical Center Ashkelon Israel
| | - Marc Riedl
- Division of Rheumatology, Allergy and Immunology University of California San Diego La Jolla California USA
| | - Bruce Ritchie
- Departments of Medicine and Medical Oncology University of Alberta Edmonton AB Canada
| | - Farrukh Rafique Sheikh
- Section of Adult Allergy & Immunology Department of Medicine King Faisal Specialist Hospital & Research Centre Riyadh Saudi Arabia
| | - William R. Smith
- Clinical Immunology and Allergy Royal Adelaide Hospital Adelaide SA Australia
| | - Peter J. Spaeth
- Institute of PharmacologyUniversity of Bern Bern Switzerland
| | - Marcin Stobiecki
- Department of Clinical and Environmental Allergology Jagiellonian University Medical College Krakow Poland
| | - Elias Toubi
- Division of Allergy and Clinical Immunology Bnai Zion Medical CenterAffiliated with Rappaport Faculty of MedicineTechnion‐Israel Institute of Technology Haifa Israel
| | - Lilian Agnes Varga
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Karsten Weller
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | - Andrea Zanichelli
- Department of Internal Medicine ASST Fatebenefratelli Sacco Ospedale Luigi Sacco‐University of Milan Milan Italy
| | - Yuxiang Zhi
- Department of Allergy and Clinical Immunology Bejing Union Medical College Hospital & Chinese Academy of Medical Sciences Bejing China
| | - Bruce Zuraw
- University of California, San Diego San Diego California USA
| | - Timothy Craig
- Departments of Medicine and Pediatrics Penn State University Hershey Pennsylvania USA
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Yoon SY, Jung JW, Park SY, Kim GW, Son K, Kang SY, Park HJ, Kang MK, Kim JH, Park KH, Lee DH, Kim SH, Kwon HS, Kang HR, Suh DI. Management of hereditary angioedema in pediatric, pregnant, and breast-feeding patients: An expert opinion. ALLERGY ASTHMA & RESPIRATORY DISEASE 2022. [DOI: 10.4168/aard.2022.10.3.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Sun Young Yoon
- Department of Internal Medicine, Chungnam National University Sejong Hospital, Sejong, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - So Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Gun-Woo Kim
- Department of Internal Medicine, St. Carollo General Hospital, Suncheon, Korea
| | - Kyunghee Son
- Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - Sung-Yoon Kang
- Division of Pulmonology and Allergy, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Hye Jung Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min-Kyu Kang
- Departmemt of Internal Medicine, Chungbuk National University Hospital and Chungbuk National College of Medicine, Cheongju, Korea
| | - Joo-Hee Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kyung Hee Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute for Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hun Lee
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyouk-Soo Kwon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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11
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Stempak-Droissart T, Rousset-Jablonski C, Spritzer PM, Lalhou N, Larger E, Pichard C, Plessier A, Gompel A. Impact of vascular liver disease on the menstrual cycle and metabolic status in premenopausal women. Clin Res Hepatol Gastroenterol 2022; 46:101756. [PMID: 34303004 DOI: 10.1016/j.clinre.2021.101756] [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] [Received: 03/29/2021] [Revised: 06/03/2021] [Accepted: 06/28/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Vascular liver disease (VLD) are rare liver diseases, which affect women at reproductive ages. Main complications are bleeding (portal hypertension, thrombopenia or anticoagulation related) and thromboembolism. Failure of liver function can occur. Thus endocrine abnormalities management and contraception are challenging. PURPOSE to evaluate the impact on the menstrual cycles and related endocrine abnormalities in women with VLD and respective roles of liver function and portal hypertension. STUDY DESIGN This was a single-center observational cohort study. Forty-seven premenopausal women with vascular liver disease were included for endocrine and gynecological assessments. Endocrine evaluation was performed at inclusion. Tolerance of contraception was followed up and assessed at 3 and 12 months. PARTICIPANTS, SETTING, METHODS Forty-seven women (aged 16-50) followed in a Reference Center for Liver Vascular Disease between February 2009 and November 2016 were included and addressed for gynecological and endocrinological management. Twenty-five women had extrahepatic portal vein obstruction, 17 had Budd Chiari Syndrome and five had a porto-sinusoidal vascular disease. We explored gonadotropin at baseline and after GnRH, testosterone, sex hormone binding globulin (SHBG), androstenedione, GH axis and glucose metabolism. All women underwent pelvic ultrasonography. RESULTS Vascular liver disease was associated with abnormal menstrual cycles in 53% of the women and clinical and/or biological hyperandrogenism and/or a polycystic ovary morphology was identified in 38%. Portal hypertension was correlated to higher testosterone levels (P = 0.04), whereas higher elevated levels SHBG in 28%, correlated with liver failure (P = 0.01). Sixteen had glucose intolerance profile or diabetes. IGF-1 levels were highly correlated with hepatic failure. Abnormal uterine bleeding occurred in 21% of women, 87% of which were due to gynecological pathologies revealed by anticoagulant treatment. Progestin contraception was well tolerated and helped to control bleeding. CONCLUSION AND IMPLICATIONS endocrine abnormalities, prior described in association with cirrhosis, are also identified in patients with vascular liver disease, and require specific management. Glucose intolerance profile is frequent, further studies are needed to assess significant consequences on cardio-vascular system.
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Affiliation(s)
- Tatiana Stempak-Droissart
- Université de Paris, Department of Gynecological Endocrinology, Hôpitaux Universitaires Centre, AP-HP, Paris, France; Department of Obstetrics and Gynecology, Groupe hospitalier Sud Ile de France, Centre hospitalier de Melun, Melun, France
| | | | - Poli M Spritzer
- Université de Paris, Department of Gynecological Endocrinology, Hôpitaux Universitaires Centre, AP-HP, Paris, France; Division of Endocrinology, Hospital de Clinicas de Porto Alegre and Department of Physiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Najiba Lalhou
- Laboratory of Hormonal Biology, Groupe hospitalier Cochin-Port Royal, AP-HP, Paris, France
| | - Etienne Larger
- Université de Paris, Department of Diabetology, Groupe hospitalier Cochin-PorRoyal, AP-HP, Paris, France
| | - Caroline Pichard
- Department of Endocrinology and metabolic diseases, Groupe hospitalier La Pitié-Salpêtrière, APHP, Paris, Fance
| | - Aurélie Plessier
- Beaujon Hospital, AP-HP, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Inserm U1149, Centre de Recherche sur l'Inflammation (CRI), Paris, Université Paris 7-Denis-Diderot, ERN Rare liver Clichy, France
| | - Anne Gompel
- Université de Paris, Department of Gynecological Endocrinology, Hôpitaux Universitaires Centre, AP-HP, Paris, France.
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Jakes AD, Thorne I, Guly J, Kiani-Alikhan S, Banerjee A. Case report: Hereditary angioedema in pregnancy. Obstet Med 2021; 14:177-180. [PMID: 34646347 DOI: 10.1177/1753495x20958225] [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: 03/26/2020] [Accepted: 08/21/2020] [Indexed: 11/15/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare genetic condition associated with episodic swelling due to dysfunction of bradykinin regulation pathways. This is most frequently caused by low level and/or function of the C1-esterase inhibitor protein (C1INH) which is known as hereditary angioedema with C1 inhibitor deficiency (C1INH-HAE). Pregnancy and labour can precipitate an attack, but the majority of women have an uncomplicated, spontaneous vaginal delivery. Intravenous C1INH is the first-line therapy in pregnancy and breastfeeding. It should be given if any obstetric intervention is planned. Routine prophylactic administration for uncomplicated vaginal birth is not mandatory but may be appropriate if symptoms recur frequently during the third trimester. Pregnant women with C1INH-HAE should deliver in a hospital with C1INH replacement, fiberoptic intubation and front-of-neck access equipment readily available. A documented treatment plan should be developed within a multi-disciplinary team to pre-empt complications. We describe a case of C1INH-HAE diagnosed in pregnancy.
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Affiliation(s)
- Adam D Jakes
- Guy's & St. Thomas' Hospital NHS Trust, St. Thomas' Hospital, London, UK
| | - Iona Thorne
- Guy's & St. Thomas' Hospital NHS Trust, St. Thomas' Hospital, London, UK
| | - John Guly
- Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | | | - Anita Banerjee
- Guy's & St. Thomas' Hospital NHS Trust, St. Thomas' Hospital, London, UK
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13
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Effectiveness of lanadelumab in patients with hereditary angioedema with normal C1 inhibitor and FXII mutation. Ann Allergy Asthma Immunol 2021; 127:391-392. [PMID: 34082125 DOI: 10.1016/j.anai.2021.05.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 11/24/2022]
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Mitigating Disparity in Health-care Resources Between Countries for Management of Hereditary Angioedema. Clin Rev Allergy Immunol 2021; 61:84-97. [PMID: 34003432 PMCID: PMC8282575 DOI: 10.1007/s12016-021-08854-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 12/28/2022]
Abstract
Hereditary angioedema (HAE) is a rare genetic disorder characterized by recurrent episodes of skin and mucosal edema. The main treatment goal is to enable a “normal life” for all patients. However, due to high costs, there are limited options for the management of HAE in most developing and low-income countries. As a result, most of the recommended first-line treatments are not available. In this review, we attempt to highlight the disparities in health-care resources for the management of patients with HAE amongst different countries. Data was collected from HAE experts in countries who provide tabulated information regarding management and availability of HAE treatments in their countries. We reviewed the two most recent international HAE guidelines. Using India, the world’s second most populous country, as a paradigm for HAE management in lower-income countries, we reviewed the evidence for second-line and non-recommended practices reported by HAE experts. Results suggest significant inequities in provision of HAE services and treatments. HAE patients in low-income countries do not have access to life-saving acute drugs or recently developed highly effective prophylactic medications. Most low-income countries do not have specialized HAE services or diagnostic facilities, resulting in consequent long delays in diagnosis. Suggestions for optimizing the use of limited resources as a basis for future discussion and reaching a global consensus are provided. There is an urgent need to improve HAE services, diagnostics and treatments currently available to lower-income countries. We recommend that all HAE stakeholders support the need for global equity and access to these essential measures.
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15
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Hormonal Effects on Urticaria and Angioedema Conditions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2209-2219. [PMID: 33895364 DOI: 10.1016/j.jaip.2021.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/02/2021] [Accepted: 04/15/2021] [Indexed: 12/18/2022]
Abstract
Women appear to be more frequently affected with urticaria and angioedema. Sex hormones are believed to have an important mechanistic role in regulating pathways involved in these conditions. This effect is likely nonspecific for chronic spontaneous urticaria (CSU) or many forms of angioedema (AE), because many other chronic diseases such as asthma are also affected by sex hormones. The role of sex hormones has been better elucidated for hereditary AE, because they have been shown to have multiple effects including upregulation of FXII, an important activator of the kallikrein pathway. However, their role in the underlying pathogenesis for CSU is less clear. Autoimmunity is clearly linked to CSU, which is more common in women. This suggests that sex hormones could act as adjuvants in activating or upregulating autoimmune pathways. The purpose of this review is to discuss in detail the role of sex hormones in CSU and AE and how a better understanding of the impact hormones has on these conditions might lead to new treatment advancements with better clinical outcomes.
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16
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Sharma J, Jindal AK, Banday AZ, Kaur A, Rawat A, Singh S, Longhurst H. Pathophysiology of Hereditary Angioedema (HAE) Beyond the SERPING1 Gene. Clin Rev Allergy Immunol 2021; 60:305-315. [PMID: 33442779 DOI: 10.1007/s12016-021-08835-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 11/29/2022]
Abstract
Hereditary Angioedema (HAE) is an autosomal dominant disorder characterized clinically by recurrent episodes of swelling involving subcutaneous tissues, gastrointestinal tract, and oro-pharyngeal area. Gene mutations are the most common genetic cause of HAE and observed in more than 90% of patients. More than 700 mutation variants have been described so far. Patients with angioedema who have no mutations in the gene for C1-INH and normal levels and activity of this inhibitor are labelled: normal C1 inhibitor HAE. These include genetic mutations in factor 12 gene, plasminogen gene, angiopoietin gene, kininogen 1, and myoferlin genes. The clinical manifestations of patients with these mutations are similar to with patients with C1-INH gene mutations. However, a later age of onset, oro-pharyngeal involvement, and higher female preponderance have been reported in these rare subtypes of hereditary angioedema. With the advent and increased accessibility of whole-exome sequencing, it is expected that new genetic defects and novel pathophysiological pathways will be identified in families with HAE of unknown cause or normal C1-INH angioedema. This review covers some of the recent advances in the field of HAE. The review focuses on pathophysiology of HAE beyond the well-known C1-INH deficiency phenotypes, including various biomarkers that can serve the diagnosis and management of these rare disorders.
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Affiliation(s)
- Jyoti Sharma
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Kumar Jindal
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Aaqib Zaffar Banday
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anit Kaur
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Hilary Longhurst
- Department of Clinical Immunology, University College Hospitals, London and Addenbrooke's Hospital, Cambridge, UK
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17
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Veronez CL, Mendes AR, Leite CS, Gomes CP, Grumach AS, Pesquero JB. The Panorama of Primary Angioedema in the Brazilian Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:2293-2304.e5. [PMID: 33276216 DOI: 10.1016/j.jaip.2020.11.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary angioedema (PA) is a complex disorder, presenting multiple hereditary (hereditary angioedema) and acquired subtypes (acquired angioedema). Despite a very similar clinical presentation among subtypes, the differential diagnosis is limited by the difficulty to identify bradykinin-mediated PA and the lack of specific biomarkers. OBJECTIVES To report the clinical and genetic features of Brazilian patients with PA. METHODS Brazilian patients referred from 50 centers were diagnosed on the basis of clinical symptoms, C1 inhibitor (C1-INH) and C4 plasma measurements, and DNA sequencing of genes associated with hereditary angioedema. RESULTS We characterized 92 patients with acquired angioedema and 425 with HAE: 125 with C1-INH deficiency, 180 with F12 mutations, and 120 of unknown cause. Thirty-one different mutations were identified in SERPING1 and 2 in F12, in addition to 2 mutations of uncertain significance in the ANGPT1 gene. The molecular diagnosis was decisive for 34 patients with HAE without family history, and for 39% of patients with inconsistent biochemical measurements. The median delay in diagnosis was 10 years, with a maximum of 18 years for HAE with C1-INH deficiency. Androgens and tranexamic acid were the most used drugs for long-term prophylaxis in all the PA subtypes, and they were used on demand by 15% of patients. Only 10% of patients reported the use of specific medication for HAE during attacks. CONCLUSIONS Our analysis exposes a broad picture of PA diagnosis and management in a developing country. Complement measurements presented considerable inconsistencies, increasing the diagnosis delay, while patients with PA with normal C1-INH remain with an inaccurate diagnosis and unspecific treatment.
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Affiliation(s)
- Camila Lopes Veronez
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil; Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, Calif; Research Service, San Diego Veterans Affairs Healthcare, San Diego, Calif.
| | | | | | - Caio Perez Gomes
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
| | - Anete Sevciovic Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitário Saúde ABC, Santo Andre, Brazil
| | - João Bosco Pesquero
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
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Yakaboski E, Motazedi T, Banerji A. Hereditary angioedema: Special considerations in women. Allergy Asthma Proc 2020; 41:S47-S50. [PMID: 33109327 DOI: 10.2500/aap.2020.41.200077] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
There are several challenges that arise in caring for women with hereditary angioedema (HAE). Most notably, the disease course during pregnancy is unpredictable, but studies show that plasma-derived C1-inhibitor is effective and safe for treatment of attacks as well as long-term prophylaxis (LTP) in select patients. Vaginal deliveries are preferred to caesarean sections, and epidural anesthesia is preferred to general anesthesia in lowering the risk of an acute attack. Lactation postpartum may increase HAE attacks. With regard to contraception, combined oral contraceptive pills that contain estrogen exacerbate symptoms. Similarly, estrogen-replacement therapy in menopause may increase attacks and is contraindicated. Fertility is not impacted by HAE itself or by HAE medications. The risk of breast cancer and female reproductive cancer in women with HAE is comparable with that of the general population, but, in patients with HAE and breast cancer, LTP with androgens is contraindicated. Estrogen modulators, e.g., tamoxifen, should be used with caution. Here, we reviewed these special considerations and others that are vital to providers in caring for women with HAE.
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Affiliation(s)
| | - Tina Motazedi
- From the Massachusetts General Hospital, Boston, Massachusetts
| | - Aleena Banerji
- From the Massachusetts General Hospital, Boston, Massachusetts
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19
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Busse PJ, Christiansen SC, Riedl MA, Banerji A, Bernstein JA, Castaldo AJ, Craig T, Davis-Lorton M, Frank MM, Li HH, Lumry WR, Zuraw BL. US HAEA Medical Advisory Board 2020 Guidelines for the Management of Hereditary Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:132-150.e3. [PMID: 32898710 DOI: 10.1016/j.jaip.2020.08.046] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 08/28/2020] [Accepted: 08/29/2020] [Indexed: 01/29/2023]
Abstract
Scientific and clinical progress together with the development of effective novel therapeutic options has engendered multiple important changes in the diagnosis and management of hereditary angioedema (HAE). We now update and extend the 2013 United States Hereditary Angioedema Association Medical Advisory Board guidelines for the treatment and management of HAE. The guidelines are based on a comprehensive literature review with recommendations indicating both the strength of our recommendation and the quality of the underlying evidence. Guidelines are provided regarding the classification, diagnosis, on-demand treatment, prophylactic treatment, special considerations for women and children, development of a comprehensive management and monitoring plan, and assessment of burden of illness for both HAE due to C1 inhibitor deficiency and HAE with normal C1 inhibitor. Advances in HAE treatment now allow the development of management plans that can help many patients with HAE lead a normal life. Achieving this goal requires that physicians be familiar with the diagnostic and therapeutic transformations that have occurred in recent years.
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Affiliation(s)
- Paula J Busse
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Sandra C Christiansen
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, Calif
| | - Marc A Riedl
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, Calif
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Harvard Medical School, Boston, Mass
| | - Jonathan A Bernstein
- Division of Immunology, Rheumatology, and Allergy, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Timothy Craig
- Division of Allergy, Asthma, and Immunology, Department of Medicine, Pediatrics, and Graduate Studies, Pennsylvania State University, Hershey, Pa
| | - Mark Davis-Lorton
- Division of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, NYU Winthrop Hospital, Mineola, NY
| | - Michael M Frank
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - H Henry Li
- Medicine Service, Institute for Asthma and Allergy, Chevy Chase, Md
| | - William R Lumry
- Allergy and Asthma Research Associates Research Center, Dallas, Tex
| | - Bruce L Zuraw
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, Calif; San Diego Veterans Administration Healthcare, San Diego, Calif.
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20
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Roche JA, Roche R. A hypothesized role for dysregulated bradykinin signaling in COVID-19 respiratory complications. FASEB J 2020; 34:7265-7269. [PMID: 32359101 PMCID: PMC7267506 DOI: 10.1096/fj.202000967] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 01/13/2023]
Abstract
As of April 20, 2020, over time, the COVID-19 pandemic has resulted in 157 970 deaths out of 2 319 066 confirmed cases, at a Case Fatality Rate of ~6.8%. With the pandemic rapidly spreading, and health delivery systems being overwhelmed, it is imperative that safe and effective pharmacotherapeutic strategies are rapidly explored to improve survival. In this paper, we use established and emerging evidence to propose a testable hypothesis that, a vicious positive feedback loop of des-Arg(9)-bradykinin- and bradykinin-mediated inflammation → injury → inflammation, likely precipitates life threatening respiratory complications in COVID-19. Through our hypothesis, we make the prediction that the FDA-approved molecule, icatibant, might be able to interrupt this feedback loop and, thereby, improve the clinical outcomes. This hypothesis could lead to basic, translational, and clinical studies aimed at reducing COVID-19 morbidity and mortality.
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Affiliation(s)
- Joseph A Roche
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Renuka Roche
- College of Health and Human Services, Eastern Michigan University, Ypsilanti, MI, USA
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21
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Treatment of patients with hereditary angioedema with the c.988A>G (p.Lys330Glu) variant in the plasminogen gene. Orphanet J Rare Dis 2020; 15:52. [PMID: 32066472 PMCID: PMC7026952 DOI: 10.1186/s13023-020-1334-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/07/2020] [Indexed: 12/02/2022] Open
Abstract
Background Hereditary angioedema (HAE) in patients with normal C1 inhibitor (C1-INH) and the c.988A > G (p.Lys330Glu; p.K330E) variant in the plasminogen gene (HAE-PLG) is associated with skin swellings, abdominal pain attacks, and the risk of asphyxiation due to upper airway obstruction. Aim of this observational, retrospective study is to report about the efficacy of various treatments for acute attacks and long-term prophylaxis. Results The study included 111 patients with HAE-PLG. Thirteen patients were treated with icatibant for 201 acute swelling attacks. The mean duration of the treated attacks (mean 4.3 h; standard deviation [SD] 2.6 h) was significantly shorter than that of the previous 149 untreated attacks (mean 44.7 h; SD 28.6 h, p < 0.0001). Twelve patients were treated with plasma-derived C1-INH for 74 acute swelling attacks. The duration of the treated attacks (mean 31.5 h; SD 18.6 h) was significantly shorter than that of the previous 129 untreated in the same patients (mean 48.2 h; SD 32.5 h, p < 0.0001). Corticosteroids alone showed good response in 61/268 attacks (8 patients), low response in 82/268 attacks (7 patients), and no response in 125/268 attacks (26 patients). Corticosteroids combined with antihistamines showed good response in 13/309 attacks (4 patients), low response in 150/309 attacks (7 patients), and no response in 146/309 attacks (17 patients). Antihistamines alone were ineffective in all 37 attacks of 5 patients. In 2 patients with imminent asphyxiation due to tongue swelling and partial obstruction of the upper airways fresh frozen plasma was used without clinical response. The mean reduction in attack frequency was 46.3% under progestins (6 patients), 93.9% under tranexamic acid (3 patients) and 83.3% under danazol (3 patients). Conclusions For patients with HAE-PLG various treatment options are available, which completely or at least partially reduce attack duration or attack frequency.
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22
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Gompel A, Fain O, Boccon-Gibod I, Gobert D, Bouillet L. Exogenous hormones and hereditary angioedema. Int Immunopharmacol 2020; 78:106080. [DOI: 10.1016/j.intimp.2019.106080] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 11/17/2019] [Accepted: 11/23/2019] [Indexed: 12/15/2022]
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Bygum A. Hereditary Angio-Oedema for Dermatologists. Dermatology 2019; 235:263-275. [PMID: 31167185 DOI: 10.1159/000500196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/08/2019] [Indexed: 11/19/2022] Open
Abstract
Among angio-oedema patients, hereditary angio-oedema (HAE) should not be overlooked. Besides skin swellings, these patients might have very painful abdominal attacks and potentially life-threatening angio-oedema of the upper airway. They will not respond to traditional anti-allergic therapy with antihistamines, corticosteroids, and adrenaline, and instead need specific drugs targeting the kallikrein-kinin pathway. Classically, patients with HAE have a quantitative or qualitative deficiency of the C1 inhibitor (C1INH) due to different mutations in SERPING1, although a new subtype with normal C1INH has been recognised more recently. This latter variant is diagnosed based on clinical features, family history, or molecular genetic testing for mutations in F12, ANGPT1,or PLG.The diagnosis of HAE is often delayed due to a general unfamiliarity with this orphan disease. However, undiagnosed patients are at an increased risk of unnecessary surgical interventions or life-threatening laryngeal swellings. Within the last decade, new and effective therapies have been developed and launched for acute and prophylactic therapy. Even more drugs are under evaluation in clinical trials. It is therefore of utmost importance that patients with HAE are diagnosed as soon as possible and offered relevant therapy with orphan drugs to reduce morbidity, prevent mortality, and improve quality of life.
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Affiliation(s)
- Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark,
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Bork K, Aygören-Pürsün E, Bas M, Biedermann T, Greve J, Hartmann K, Magerl M, Martinez-Saguer I, Maurer M, Ott H, Schauf L, Staubach P, Wedi B. Leitlinie: Hereditäres Angioödem durch C1-Inhibitor-Mangel. ALLERGO JOURNAL 2019. [DOI: 10.1007/s15007-019-1773-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Bork K, Aygören-Pürsün E, Bas M, Biedermann T, Greve J, Hartmann K, Magerl M, Martinez-Saguer I, Maurer M, Ott H, Schauf L, Staubach P, Wedi B. Guideline: Hereditary angioedema due to C1 inhibitor deficiency. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s40629-018-0088-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Abstract
Non-hereditary angioedema (AE) with normal C1 esterase inhibitor (C1INH) can be presumably bradykinin- or mast cell-mediated, or of unknown cause. In this systematic review, we searched PubMed, EMBASE, and Scopus to provide an overview of the efficacy of different treatment options for the abovementioned subtypes of refractory non-hereditary AE with or without wheals and with normal C1INH. After study selection and risk of bias assessment, 61 articles were included for data extraction and analysis. Therapies were described for angiotensin-converting enzyme inhibitor-induced AE (ACEi-AE), for idiopathic AE, and for AE with wheals. Described treatments consisted of ecallantide, icatibant, C1INH, fresh frozen plasma (FFP), tranexamic acid (TA), and omalizumab. Additionally, individual studies for anti-vitamin K, progestin, and methotrexate were found. Safety information was available in 26 articles. Most therapies were used off-label and in few patients. There is a need for additional studies with a high level of evidence. In conclusion, in acute attacks of ACEi-AE and idiopathic AE, treatment with icatibant, C1INH, TA, and FFP often leads to symptom relief within 2 h, with limited side effects. For prophylactic treatment of idiopathic AE and AE with wheals, omalizumab, TA, and C1INH were effective and safe in the majority of patients.
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Maurer M, Magerl M, Ansotegui I, Aygören-Pürsün E, Betschel S, Bork K, Bowen T, Balle Boysen H, Farkas H, Grumach AS, Hide M, Katelaris C, Lockey R, Longhurst H, Lumry WR, Martinez-Saguer I, Moldovan D, Nast A, Pawankar R, Potter P, Riedl M, Ritchie B, Rosenwasser L, Sánchez-Borges M, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema-The 2017 revision and update. Allergy 2018; 73:1575-1596. [PMID: 29318628 DOI: 10.1111/all.13384] [Citation(s) in RCA: 298] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 12/25/2022]
Abstract
Hereditary Angioedema (HAE) is a rare and disabling disease. Early diagnosis and appropriate therapy are essential. This update and revision of the global guideline for HAE provides up-to-date consensus recommendations for the management of HAE. In the development of this update and revision of the guideline, an international expert panel reviewed the existing evidence and developed 20 recommendations that were discussed, finalized and consented during the guideline consensus conference in June 2016 in Vienna. The final version of this update and revision of the guideline incorporates the contributions of a board of expert reviewers and the endorsing societies. The goal of this guideline update and revision is to provide clinicians and their patients with guidance that will assist them in making rational decisions in the management of HAE with deficient C1-inhibitor (type 1) and HAE with dysfunctional C1-inhibitor (type 2). The key clinical questions covered by these recommendations are: (1) How should HAE-1/2 be defined and classified?, (2) How should HAE-1/2 be diagnosed?, (3) Should HAE-1/2 patients receive prophylactic and/or on-demand treatment and what treatment options should be used?, (4) Should HAE-1/2 management be different for special HAE-1/2 patient groups such as pregnant/lactating women or children?, and (5) Should HAE-1/2 management incorporate self-administration of therapies and patient support measures?
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Affiliation(s)
- M. Maurer
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - M. Magerl
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - I. Ansotegui
- Department of Allergy and Immunology; Hospital Quironsalud Bizkaia; Bilbao Spain
| | - E. Aygören-Pürsün
- Center for Children and Adolescents; University Hospital Frankfurt; Frankfurt Germany
| | - S. Betschel
- Division of Clinical Immunology and Allergy; St. Michael's Hospital; University of Toronto; Toronto ON Canada
| | - K. Bork
- Department of Dermatology; Johannes Gutenberg University Mainz; Mainz Germany
| | - T. Bowen
- Department of Medicine and Pediatrics; University of Calgary; Calgary AB Canada
| | | | - H. Farkas
- Hungarian Angioedema Center; 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - A. S. Grumach
- Clinical Immunology; Faculdade de Medicina ABC; São Paulo Brazil
| | - M. Hide
- Department of Dermatology; Hiroshima University; Hiroshima Japan
| | - C. Katelaris
- Department of Medicine; Campbelltown Hospital and Western Sydney University; Sydney NSW Australia
| | - R. Lockey
- Department of Internal Medicine; University of South Florida Morsani College of Medicine; Tampa FL USA
| | - H. Longhurst
- Department of Clinical Biochemistry and Immunology; Addenbrooke's Hospital; Cambridge University Hospitals NHS Foundation Trust; UK
| | - W. R. Lumry
- Department of Internal Medicine; Allergy/Immunology Division; Southwestern Medical School; University of Texas; Dallas TX USA
| | | | - D. Moldovan
- University of Medicine and Pharmacy; Tîrgu Mures Romania
| | - A. Nast
- Berlin Institute of Health; Department of Dermatology, Venereology und Allergy; Division of Evidence based Medicine (dEBM); Corporate Member of Freie Universität Berlin; Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - R. Pawankar
- Department of Pediatrics; Nippon Medical School; Tokyo Japan
| | - P. Potter
- Department of Medicine; University of Cape Town; Cape Town South Africa
| | - M. Riedl
- Department of Medicine; University of California-San Diego; La Jolla CA USA
| | - B. Ritchie
- Division of Hematology; University of Alberta; Edmonton AB Canada
| | - L. Rosenwasser
- Allergy and Immunology Department; University of Missouri at Kansas City School of Medicine; Kansas City MO USA
| | - M. Sánchez-Borges
- Allergy and Clinical Immunology Department; Centro Medico Docente La Trinidad; Caracas Venezuela
| | - Y. Zhi
- Department of Allergy; Peking Union Medical College Hospital and Chinese Academy of Medical Sciences; Beijing China
| | - B. Zuraw
- Department of Medicine; University of California-San Diego; La Jolla CA USA
- San Diego VA Healthcare; San Diego CA USA
| | - T. Craig
- Department of Medicine and Pediatrics; Penn State University; Hershey PA USA
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Omalizumab for Idiopathic Nonhistaminergic Angioedema: Evidence for Efficacy in 2 Patients. Case Reports Immunol 2018; 2018:8067610. [PMID: 30140474 PMCID: PMC6081528 DOI: 10.1155/2018/8067610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 07/05/2018] [Indexed: 12/03/2022] Open
Abstract
Presently, there is inconclusive evidence regarding the most effective treatment for idiopathic nonhistaminergic acquired angioedema (InH-AAE). Omalizumab may, however, prove to be a promising option. This case report describes two patients who presented with recurrent angioedema attacks, which was refractory to antihistamine therapy. Hence, they were treated with 300 mg omalizumab, every 4 weeks, for a period of 6 months. Both patients had shown a rapid response to the treatment and achieved complete resolution of symptoms without further AE attacks throughout the entire duration of the treatment period. After omalizumab's suspension, one patient remained symptom free for the following 6 months and the other patient had recurrence of symptoms after 2 months for which he was retreated with omalizumab and once again became symptom free. Although omalizumab seems to be effective as a prophylactic treatment for InH-AAE, the determining factors leading to the differences in time-to-relapse between patients after its suspension remain unclear. Further studies are needed in order to better determine the potential therapeutic application of omalizumab and its role in maintenance therapy.
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Pharmacological Management of Hereditary Angioedema with C1-Inhibitor Deficiency in Pediatric Patients. Paediatr Drugs 2018; 20:135-151. [PMID: 29214395 DOI: 10.1007/s40272-017-0273-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hereditary angioedema with C1-inhibitor deficiency (C1-INH-HAE) is a form of bradykinin-mediated angioedema. It is a rare disorder with an onset during childhood in most instances. Therefore, familiarity with the options for the management of pediatric cases is indispensable. The recurrent angioedematous episodes do not respond to conventional treatments and may evolve into a life-threatening condition. In view of the recommendations adopted by international consensus in 2016, patient management and follow-up should be guided by an individualized strategy. During the last decade, various medicinal products with novel modes of action and different posology have been developed for the treatment of C1-INH-HAE. These drugs either inhibit the release of bradykinin (plasma-derived C1-inhibitors, recombinant C1-inhibitors, kallikrein inhibitors) or prevent the released bradykinin from binding to its receptor (bradykinin B2 receptor antagonists). This review summarizes the properties of the medicinal products currently available for the treatment of C1-INH-HAE, the indications for their use in pediatric patients, and the findings of the clinical trials conducted in this patient population. It is concluded by a brief outline of future therapeutic options.
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Maurer M, Magerl M, Ansotegui I, Aygören-Pürsün E, Betschel S, Bork K, Bowen T, Boysen HB, Farkas H, Grumach AS, Hide M, Katelaris C, Lockey R, Longhurst H, Lumry WR, Martinez-Saguer I, Moldovan D, Nast A, Pawankar R, Potter P, Riedl M, Ritchie B, Rosenwasser L, Sánchez-Borges M, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema – the 2017 revision and update. World Allergy Organ J 2018. [DOI: 10.1186/s40413-017-0180-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Farkas H, Debreczeni ML, Kőhalmi KV. Investigational drugs in phase I and phase II clinical trials for hereditary angioedema. Expert Opin Investig Drugs 2017; 27:87-103. [PMID: 29226721 DOI: 10.1080/13543784.2018.1415325] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Hereditary angioedema (HAE) with C1-inhibitor deficiency (C1-INH-HAE) is a rare bradykinin-mediated disease characterized by recurrent subcutaneous and/or submucosal angioedematous attacks (HAE attacks), which occur unpredictably. The recurrent HAE attacks do not respond to conventional treatments, and may evolve into a life-threatening condition; therefore, special therapy is required. AREAS COVERED The agents used so far for the acute management of HAE attacks act by blocking the release of bradykinin, or its binding to its receptor. By contrast, the investigational medicinal products under evaluation in Phase I and II clinical trials are targeted at the prevention of HAE attacks. Chemically, these new drugs are small synthetic molecules, oligonucleotides, or antibodies, which inhibit either kallikrein, or Factor XII. EXPERT OPINION The key considerations for the development of new medicinal products include more straightforward dosing, self-administration, longer duration of action, and keeping the patient attack-free. This review summarizes the status and the findings of the currently ongoing Phase I and Phase II clinical trials of C1-INH-HAE.
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Affiliation(s)
- Henriette Farkas
- a Hungarian Angioedema Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
| | - Márta Lídia Debreczeni
- a Hungarian Angioedema Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
| | - Kinga Viktória Kőhalmi
- a Hungarian Angioedema Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
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Bucher MC, Petkovic T, Helbling A, Steiner UC. Idiopathic non-histaminergic acquired angioedema: a case series and discussion of published clinical trials. Clin Transl Allergy 2017; 7:27. [PMID: 28861213 PMCID: PMC5577688 DOI: 10.1186/s13601-017-0164-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 07/17/2017] [Indexed: 01/03/2023] Open
Abstract
Background Idiopathic non-histaminergic acquired angioedema (InH-AAE) is a rare disease for which there are no available laboratory parameters to clearly define the disorder. Therapy is often difficult and various treatment options have been proposed. In this paper, we have evaluated the most effective therapies for InH-AAE on the basis of current literature and report the therapeutic effect of omalizumab in three patients with InH-AAE. Methods Literature was searched with a combination of MeSH/EMTREE terms and freetext search for angioedema and therapy/omalizumab in the databases Medline (Ovid), PubMed/Premedline, Embase, Cochrane library and Scopus with no time or language restrictions. In three patients affected by InH-AAE the therapeutic effect of omalizumab was demonstrated by clinical outcome. In one patient the FcεRI receptor density on basophils was monitored under therapy with omalizumab. Results From the review of the current literature, 25 out of 286 publications dealing with relevant therapeutic recommendations for InH-AAE were analyzed. Six publications with 98 patients referred to tranexamic acid, of which 27 had a complete, 70 a partial and 1 no response. In three case reports ecallantide showed 2 patients with a complete and 1 a partial response. In four case reports for Icatibant 2 had a complete and 3 a partial response. When evaluated in three reports, C1-INH found complete and partial responses in 2 patients each. One patient had a complete response to progestin. Omalizumab was described in 6 reports with 20 patients, all of whom showed a complete response. All three patients described in our study responded to omalizumab with a complete remission. Density of FcεRI receptors on basophils, monitored in patient 1 on a long-term course of 31 months, decreased from 74,051.61 to a minimal level of 1907 receptors per cell. Conclusions Omalizumab seems to be the most effective therapy in InH-AAE. The continuous decrease of FcεRI-receptor density on basophils under therapy with omalizumab along with clinical improvement observed in one patient, could serve as a new approach for further studies to evaluate FcεRI-receptor density as a surrogate marker for therapeutic efficacy and for dosing and determining injection intervals of omalizumab. Trial registration BASEC-Nr. Req-2016-00692. Retrospectively registered 24.11.2016. Electronic supplementary material The online version of this article (doi:10.1186/s13601-017-0164-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin Christian Bucher
- Department of Clinical Immunology, University Hospital Zurich, Gloriastrasse 23, 8091 Zurich, Switzerland
| | - Tatjana Petkovic
- Adverse Drug Reaction-Analysis and Consulting (ADR-AC) GmbH, Bern, Switzerland
| | - Arthur Helbling
- Department of Rheumatology, Immunology and Allergology, Inselspital, University Bern, Bern, Switzerland
| | - Urs Christian Steiner
- Department of Clinical Immunology, University Hospital Zurich, Gloriastrasse 23, 8091 Zurich, Switzerland
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33
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Longhurst H, Zinser E. Prophylactic Therapy for Hereditary Angioedema. Immunol Allergy Clin North Am 2017; 37:557-570. [DOI: 10.1016/j.iac.2017.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Williams WV. Hormonal contraception and the development of autoimmunity: A review of the literature. LINACRE QUARTERLY 2017; 84:275-295. [PMID: 28912620 PMCID: PMC5592309 DOI: 10.1080/00243639.2017.1360065] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Estrogens and progestins are known to have profound effects on the immune system and may modulate the susceptibility to autoimmune diseases. A comprehensive literature search was carried out using PubMed for any of 153 autoimmune disease terms and the terms contraception, contraceptive, or their chemical components with limits of Humans + Title or Abstract. Over 1,800 titles were returned and scanned, 352 papers retrieved and reviewed in depth and an additional 70 papers retrieved from the bibliographies. Based on this review, substantial evidence exists linking the use of combined oral contraceptives to a lower incidence of hyperthyroidism, an increase in multiple sclerosis, ulcerative colitis, Crohn's disease, Systemic Lupus Erythematosus, and interstitial cystitis. Progesterone only contraceptives are linked to progesterone dermatitis and in one large developing world concurrent cohort study are associated with increases in arthropathies and related disorders, eczema and contact dermatitis, pruritis and related conditions, alopecia, acne, and urticaria. Hormonal contraceptives modulate the immune system and may influence the susceptibility to autoimmune diseases with significant increases in risk for several autoimmune diseases. SUMMARY Hormonal contraceptives (HCs), such as the "pill," Norplant, and vaginal rings, are very potent hormones that have effects on the immune system, which is made up of white blood cells and lymph nodes and normally defends the body against invading bacteria, viruses and parasites. This review looked at the association of HC use to the development of autoimmune diseases, where the immune system turns against the body and causes damage to organs. There is good evidence that HC use is associated with an increased risk of several serious autoimmune diseases such as Crohn's disease (which causes inflammation of the bowels), Lupus (which causes inflammation in many organs), and interstitial cystitis (which causes inflammation in the bladder). Several other rarer autoimmune diseases are also linked to HC use. People contemplating the use of HCs should be informed of these risks.
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Affiliation(s)
- William V Williams
- BriaCell Therapeutics Corporation, Havertown, PA, USA
- University of Pennsylvania, Philadelphia, PA, USA
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35
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Magerl M, Germenis AE, Maas C, Maurer M. Hereditary Angioedema with Normal C1 Inhibitor. Immunol Allergy Clin North Am 2017; 37:571-584. [DOI: 10.1016/j.iac.2017.04.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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36
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Prieto-García A, Roa Medellín D, Baeza ML. Angioedema attacks related to endometrial hyperplasia in a case of estrogen-dependent factor XII hereditary angioedema. Ann Allergy Asthma Immunol 2017; 118:736-737. [PMID: 28476524 DOI: 10.1016/j.anai.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 03/30/2017] [Accepted: 04/02/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Alicia Prieto-García
- Allergy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
| | - Dasha Roa Medellín
- Allergy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Maria Luisa Baeza
- Allergy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER) U761, Madrid, Spain
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Deroux A, Boccon-Gibod I, Fain O, Pralong P, Ollivier Y, Pagnier A, Djenouhat K, Du-Thanh A, Gompel A, Faisant C, Launay D, Bouillet L. Hereditary angioedema with normal C1 inhibitor and factor XII mutation: a series of 57 patients from the French National Center of Reference for Angioedema. Clin Exp Immunol 2017; 185:332-7. [PMID: 27271546 DOI: 10.1111/cei.12820] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 11/29/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare disease associated with either a quantitative or qualitative deficiency in C1-inhibitor (C1-INH) or normal C1-INH. HAE with normal C1-INH is associated in 20% of cases with mutations in the gene for factor XII (FXII) or FXII-HAE. A recent review described 41 families, including 14 German and 15 Spanish families. We have constructed a register of French patients and their characteristics. A national survey was launched through the French National Center of Reference for Angioedema (CREAK) to study the clinical, biological and therapeutic characteristics of patients with HAE linked to a mutation of FXII gene. Fifty-seven patients were identified from 24 different families. In most cases they were young women (mean age at diagnosis: 31 years, mean age at first symptom: 21 years, female/male ratio: 76%). Twenty-one per cent of the patients experienced angioedema attacks only during pregnancy or when on oestrogen contraception. Sixty-three per cent had attacks at all times, but they were more severe during these same periods. Male carriers of the mutation were more frequently asymptomatic than females (P = 0·003). C1-INH concentrate and icatibant were both effective for treating attacks. The prophylactic use of tranexamic acid led to a 64% decrease in the number of attacks. This is one of the largest series reported of HAE patients with FXII mutation. The therapeutic management appeared to be identical to that of HAE with C1-INH deficiency.
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Affiliation(s)
- A Deroux
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
| | - I Boccon-Gibod
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
| | - O Fain
- Internal Medicine Department, Hôpital Saint Antoine, Université Paris, France
| | - P Pralong
- Dermatology Department, Allergology and Photobiology, CHU De Grenoble, Grenoble, France
| | - Y Ollivier
- Internal Medicine Department, Caen, France
| | - A Pagnier
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
| | - K Djenouhat
- Service De Biologie Médicale, EPH De Rouïba, Alger, Algéria
| | - A Du-Thanh
- Dermatology Department, Hôpital Saint-Eloi, Centre Hospitalier Universitaire De Montpellier, Montpellier, France
| | - A Gompel
- Gynecology Department, CHU Paris-Centre, Hopital, Cochin, Paris, France
| | - C Faisant
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
| | - D Launay
- Université Lille, Lille Inflammation Research International Center, Lille, France.,Département De Médecine Interne Et Immunologie Clinique, Lille, Lille, France
| | - L Bouillet
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
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Bork K, Wulff K, Witzke G, Hardt J. Treatment for hereditary angioedema with normal C1-INH and specific mutations in the F12 gene (HAE-FXII). Allergy 2017; 72:320-324. [PMID: 27905115 DOI: 10.1111/all.13076] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 11/28/2022]
Abstract
Hereditary angioedema with normal C1 esterase inhibitor and mutations in the F12 gene (HAE-FXII) is associated with skin swellings, abdominal pain attacks, and the risk of asphyxiation due to upper airway obstruction. It occurs nearly exclusively in women. We report our experience treating HAE-FXII with discontinuation of potential trigger factors and drug therapies. The study included 72 patients with HAE-FXII. Potential triggers included estrogen-containing oral contraceptives (eOC), hormonal replacement therapy, or angiotensin-converting enzyme inhibitors. Drug treatment comprised plasma-derived C1 inhibitor (pdC1-INH) for acute swelling attacks and progestins, tranexamic acid, and danazol for the prevention of attacks. Discontinuation of eOC was effective in 25 (89.3%) of 28 women and led to a reduction in the number of attacks (about 90%). After ending hormonal replacement therapy, three of eight women became symptom-free. Three women with exacerbation of HAE-FXII during intake of quinapril or enalapril had no further HAE-FXII attacks after discontinuation of those drugs. Eleven women were treated with pdC1-INH for 143 facial attacks. The duration of the treated facial attacks (mean: 26.6 h; SD: 10.1 h) was significantly shorter than that of the previous 88 untreated facial attacks in the same women (mean: 64.1 h; SD: 28.0 h; P < 0.01). The mean reduction in attack frequency was 99.8% under progestins after discontinuing eOC (16 women), 93.8% under tranexamic acid (four women), and 100% under danazol (three women). For patients with HAE-FXII, various treatment options are available which completely or at least partially reduce the number or duration of attacks.
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Affiliation(s)
- K. Bork
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
| | - K. Wulff
- University Medicine; Ernst Moritz Arndt University; Greifswald Germany
| | - G. Witzke
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
| | - J. Hardt
- Department of Medical Psychology and Medical Sociology; Johannes Gutenberg University; Mainz Germany
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39
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Zuraw BL, Christiansen SC. How we manage persons with hereditary angioedema. Br J Haematol 2016; 173:831-43. [DOI: 10.1111/bjh.14059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Bruce L. Zuraw
- University of California, San Diego; La Jolla CA USA
- San Diego VA Health System; San Diego CA USA
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Amsler E, Augey F, Soria A, Boccon-Gibod I, Doutre M, Mathelier-Fusade P, Nicolas J, Rayson-Peyron N, Gompel A. Chronic urticaria and hormones: Is there a link? J Eur Acad Dermatol Venereol 2016; 30:1527-30. [DOI: 10.1111/jdv.13644] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 02/15/2016] [Indexed: 11/29/2022]
Affiliation(s)
- E. Amsler
- Service de Dermatologie-Allergologie; Hôpital Tenon; HUEP, APHP; Paris France
- GUS: Groupe Urticaire de la Société Française de Dermatologie; France
| | - F. Augey
- GUS: Groupe Urticaire de la Société Française de Dermatologie; France
- Université Lyon1; INSERM U1111 - CIRI; Hôpitaux de Lyon; CH Lyon-Sud; Lyon France
| | - A. Soria
- Service de Dermatologie-Allergologie; Hôpital Tenon; HUEP, APHP; Paris France
- GUS: Groupe Urticaire de la Société Française de Dermatologie; France
- Sorbonne Universités; UPMC Univ Paris 06; Unité Mixte de Recherche de Santé (UMR S) CR7; Centre d'Immunologie et des Maladies Infectieuses - Paris (Cimi-Paris); INSERM U1135; Paris France
| | - I. Boccon-Gibod
- GUS: Groupe Urticaire de la Société Française de Dermatologie; France
- Clinique Universitaire de Médecine Interne; CHU de Grenoble; Grenoble Cedex France
- Centre National de Référence des Angiœdèmes (CRéAK); France
| | - M.S. Doutre
- GUS: Groupe Urticaire de la Société Française de Dermatologie; France
- Service de Dermatologie; Hôpital Saint-André; CHU de Bordeaux; Bordeaux France
| | - P. Mathelier-Fusade
- Service de Dermatologie-Allergologie; Hôpital Tenon; HUEP, APHP; Paris France
- GUS: Groupe Urticaire de la Société Française de Dermatologie; France
| | - J.F. Nicolas
- GUS: Groupe Urticaire de la Société Française de Dermatologie; France
- Université Lyon1; INSERM U1111 - CIRI; Hôpitaux de Lyon; CH Lyon-Sud; Lyon France
| | - N. Rayson-Peyron
- GUS: Groupe Urticaire de la Société Française de Dermatologie; France
- Centre National de Référence des Angiœdèmes (CRéAK); France
- Service de Dermatologie; hôpital St Eloi; Montpellier Cedex France
| | - A. Gompel
- GUS: Groupe Urticaire de la Société Française de Dermatologie; France
- Centre National de Référence des Angiœdèmes (CRéAK); France
- Unité de Gynécologie Endocrinienne; Université Paris Descartes; APHP, Port Royal Cochin; Paris France
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Abstract
Hereditary angioedema (HAE) is a rare disorder resulting from decreased functional levels of C1-inhibitor (C1-INH), which manifests as periodic episodes of localized edema which can be extremely painful, debilitating and even fatal if the swelling affects the larynx. HAE can complicate many aspects of obstetric/gynecologic care, and an awareness of the disease is critical for clinicians involved in the care of women because of potential HAE-related complications pertaining to pregnancy, labor and delivery, and other women's health issues. This article provides a review of published literature specific to HAE and its management in female patients, including important concerns regarding obstetric/gynecologic care. A growing body of relevant experience is presented to help guide the care of women with HAE.
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Affiliation(s)
- Aleena Banerji
- Massachusetts General Hospital, Cox 201, 55 Fruit Street, Boston, MA, USA
| | - Marc Riedl
- University of California, San Diego, La Jolla, CA, USA
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42
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Powell RJ, Leech SC, Till S, Huber PAJ, Nasser SM, Clark AT. BSACI guideline for the management of chronic urticaria and angioedema. Clin Exp Allergy 2015; 45:547-65. [PMID: 25711134 DOI: 10.1111/cea.12494] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 12/11/2014] [Accepted: 01/09/2015] [Indexed: 12/11/2022]
Abstract
This guidance for the management of patients with chronic urticaria and angioedema has been prepared by the Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is aimed at both adult physicians and paediatricians practising in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a Web-based system. Their comments and suggestions were carefully considered by the Standards of Care Committee. Where evidence was lacking, a consensus was reached by the experts on the committee. Included in this management guideline are clinical classification, aetiology, diagnosis, investigations, treatment guidance with special sections on children with urticaria and the use of antihistamines in women who are pregnant or breastfeeding. Finally, we have made recommendations for potential areas of future research.
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Affiliation(s)
- R J Powell
- Department of Clinical Immunology and Allergy, Nottingham University, Nottingham, UK
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43
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Nasr IH, Manson AL, Al Wahshi HA, Longhurst HJ. Optimizing hereditary angioedema management through tailored treatment approaches. Expert Rev Clin Immunol 2015; 12:19-31. [PMID: 26496459 DOI: 10.1586/1744666x.2016.1100963] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hereditary angioedema (HAE) is a rare but serious and potentially life threatening autosomal dominant condition caused by low or dysfunctional C1 esterase inhibitor (C1-INH) or uncontrolled contact pathway activation. Symptoms are characterized by spontaneous, recurrent attacks of subcutaneous or submucosal swellings typically involving the face, tongue, larynx, extremities, genitalia or bowel. The prevalence of HAE is estimated to be 1:50,000 without known racial differences. It causes psychological stress as well as significant socioeconomic burden. Early treatment and prevention of attacks are associated with better patient outcome and lower socioeconomic burden. New treatments and a better evidence base for management are emerging which, together with a move from hospital-centered to patient-centered care, will enable individualized, tailored treatment approaches.
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Affiliation(s)
- Iman H Nasr
- a Department of Immunology, Barts Health NHS Trust , London , UK
| | - Ania L Manson
- a Department of Immunology, Barts Health NHS Trust , London , UK
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44
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Current treatment options for idiopathic angioedema. Ann Allergy Asthma Immunol 2015; 115:429-33. [PMID: 26341649 DOI: 10.1016/j.anai.2015.07.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/24/2015] [Accepted: 07/31/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Idiopathic angioedema is defined as localized swelling of the cutaneous and mucosal tissue that occurs in episodes without a clear etiology. It can be problematic to treat when the underlying pathophysiology is not well understood. OBJECTIVE To identify successful treatments of idiopathic angioedema reported in the literature. METHODS A literature search was performed using PubMed. Published case reports and articles discussing treatment of idiopathic angioedema were used in the formulation of this review. In addition, 2 case reports are provided. RESULTS Although there are no approved treatments for idiopathic angioedema, several medications used for the treatment of hereditary angioedema, such as bradykinin receptor antagonists (icatibant), kallikrein inhibitors (ecallantide), and C1 inhibitors, were successful in 10 patients. Anti-IgE monoclonal antibody (omalizumab) proved successful in 5 patients. The most widely used and successful medication was tranexamic acid (154 patients). CONCLUSION Despite an unknown etiology, this article highlights viable treatment options for idiopathic angioedema. More clinical trials and better markers identifying the cause of angioedema are needed.
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45
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Blankestijn MA, Boyle RJ, Gore R, Hawrylowicz C, Jarvis D, Knulst AC, Wardlaw AJ. Developments in the field of allergy in 2013 through the eyes of Clinical and Experimental Allergy. Clin Exp Allergy 2015; 44:1436-57. [PMID: 25346287 DOI: 10.1111/cea.12442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
2013 was another exciting year for allergy in general and Clinical and Experimental Allergy in particular. In the field of asthma and rhinitis, there continued to be a focus on heterogeneity and phenotypes with increasing use of biostatistical techniques to determine clusters of similar populations. Obesity- and aspirin-associated disease are intriguing associations with asthma which were explored in a number of papers. We published a number of excellent papers on mechanisms of airway inflammation and how this relates to physiology, pathology, genetics and biomarkers in both human and experimental model systems. In terms of mechanisms, there is less on individual cell types in allergic disease at the moment, but the immunology of allergic disease continued to fascinate our authors. Another area that was popular both in the mechanisms and in the epidemiology sections was early life events and how these lead to allergic disease, with an increasing focus on the role of the microbiome and how this influences immune tolerance. In the clinical allergy section, oral immunotherapy for food allergy is clearly a major topic of interest at the moment as was in vitro testing to distinguish between sensitization and allergic disease. There was less on inhalant allergy this year, but a good representation from the drug allergy community including some interesting work on non-IgE-mediated mechanisms. In the allergen section, important new allergens continue to be discovered, but the major focus as in the last couple of years was on working out how component-resolved approaches can improve diagnosis and management of food and venom allergy.
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Affiliation(s)
- M A Blankestijn
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
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46
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Zanichelli A, Mansi M, Wu MA, Azin G, Cicardi M. Differential Diagnosis and Management Issues of Idiopathic Angiooedema and their Resolution. ACTA ACUST UNITED AC 2015; 1:55-60. [PMID: 29967816 PMCID: PMC5953287 DOI: 10.1515/jccm-2015-0008] [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: 03/10/2015] [Accepted: 04/18/2015] [Indexed: 11/15/2022]
Abstract
Angiooedema is a local and self-limiting swelling of the subcutaneous and sub mucosal tissues, produced by vasoactive peptides that temporary increase the vascular permeability. It is recognized that recurrent angiooedema exposes patients to the risk of fatalities and reduced quality of life, being in some circumstances associated with a critical condition. Angiooedema can occur with or without wheals. The first symptom is urticaria, the second is a distinct nosologic entity. In absence of an identifiable cause, recurrent angiooedema without wheals can be defined as idiopathic and marked"idiopathic histaminergic angiooedema" when it is responsive to anti histamine treatment, and "idiopathic non-histaminergic angiooedema" when it is not. Furthermore, idiopathic non-histaminergic angiooedema can be diagnosed as hereditary or sporadic by family history. In this review, we summarize the approaches to diagnose and treat different forms of idiopathic angiooedema.
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Affiliation(s)
- Andrea Zanichelli
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan and Ospedale L. Sacco Milan, Milan, Italy
| | - Marta Mansi
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan and Ospedale L. Sacco Milan, Milan, Italy
| | - Maddalena A Wu
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan and Ospedale L. Sacco Milan, Milan, Italy
| | - Giulia Azin
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan and Ospedale L. Sacco Milan, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan and Ospedale L. Sacco Milan, Milan, Italy
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Longhurst HJ, Tarzi MD, Ashworth F, Bethune C, Cale C, Dempster J, Gompels M, Jolles S, Seneviratne S, Symons C, Price A, Edgar D. C1 inhibitor deficiency: 2014 United Kingdom consensus document. Clin Exp Immunol 2015; 180:475-83. [PMID: 25605519 PMCID: PMC4449776 DOI: 10.1111/cei.12584] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2014] [Indexed: 12/18/2022] Open
Abstract
C1 inhibitor deficiency is a rare disorder manifesting with recurrent attacks of disabling and potentially life-threatening angioedema. Here we present an updated 2014 United Kingdom consensus document for the management of C1 inhibitor-deficient patients, representing a joint venture between the United Kingdom Primary Immunodeficiency Network and Hereditary Angioedema UK. To develop the consensus, we assembled a multi-disciplinary steering group of clinicians, nurses and a patient representative. This steering group first met in 2012, developing a total of 48 recommendations across 11 themes. The statements were distributed to relevant clinicians and a representative group of patients to be scored for agreement on a Likert scale. All 48 statements achieved a high degree of consensus, indicating strong alignment of opinion. The recommendations have evolved significantly since the 2005 document, with particularly notable developments including an improved evidence base to guide dosing and indications for acute treatment, greater emphasis on home therapy for acute attacks and a strong focus on service organization.
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Affiliation(s)
- H J Longhurst
- Department of Immunology, Barts Health NHS Trust and Medical Adviser HAE, UK
| | - M D Tarzi
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - F Ashworth
- Department of Immunology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - C Bethune
- Department of Immunology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - C Cale
- Department of Immunology, Great Ormond Street Hospital for Children, London, UK
| | - J Dempster
- Department of Immunology, Barts Health NHS Trust and Medical Adviser HAE, UK
| | - M Gompels
- Department of Immunology, North Bristol NHS Trust, Bristol, UK
| | - S Jolles
- Department of Immunology, University Hospital of Wales, Cardiff, UK
| | - S Seneviratne
- Department of Immunology, Royal Free London NHS Trust, London, UK
| | - C Symons
- Department of Immunology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - A Price
- Herditary Angioedema, UK (HAE UK)
| | - D Edgar
- UK Primary Immunodeficiency Network (UK PIN), Newcastle upon Tyne, UK
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48
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Bouillet L, Lehmann A, Gompel A, Boccon-Gibod I, Launay D, Fain O. Traitements des angiœdèmes héréditaires : recommandations du centre de référence national des angiœdèmes (consensus 2014 de Bordeaux). Presse Med 2015; 44:526-32. [DOI: 10.1016/j.lpm.2015.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/04/2014] [Accepted: 01/02/2015] [Indexed: 11/28/2022] Open
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49
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Firinu D, Bafunno V, Vecchione G, Barca MP, Manconi PE, Santacroce R, Margaglione M, Del Giacco SR. Characterization of patients with angioedema without wheals: the importance of F12 gene screening. Clin Immunol 2015; 157:239-48. [PMID: 25744496 DOI: 10.1016/j.clim.2015.02.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/20/2015] [Indexed: 11/28/2022]
Abstract
Sporadic and familiar forms of non-histaminergic angioedema and normal C1 inhibitor encompass a group of disorders possibly caused by bradikinin. We aimed to study the subgroups of hereditary angioedema with FXII mutation (FXII-HAE), unknown genetic defect (U-HAE) and idiopathic non-histaminergic acquired angioedema (InH-AAE). We screened the F12 locus in our cohort and delineated the clinical, laboratory and genetic features. Four families carried the p.Thr309Lys mutation in F12 gene. Haplotyping confirmed the hypothesis of a common founder. Six families were affected by U-HAE and 13 patients by sporadic InH-AAE. C4 levels were significantly lower in FXII-HAE than in InH-AAE. In the FXII-HAE group, none had attacks exclusively in high estrogenic states; acute attacks were treated with icatibant. Prophylaxis with tranexamic acid reduced the attack frequency in most patients. Our study provides new data on the diagnosis, clinical features and treatment of non-histaminergic angioedema, underlying the role of the screening for F12 mutations.
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Affiliation(s)
- Davide Firinu
- Department of Medical Sciences "M. Aresu", University of Cagliari, Italy.
| | - Valeria Bafunno
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Gennaro Vecchione
- Atherosclerosis and Thrombosis Unit, I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
| | - Maria Pina Barca
- Department of Medical Sciences "M. Aresu", University of Cagliari, Italy
| | | | - Rosa Santacroce
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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50
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Dessart P, Defendi F, Humeau H, Nicolie B, Sarre ME, Charignon D, Ponard D, Cichon S, Drouet C, Martin L. Distinct conditions support a novel classification for bradykinin-mediated angio-oedema. Dermatology 2015; 230:324-31. [PMID: 25720836 DOI: 10.1159/000371814] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 12/13/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Angio-oedema (AO) can be attributable to bradykinin (BK) accumulation, as is the case for prototypical hereditary AO (HAO) due to C1 inhibitor (C1-INH) deficiency. However, our clinical experience in a reference centre has shown that some patients display a clinical history suggestive of HAO, but exhibit normal C1-INH function, have no mutation in the causative genes associated with HAO (SERPING1, F12), and report no intake of drugs known to promote AO. OBJECTIVE We sought to determine the frequency and distribution of different AO subtypes suspected to be BK-mediated AO (BK-AO) and defined by clinical, history and biological criteria (enzyme activities implicated in BK formation and catabolism). METHODS The files of all patients referred to our centre for suspected BK-AO were retrospectively analysed. RESULTS The distribution of patients (n = 162) was 16 and 4% with a hereditary deficiency of C1-INH or a gain of factor XII function, respectively, 29% with iatrogenic BK-AO, 21% with non-iatrogenic defective kininase activity and 30% with idiopathic increased kinin formation. CONCLUSION BK-AO may be caused by multiple inherited or acquired factors triggering BK accumulation. Therefore, we propose a novel typology for BK-AO based on the imbalance of production/catabolism of BK.
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Affiliation(s)
- Panteha Dessart
- Department of Dermatology, Angers Hospital, L'UNAM University, Angers, France
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