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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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2
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Dass C, Mahaffa M, Dang E, Campbell R, Ballas Z, Lee S. Evaluation of staging criteria for disposition and airway intervention in emergency department angioedema patients. Acute Med Surg 2021; 8:e704. [PMID: 34729186 PMCID: PMC8548721 DOI: 10.1002/ams2.704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/13/2021] [Accepted: 10/07/2021] [Indexed: 11/09/2022] Open
Abstract
AIM Angioedema is a nonpitting edema that can lead to death secondary to airway obstruction. Previously, a staging system based on localization of the angioedema was proposed for risk stratification of likelihood of need for admission or airway intervention. This study aims to evaluate a staging system based on angioedema localization as a method of predicting need for admission or airway intervention. METHODS This was a retrospective chart review of angioedema cases that presented to an academic emergency department (ED) from August 1, 2006, to January 31, 2018. Data were collected on location of swelling, treatment setting, and medical and procedural interventions. Cases were categorized by modified Ishoo criteria, defined as follows: 1, lips, face, periorbital, extremities, total body/diffuse swelling; 2, soft palate, posterior pharynx; 3, tongue; 4, larynx. Predictive probability of disposition by stage was then compared. RESULTS A total of 320 patients were included in this study (median age, 44 years; 54.4% female). Stage 4 was more likely to require intensive care unit care without (probability 17%) and with (67%) airway intervention compared with stage 1 without (2.5%) and with (0.1%) airway intervention. Conversely, stage 1 was more likely to be treated in ED and discharged (85%) compared with stage 4 (0%). Stage 4 was also more likely to require airway intervention (67%) compared with other stages (1, 0.1%; 2, 8.6%; 3, 16%). CONCLUSION Higher-stage patients were more likely to require higher levels of care and airway intervention. Thus, the staging system appears to be a valid method of predicting risk among ED angioedema patients.
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Affiliation(s)
- Conor Dass
- Department of Emergency MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Maggie Mahaffa
- Department of Emergency MedicineState University of New York at BuffaloBuffaloNew YorkUSA
| | | | - Ronna Campbell
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - Zuhair Ballas
- Department of Internal MedicineDivision of ImmunologyUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
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Piras V, Alves F, Gonçalo M. Self‐administration of icatibant in acute attacks of Type I hereditary angioedema: A case report and review of hereditary angioedema. Dermatol Ther 2019; 32:e13098. [DOI: 10.1111/dth.13098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Viviana Piras
- Department of Medical Sciences and Public Health, Unit of DermatologyUniversity of Cagliari Cagliari Italy
| | - Francisca Alves
- Department of DermatologyUniversity Hospital of Coimbra Coimbra Portugal
| | - Margarida Gonçalo
- Department of DermatologyUniversity Hospital of Coimbra Coimbra Portugal
- Department of Dermatology, Faculty of MedicineUniversity of Coimbra Coimbra Portugal
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4
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Horiuchi T, Hide M, Yamashita K, Ohsawa I. The use of tranexamic acid for on-demand and prophylactic treatment of hereditary angioedema-A systematic review. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2018. [DOI: 10.1002/cia2.12029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Takahiko Horiuchi
- Department of Internal Medicine; Kyushu University Beppu Hospital; Beppu Oita Japan
| | - Michihiro Hide
- Department of Dermatology; Graduate School of Biomedical and Health Sciences; Hiroshima University; Hiroshima Japan
| | - Kouhei Yamashita
- Department of Hematology; Kyoto University Hospital; Kyoto Japan
| | - Isao Ohsawa
- Department of Nephrology; Saiyu Soka Hospital; Soka Saitama Japan
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Activation of bradykinin B2 receptor induced the inflammatory responses of cytosolic phospholipase A 2 after the early traumatic brain injury. Biochim Biophys Acta Mol Basis Dis 2018; 1864:2957-2971. [PMID: 29894755 DOI: 10.1016/j.bbadis.2018.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/02/2018] [Accepted: 06/07/2018] [Indexed: 12/17/2022]
Abstract
Phospholipase A2 is a known aggravator of inflammation and deteriorates neurological outcomes after traumatic brain injury (TBI), however the exact inflammatory mechanisms remain unknown. This study investigated the role of bradykinin and its receptor, which are known initial mediators within inflammation activation, as well as the mechanisms of the cytosolic phospholipase A2 (cPLA2)-related inflammatory responses after TBI. We found that cPLA2 and bradykinin B2 receptor were upregulated after a TBI. Rats treated with the bradykinin B2 receptor inhibitor LF 16-0687 exhibited significantly less cPLA2 expression and related inflammatory responses in the brain cortex after sustaining a controlled cortical impact (CCI) injury. Both the cPLA2 inhibitor and the LF16-0687 improved CCI rat outcomes by decreasing neuron death and reducing brain edema. The following TBI model utilized both primary astrocytes and primary neurons in order to gain further understanding of the inflammation mechanisms of the B2 bradykinin receptor and the cPLA2 in the central nervous system. There was a stronger reaction from the astrocytes as well as a protective effect of LF16-0687 after the stretch injury and bradykinin treatment. The protein kinase C pathway was thought to be involved in the B2 bradykinin receptor as well as the cPLA2-related inflammatory responses. Rottlerin, a Protein Kinase C (PKC) δ inhibitor, decreased the activity of the cPLA2 activity post-injury, and LF16-0687 suppressed both the PKC pathway and the cPLA2 activity within the astrocytes. These results indicated that the bradykinin B2 receptor-mediated pathway is involved in the cPLA2-related inflammatory response from the PKC pathway.
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6
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Katelaris CH. Acute Management of Hereditary Angioedema Attacks. Immunol Allergy Clin North Am 2017; 37:541-556. [DOI: 10.1016/j.iac.2017.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bernstein JA, Cremonesi P, Hoffmann TK, Hollingsworth J. Angioedema in the emergency department: a practical guide to differential diagnosis and management. Int J Emerg Med 2017; 10:15. [PMID: 28405953 PMCID: PMC5389952 DOI: 10.1186/s12245-017-0141-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 03/28/2017] [Indexed: 11/23/2022] Open
Abstract
Background Angioedema is a common presentation in the emergency department (ED). Airway angioedema can be fatal; therefore, prompt diagnosis and correct treatment are vital. Objective of the review Based on the findings of two expert panels attended by international experts in angioedema and emergency medicine, this review aims to provide practical guidance on the diagnosis, differentiation, and management of histamine- and bradykinin-mediated angioedema in the ED. Review The most common pathophysiology underlying angioedema is mediated by histamine; however, ED staff must be alert for the less common bradykinin-mediated forms of angioedema. Crucially, bradykinin-mediated angioedema does not respond to the same treatment as histamine-mediated angioedema. Bradykinin-mediated angioedema can result from many causes, including hereditary defects in C1 esterase inhibitor (C1-INH), side effects of angiotensin-converting enzyme inhibitors (ACEis), or acquired deficiency in C1-INH. The increased use of ACEis in recent decades has resulted in more frequent encounters with ACEi-induced angioedema in the ED; however, surveys have shown that many ED staff may not know how to recognize or manage bradykinin-mediated angioedema, and hospitals may not have specific medications or protocols in place. Conclusion ED physicians must be aware of the different pathophysiologic pathways that lead to angioedema in order to efficiently and effectively manage these potentially fatal conditions.
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Affiliation(s)
- Jonathan A Bernstein
- Division of Immunology/Allergy, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
| | - Paolo Cremonesi
- Department of Emergency Medicine, E. O. Galliera Hospital, Genoa, Italy
| | - Thomas K Hoffmann
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - John Hollingsworth
- Department of Emergency Medicine, University Hospital, Aintree, Liverpool, UK
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8
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Rohart J, Bouillet L, Moizan H. [Management of patients with bradykinin-mediated angioedema in oral and maxillofacial surgery]. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2017; 118:109-114. [PMID: 28345520 DOI: 10.1016/j.jormas.2017.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 01/06/2017] [Accepted: 02/17/2017] [Indexed: 10/20/2022]
Abstract
Bradykinin-mediated angioedema (AE) is a rare disease characterized by recurrent cutaneous or mucosal angioedema. This hereditary or acquired disease is of rapid installation, non-pruritic, usually painless and can affect the face, lips, larynx, gastrointestinal tract or extremities. When the affected area involves the upper respiratory tract, laryngeal angioedema can lead to imminent death by asphyxia. This is the reason for the high mortality rate (30 %) in undiagnosed or improperly managed patients. High-risk situations in oral and maxillofacial surgery procedures should be identified preoperatively. Short-term prophylaxis must be carried-out prior to any procedure that may trigger an attack. A multi-site reference center (CREAK) has been created to help clinicians to manage this disease. This article reviews the pathophysiologic mechanisms, the clinical presentations, the possible treatments, the acute strategies for attacks and different prophylactic possibilities in oral and maxillofacial surgery.
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Affiliation(s)
- J Rohart
- Service d'odontologie, hôpital Saint-Julien, CHU de Rouen, 76031 Rouen, France; UDSL, université Lille Nord de France, 59000 Lille, France.
| | - L Bouillet
- Centre national de référence des angiœdèmes, CHU de Grenoble, 38043 Grenoble cedex 09, France; Centre de référence des angiœdèmes, clinique universitaire de médecine interne, CHU de Grenoble, 38043 Grenoble cedex 09, France; Unité Inserm 1036, CEA-Grenoble, université Grenoble-Alpes, 38054 Grenoble cedex 09, France
| | - H Moizan
- Service d'odontologie, hôpital Saint-Julien, CHU de Rouen, 76031 Rouen, France
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Bernstein JA, Moellman JJ. Progress in the Emergency Management of Hereditary Angioedema: Focus on New Treatment Options in the United States. Postgrad Med 2015; 124:91-100. [DOI: 10.3810/pgm.2012.05.2552] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Icatibant in the treatment of Angiotensin-converting enzyme inhibitor-induced angioedema. Case Rep Crit Care 2014; 2014:864815. [PMID: 25328718 PMCID: PMC4189935 DOI: 10.1155/2014/864815] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 08/15/2014] [Indexed: 11/18/2022] Open
Abstract
We describe the case of a 75-year-old woman who presented with massive tongue and lip swelling secondary to angiotensin-converting enzyme inhibitor-induced angioedema. An awake fibre-optic intubation was performed because of impending airway obstruction. As there was no improvement in symptoms after 72 hours, the selective bradykinin B2 receptor antagonist icatibant (Firazyr) was administered and the patient's trachea was successfully extubated 36 hours later. To our knowledge this is the first documented case of icatibant being used for the treatment of angiotensin-converting enzyme inhibitor-induced angioedema in the United Kingdom and represents a novel therapeutic option in its management.
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Campos RA, Valle SOR, França AT, Cordeiro E, Serpa FS, Mello YF, Malheiros T, Toledo E, Mansour E, Fusaro G, Grumach AS. Icatibant, an inhibitor of bradykinin receptor 2, for hereditary angioedema attacks: prospective experimental single-cohort study. SAO PAULO MED J 2014; 132:261-5. [PMID: 25054967 PMCID: PMC10496749 DOI: 10.1590/1516-3180.2014.1325652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 09/19/2013] [Accepted: 09/25/2013] [Indexed: 11/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Hereditary angioedema (HAE) with C1 inhibitor deficiency manifests as recurrent episodes of edema involving the skin, upper respiratory tract and gastrointestinal tract. It can be lethal due to asphyxia. The aim here was to evaluate the response to therapy for these attacks using icatibant, an inhibitor of the bradykinin receptor, which was recently introduced into Brazil. DESIGN AND SETTING Prospective experimental single-cohort study on the efficacy and safety of icatibant for HAE patients. METHODS Patients with a confirmed HAE diagnosis were enrolled according to symptoms and regardless of the time since onset of the attack. Icatibant was administered in accordance with the protocol that has been approved in Brazil. Symptom severity was assessed continuously and adverse events were monitored. RESULTS 24 attacks in 20 HAE patients were treated (female/male 19:1; 19-55 years; median 29 years of age). The symptoms were: subcutaneous edema (22/24); abdominal pain (15/24) and upper airway obstruction (10/24). The time taken until onset of relief was: 5-10 minutes (5/24; 20.8%); 10-20 (5/24; 20.8%); 20-30 (8/24; 33.4%); 30-60 (5/24; 20.8%); and 2 hours (1/24; 4.3%). The time taken for complete resolution of symptoms ranged from 4.3 to 33.4 hours. Adverse effects were only reported at injection sites. Mild to moderate erythema and/or feelings of burning were reported by 15/24 patients, itching by 3 and no adverse effects in 6. CONCLUSION HAE type I patients who received icatibant responded promptly; most achieved improved symptom severity within 30 minutes. Local adverse events occurred in 75% of the patients.
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Affiliation(s)
- Regis Albuquerque Campos
- MD, PhD. Associate Professor in the Discipline of Allergy and Immunology, Faculdade de Medicina, Universidade Federal da Bahia (UFB), Salvador, Bahia, Brazil
| | - Solange Oliveira Rodrigues Valle
- MD, PhD. Attending Physician in the Allergy Outpatient Group, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Alfeu Tavares França
- MD, PhD. Attending Physician in the Allergy Outpatient Group, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Elisabete Cordeiro
- MD. Attending Physician in the Recurrent Infections Outpatient Group, Faculdade de Medicina do ABC (FMABC), Santo André, São Paulo, Brazil
| | - Faradiba Sarquis Serpa
- MD, MSc. Assistant Professor in the Department of Internal Medicine, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), Vitória, Espírito Santo, Brazil
| | - Yara Ferreira Mello
- MD. Attending Physician in the Allergy Service, Hospital Edmundo Vasconcelos, São Paulo, São Paulo, Brazil
| | - Teresinha Malheiros
- MD. Attending Physician in the Allergy Service, Hospital Edmundo Vasconcelos, São Paulo, São Paulo, Brazil
| | - Eliana Toledo
- MD, PhD. Associate Professor in the Department of Pediatrics, Faculdade de Medicina da Universidade de São José do Rio Preto (Famerp), São José do Rio Preto, São Paulo, Brazil
| | - Elie Mansour
- MD. Associate Professor in the Department of Pediatrics, Universidade Estadual de Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Gustavo Fusaro
- MD. Attending Physician in the Department of Pediatrics, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Anete Sevciovic Grumach
- MD, PhD. Professor, Attending Physician in the Recurrent Infections Outpatient Group and Responsible for Clinical Immunology Laboratory, Faculdade de Medicina do ABC (FMABC), Santo André, São Paulo, Brazil
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Kalra N, Craig T. Icatibant for the treatment of hereditary angioedema. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.924852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jalaj S, Scolapio JS. Gastrointestinal manifestations, diagnosis, and management of hereditary angioedema. J Clin Gastroenterol 2013; 47:817-23. [PMID: 24141983 DOI: 10.1097/mcg.0b013e31829e7edf] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Abdominal pain is one of the most common conditions in clinical practice and yet a challenging complaint to accurately diagnose due to the vast number of possible etiologies. When other health care providers cannot identify the cause of abdominal pain, gastroenterologists are often looked upon to help solve the diagnostic dilemma. Consequently, it is incumbent upon gastroenterologists to be well versed in the diagnosis and management of not only common but also rare causes of abdominal pain. One such uncommon but well-described cause of abdominal pain is angioedema of the intestinal tract due to hereditary angioedema. Acute onset, recurrent abdominal pain of varying severity is its most common presenting symptom, and misdiagnosis can not only lead to unnecessary surgical procedures but also death. The purpose of this review is to raise awareness among gastroenterologists about hereditary angioedema as a potential cause of recurrent, unexplained abdominal pain.
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Affiliation(s)
- Sujai Jalaj
- Department of Medicine, Division of Gastroenterology, University of Florida, Jacksonville, FL
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14
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Baş M, Greve J, Hoffmann TK, Reshef A, Aberer W, Maurer M, Kivity S, Farkas H, Floccard B, Arcoleo F, Martin L, Sitkauskiene B, Bouillet L, Schmid-Grendelmeier P, Li H, Zanichelli A. Repeat treatment with icatibant for multiple hereditary angioedema attacks: FAST-2 open-label study. Allergy 2013; 68:1452-9. [PMID: 24111645 DOI: 10.1111/all.12244] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The For Angioedema Subcutaneous Treatment (FAST)-2, a phase III, double-blind, randomized, multicenter, placebo-controlled study (ClinicalTrials.gov identifier: NCT00500656), established the efficacy and safety of single injections of icatibant, a bradykinin B₂ receptor antagonist, in the treatment of hereditary angioedema (HAE) attacks. Here, we evaluate the efficacy and safety of repeated treatment with icatibant in adult patients experiencing HAE attacks during the FAST-2 open-label extension (OLE) phase. METHODS Patients completing the controlled phase were eligible to participate in the OLE phase and receive open-label icatibant (30 mg subcutaneously) for the treatment of cutaneous, abdominal, and/or laryngeal HAE attack(s) severe enough to warrant treatment. Time to onset of symptom relief was calculated for each attack. Descriptive analyses (median, 95% CIs) were performed for all attacks; post hoc analyses were conducted in patients with at least five icatibant-treated attacks throughout the FAST-2 OLE phase. Safety was also monitored. RESULTS Fifty-four patients received icatibant for 374 attacks (176 cutaneous, 168 abdominal, and 30 laryngeal). For cutaneous and/or abdominal attacks (attacks 2-5), the median times to onset of symptom relief ranged between 2.0 and 2.5 h. For all laryngeal attacks, the median times to regression (start of improvement) of symptoms ranged between 0.3 and 4.0 h. Post hoc analyses showed that the overall median time to onset of symptom relief was 2.0 h. Overall, 89.8% of attacks resolved with a single icatibant injection. No drug-related serious adverse events were reported. CONCLUSIONS These findings have demonstrated the efficacy and safety of repeated icatibant treatment for HAE attacks.
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Affiliation(s)
- M. Baş
- Department of Otorhinolaryngology; Klinikum rechts der Isar; Technische Universität München; Munich Germany
| | - J. Greve
- Department of Otorhinolaryngology, Head and Neck Surgery; University Hospital Ulm; Ulm Germany
| | - T. K. Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery; University Hospital Ulm; Ulm Germany
| | - A. Reshef
- Allergy, Immunology and Angioedema Center; Sheba Medical Center; Tel Hashomer Israel
| | - W. Aberer
- Department of Dermatology and Venerology; Medical University of Graz; Graz Austria
| | - M. Maurer
- Department of Allergy and Clinical Immunology, Allergie-Centrum-Charité; Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - S. Kivity
- Tel Aviv Medical Center; Sackler Medical School; Tel Aviv Israel
| | - H. Farkas
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - B. Floccard
- Service de Reanimation; Hospices Civils de Lyon; Hôpital Edouard Herriot; Lyon France
| | - F. Arcoleo
- Azienda Ospedaliera V. Cervello; Palermo Italy
| | - L. Martin
- Department of Dermatology; Angers University Hospital; Angers France
| | - B. Sitkauskiene
- Department of Pulmonology and Immunology; Lithuanian University of Health Sciences; Kaunas Lithuania
| | - L. Bouillet
- Internal Medicine Department; National Reference Centre for Angioedema; Grenoble University Hospital; Grenoble France
| | | | - H. Li
- Shire Human Genetics Therapies (HGT); Lexington MA USA
| | - A. Zanichelli
- Ospedale Luigi Sacco; Università degli Studi di Milano; Milan Italy
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15
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Volans A, Ferguson R. Using a bradykinin blocker in ACE inhibitor-associated angioedema in the emergency department. BMJ Case Rep 2013; 2013:bcr-2012-008295. [PMID: 23376672 DOI: 10.1136/bcr-2012-008295] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report two cases of ACE inhibitor-associated angioedema and critical airway compromise, where the use of a selective bradykinin 2 receptor blocker resulted in rapid symptom resolution and prevented intubation to protect the airway.
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Affiliation(s)
- Andrew Volans
- Department of Emergency, Scarborough Hospital, Scarborough, UK.
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16
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Li HH, Campion M, Craig TJ, Soteres DF, Riedl M, Lumry WR, MacGinnitie AJ, Shea EP, Bernstein JA. Analysis of hereditary angioedema attacks requiring a second dose of ecallantide. Ann Allergy Asthma Immunol 2013; 110:168-72. [PMID: 23548526 DOI: 10.1016/j.anai.2012.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/30/2012] [Accepted: 12/09/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Effective treatment of acute attacks is critical in managing hereditary angioedema (HAE). Ecallantide, a plasma kallikrein inhibitor, is approved for the treatment of HAE attacks. Occasionally, a second dose is needed when treating attacks of HAE. OBJECTIVE To evaluate the characteristics of HAE attacks requiring a second dose (dose B) of ecallantide. METHODS Data from all ecallantide clinical trials (EDEMA2, EDEMA4, and DX-88/19) that allowed an open-label dose B were included in this analysis. Patient and attack characteristics potentially predictive of dose B after ecallantide were analyzed by logistic regression. A multivariate model was built using a backward selection process, incorporating variables from the univariate model with P < .20 and removing factors with the highest P value until only significant (P < .05) factors remained. RESULTS The analysis included 732 ecallantide-treated HAE attacks in 179 patients. Dose B was required in 88 attacks (12.0%), most (80.5%) for incomplete response. By attack location, 31 of 325 abdominal attacks (9.5%), 17 of 158 laryngeal attacks (10.8%), and 40 of 242 peripheral attacks (16.5%) required dose B. On the basis of the univariate analysis, baseline severity (odds ratio = 1.33, P = .15) and peripheral attack (odds ratio = 1.80, P = .01) were identified as potential predictive factors; abdominal attacks had an inverse correlation (odds ratio = 0.64, P = .055). However, the multivariate analysis identified only peripheral attacks as statistically significantly correlated (P < .05) with dose B requirement. CONCLUSION A single, 30-mg dose of ecallantide was effective for most HAE attacks (88.0%). Patients with peripheral attacks of HAE were more likely to require a second dose of ecallantide after 4 hours. TRIAL REGISTRATION clinicaltrials.gov Identifiers: not applicable for EDEMA2 (trial was conducted before registration requirements were implemented), NCT00457015 for EDEMA4, and NCT00456508 for DX-88/19.
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Affiliation(s)
- H Henry Li
- Institute for Asthma and Allergy, Wheaton, MD 20902, USA.
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Cole SW, Lundquist LM. Icatibant for the Treatment of Hereditary Angioedema. Ann Pharmacother 2012; 47:49-55. [DOI: 10.1345/aph.1r423] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the pharmacology, pharmacokinetics, clinical trials, and safety of icatibant, a recently approved bradykinin B2 receptor antagonist for treatment of acute attacks of hereditary angioedema (HAE). DATA SOURCES Articles indexed in MEDLINE (1948-June 2012), International Pharmaceutical Abstracts(1970-May 2012), and Cumulative Index to Nursing and Allied Health Literature (1981-June 2012) were identified using the search terms icatibant, bradykinin B2 receptor antagonist, and hereditary angioedema. Additional references were identified from the reference lists of the articles identified. STUDY SELECTION AND DATA EXTRACTION English-language articles were reviewed. DATA SYNTHESIS Icatibant was evaluated in 3 Phase 3 clinical trials and found to be a safe and effective option for treatment of acute HAE. Icatibant was compared to placebo in 2 clinical trials (FAST-1 and FAST-3) and to tranexamic acid in the FAST-2 trial. Patients receiving icatibant in FAST-1 did not experience a significant improvement in median time to clinically significant relief of the index symptom (p = 0.14), whereas patients receiving icatibant in FAST-3 experienced a significant improvement in median time to at least 50% reduction in symptom severity (p < 0.001). When icatibant was compared to tranexamic acid in FAST-2, the median time to clinically significant relief of the index symptom was shorter for patients receiving icatibant (p < 0.001). The most common adverse events associated with the administration of icatibant were injection-site reactions, which were mild to moderate and transient. These data suggest that icatibant is a safe and effective treatment for acute attacks of HAE. Although direct comparisons of recently approved alternatives for treatment of acute attacks are lacking, there are administration advantages of icatibant over other agents. Additionally, the cost of icatibant is comparable to that of the C1 esterase inhibitor Berinert and less expensive than ecallantide. CONCLUSIONS Available efficacy data support that icatibant should be considered a safe and effective treatment for acute attacks of HAE. Additionally, limited treatment options for this rare condition, ease of administration, and comparable cost profile support its consideration for formulary inclusion.
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Affiliation(s)
- Sabrina W Cole
- Sabrina W Cole PharmD BCPS, Director of Biomedical Informatics and Assistant Professor, School of Pharmacy, Wingate University, Wingate, NC
| | - Lisa M Lundquist
- Lisa M Lundquist PharmD BCPS, Associate Dean for Administration and Clinical Associate Professor, College of Pharmacy and Health Sciences, Mercer University, Atlanta, GA
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Floccard B, Hautin E, Bouillet L, Coppere B, Allaouchiche B. An evidence-based review of the potential role of icatibant in the treatment of acute attacks in hereditary angioedema type I and II. CORE EVIDENCE 2012; 7:105-14. [PMID: 23055948 PMCID: PMC3467996 DOI: 10.2147/ce.s24743] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Icatibant, a first-in-class B2 bradykinin receptor antagonist, appears to have a favorable efficacy and safety profile for the treatment of acute attacks of hereditary angioedema in adults. AIMS To update the evidence and provide an overview of the available data on icatibant. EVIDENCE REVIEW Peer reviewed articles published and listed in Medline Search and published updated guidelines for the treatment of acute attacks in hereditary angioedema type I and II in adults were reviewed. The validity and quality of evidence were evaluated. PLACE IN THERAPY Clinical evidence for the treatment of acute hereditary angioedema attacks with icatibant is strong. Approximately 10% of the patients require a second dose. No serious adverse reactions have been reported. The only significant side effects consistently registered by 90% of patients are transient local pain, swelling, and erythema at the local injection site. CONCLUSION Subcutaneously administered 30 mg icatibant has been shown to be a safe and efficacious treatment in clinical trials. It is the only specific treatment authorized for self-administration by the subcutaneous route offering increased patient independence.
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Affiliation(s)
- Bernard Floccard
- Département d'Anesthésie Réanimation, Centre de Référence des Angioedèmes à Bradykinine, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon
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Grumach A, Valle S, Toledo E, de Moraes Vasconcelos D, Villela M, Mansour E, Pinto J, Campos R, França A. Hereditary angioedema: first report of the Brazilian registry and challenges. J Eur Acad Dermatol Venereol 2012; 27:e338-44. [DOI: 10.1111/j.1468-3083.2012.04670.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Many faces of angioedema: focus on the diagnosis and management of abdominal manifestations of hereditary angioedema. Eur J Gastroenterol Hepatol 2012; 24:353-61. [PMID: 22410711 DOI: 10.1097/meg.0b013e3283517998] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Angioedema of the intestinal tract is an infrequent but well-described cause of abdominal pain that can occur because of inherited, acquired, allergic, or drug-induced causes. Hereditary angioedema (HAE) is a genetic disorder that causes recurrent attacks of severe edema of various body parts, including the intestinal tract. Moderate to severe abdominal pain occurs in 43-93% of such attacks due to intestinal edema. Laryngeal edema is a potentially life-threatening manifestation. Failure to recognize and diagnose HAE or other causes of intestinal angioedema can lead to years of delay in diagnosis, and in the case of HAE, often to unnecessary abdominal surgeries. Recognizing the typical history of recurrent attacks of abdominal pain, oropharyngeal/laryngeal angioedema or cutaneous angioedema, family history of similar symptoms, association of attacks with stress or menses, and exacerbation of attacks after administration of estrogens or angiotensin-converting enzyme inhibitors will increase diagnostic accuracy. Interdisciplinary treatment is often necessary after the diagnosis of HAE, first with acute management in the emergency room or the intensive care unit, followed by either drug prophylaxis against future attacks using a C1-esterase inhibitor concentrate or attenuated androgens and discontinuation of medications known to trigger attacks. Newer drugs approved for treatment of acute attacks may have future roles in the prevention of attacks if further studies support their efficacy. Gastroenterologists in particular should maintain a high index of suspicion for the possibility of HAE or other causes of intestinal angioedema in patients with a history of recurrent abdominal pain.
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Cicardi M, Bork K, Caballero T, Craig T, Li HH, Longhurst H, Reshef A, Zuraw B. Evidence-based recommendations for the therapeutic management of angioedema owing to hereditary C1 inhibitor deficiency: consensus report of an International Working Group. Allergy 2012; 67:147-57. [PMID: 22126399 DOI: 10.1111/j.1398-9995.2011.02751.x] [Citation(s) in RCA: 270] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Angioedema owing to hereditary deficiency of C1 inhibitor (HAE) is a rare, life-threatening, disabling disease. In the last 2 years, the results of well-designed and controlled trials with existing and new therapies for this condition have been published, and new treatments reached the market. Current guidelines for the treatment for HAE were released before the new trials and before the new treatments became available and were essentially based on observational studies and expert opinion. To provide evidence-based HAE treatment guidelines supported by the new studies, a conference was held in Gargnano del Garda, Italy, from September 26 to 29, 2010. The meeting hosted 58 experienced HAE expert physicians, representatives of pharmaceutical companies and representatives of HAE patients' associations. Here, we report the topics discussed during the meeting and evidence-based consensus about management approaches for HAE in adult/adolescent patients.
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Affiliation(s)
- M Cicardi
- Dipartimento di Scienze Cliniche "Luigi Sacco", Università di Milano, Ospedale L. Sacco, Milano, Italy.
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Abstract
Hereditary angioedema (HAE) is characterized by acute attacks of edema with multiple localizations, the laryngeal angioedema being the most potentially lethal. In HAE, C1-INH impairments cause episodic increase in kallikrein activity leading to attacks of angioedema. Several therapies have recently become available to treat or to prevent HAE attacks, and others are under evaluation for this indication. Plasma-derived C1-INH, bradykinin receptor antagonists (icatibant), kallikrein inhibitors (ecallantide), or recombinant C1-INH is authorized on the market for HAE attack therapy or prophylaxis. Some of these compounds can be used exclusively to treat HAE attacks, whereas others can also be used as prophylactic therapies. Such therapies, although not available worldwide, can improve disease outcome due to their different mechanisms of action.
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Abstract
Hereditary angioedema (HAE) is a rare condition. Its prognosis depends on whether there is laryngeal involvement with a risk of asphyxia, which is present in 25% of such cases. Improved understanding of the pathophysiology of this disease has resulted in the development of targeted therapies including icatibant, which acts as an antagonist at bradykinin B2 receptors. This agent has been shown to be effective in the treatment of attacks of HAE in three Phase III randomized double-blind published studies. Efficacy data have been collected in all types of attack: cutaneous, abdominal and laryngeal. Safety data are also encouraging. Icatibant is administered subcutaneously, with the potential for patients to self-administer. In the future, this therapy may offer increased independence for HAE patients.
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Affiliation(s)
- Laurence Bouillet
- National Reference Centre for Angioedema, Department of Internal Medicine, Grenoble University Hospital, Grenoble, France.
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Varga L, Farkas H. rhC1INH: a new drug for the treatment of attacks in hereditary angioedema caused by C1-inhibitor deficiency. Expert Rev Clin Immunol 2011; 7:143-53. [PMID: 21426252 DOI: 10.1586/eci.11.5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recombinant human C1 esterase inhibitor (rhC1INH) (Ruconest(®), Pharming) is a new drug developed for the relief of symptoms occurring in patients with angioedema due to C1-inhibitor deficiency. Pertinent results have already been published elsewhere; this article summarizes the progress made since then. Similar to the purified C1-inhibitor derived from human plasma, the therapeutic efficacy of rhC1INH results from its ability to block the actions of enzymes belonging to the overactivated bradykinin-forming pathway, at multiple locations. During clinical trials into the management of acute edema, a total of 190 subjects received recombinant C1-inhibitor by intravenous infusion on 714 occasions altogether. Dose-ranging efficacy studies established 50 U/kg as the recommended dose, and demonstrated the effectiveness of this agent in all localizations of hereditary angioedema attacks. Studies into the safety of rhC1INH based on 300 administrations to healthy subjects or hereditary angioedema patients followed-up for 90 days have not detected the formation of autoantibodies against rhC1INH or IgE antibodies directed against rabbit proteins, even after repeated administration on multiple occasions. These findings met favorable appraisal by the EMA, which granted European marketing authorization for rhC1INH. Pharming is expected to file a biological licence with the US FDA by the end of 2010 to obtain marketing approval in the USA. The launch of rhC1INH onto the pharmaceutical market may represent an important progress in the management of hereditary angioedema patients.
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Affiliation(s)
- Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University Budapest, H-1125 Kútvölgyi street 4, Budapest, Hungary.
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