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Khan S. Tumid lupus erythematosus in C1-inhibitor deficiency. J R Coll Physicians Edinb 2024:14782715241254872. [PMID: 38756017 DOI: 10.1177/14782715241254872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
A case of a 28-year-old woman with known C1-inhibitor deficiency (functional, Type II) with persistent bilateral non-pruritic, mildly photosensitive facial rash for 10 months following delivery of her second child is presented. Histology of the skin was suggestive of tumid lupus erythematosus (LE), but no other features of systemic LE (ANA, dsDNA negative) were evident. She had stopped danazol which was controlling the underlying disease, and once this was restarted and treatment for tumid lupus was started, she improved. More rigorous control preventing all C1-inhibitor deficiency-related attacks proved successful. The hypothesis that uncontrolled classical pathway complement activation that led to the lupus-like skin lesions is being presented as a clinical case, highlighting the complex interrelationships between immunodeficiency and autoimmunity in inborn errors in immunity.
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Affiliation(s)
- Sujoy Khan
- Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
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2
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Kanepa A, Nartisa I, Rots D, Gailite L, Farkas H, Kurjane N. National survey on clinical and genetic characteristics of patients with hereditary angioedema in Latvia. Allergy Asthma Clin Immunol 2023; 19:28. [PMID: 37031173 PMCID: PMC10082512 DOI: 10.1186/s13223-023-00783-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/12/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare and life-threatening inborn error of immunity. HAE is mostly caused by pathogenic variations in the serine protease inhibitor gene 1 (SERPING1), leading to deficient or dysfunctional C1-inhibitor (C1-INH), overproduction of bradykinin, and development of recurrent subcutaneous and/or submucosal oedema. The prevalence of HAE is 1 in 50,000 - 100000 people worldwide. We aimed to describe the clinical features and genetic spectrum of hereditary angioedema with C1-INH deficiency (C1-INH-HAE) in Latvia. METHODS All patients from Latvia diagnosed with HAE (types I/II) from 2006 to March 2022 were included in the study. Laboratory tests and clinical data were analysed, and genetic tests with Sanger sequencing and whole genome sequencing were performed. RESULTS The study identified 10 C1-INH-HAE patients (nine females, one male) from eight families. The point prevalence of HAE in Latvia is 0.53 per 100 000 inhabitants. Of all patients, seven (70%) had HAE type I and three (30%) had HAE type II. The median age of patients was 54 years and the median age at onset of symptoms was 15 years. A significant delay (median 20.5 years) until diagnosis was observed, and 60% of patients had a positive family history of angioedema. All HAE patients have been hospitalised a median two times during their lifetime. Skin (100%), abdominal (80%), and airway (80%) oedema were the most frequent symptoms. Triggering factors (60%) and prodromal symptoms (90%) were referred. Attacks were severe in 50% of patients, moderate in 10%, and mild in 40%. Pathogenic variations of SERPING1 were identified in eight patients (six families), confirming the diagnosis molecularly. In two patients (two families), no pathogenic variations in the genes were found even after whole genome sequencing. CONCLUSIONS Current data shows a significant delay and clear underdiagnosis of HAE in Latvia. Higher awareness and better information and communication between doctors would improve the diagnosis and management of HAE; as would screening of family members, patients with recurrent angioedema unresponsive to antihistamines and glucocorticoids, and patients with recurrent episodes of severe, unexplained abdominal pain.
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Affiliation(s)
- Adine Kanepa
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia.
| | - Inga Nartisa
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia
- Children's Clinical University Hospital, Riga, Latvia
| | - Dmitrijs Rots
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia
- Children's Clinical University Hospital, Riga, Latvia
| | - Linda Gailite
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Natalja Kurjane
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia
- Pauls Stradiņš Clinical University Hospital, Riga, Latvia
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3
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Varandas C, Esteves Caldeira L, Silva SL, Costa C, Limão R, Silva MI, Lopes A, Caiado J, Cosme J, Alonso E, Marcelino J, Cabral Duarte F, Fernandes NP, Neto M, Pedro E, Branco Ferreira M, Spínola Santos A. Hereditary angioedema: 24 years of experience in a Portuguese Reference Center. Eur Ann Allergy Clin Immunol 2022. [PMID: 36515257 DOI: 10.23822/eurannaci.1764-1489.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Summary Hereditary angioedema (HAE) poses a high burden of disease, being its epidemiological and clinical data heterogeneous among countries, with no recent published studies concerning Portuguese patients. Therefore, we aimed to raise awareness of HAE and to contribute to clinical knowledge. An observational, descriptive, retrospective, and cross-sectional study was performed, that included a cohort of 126 patients followed in a single Portuguese Center. We observed a high prevalence of HAE-C1-INH type II (45.2% of patients). Most HAE patients (67.4%) presented the initial manifestations of the disease before adulthood, at a mean age of 12.6 ± 8.4 years. However, we found a long delay in HAE diagnosis, especially in those without family history (mean 20.7 ± 17.3 years). Stress was the most common trigger, followed by trauma and infection. Symptoms involving different systems were increasingly reported with increased disease duration. Cutaneous symptoms (95.0%) were more frequent, followed by gastrointestinal (80.7%), and respiratory symptoms (50.4%). HAE symptoms led to abdominal surgery in 22 (17.5%) patients and induced laryngeal edema requiring intubation/tracheostomy in 8 (6.3%) patients. Most patients were under long-term prophylaxis, mainly with attenuated androgens (62.7% of patients).The correct distinction between HAE and other common causes of angioedema is critical, allowing reduction of diagnostic delay, improvement of adequate management, and ultimately improving outcomes and quality of life of HAE patients.
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Affiliation(s)
- C Varandas
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - L Esteves Caldeira
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - S L Silva
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
- Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - C Costa
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
- Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - R Limão
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - M I Silva
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - A Lopes
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
- Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - J Caiado
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
- Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - J Cosme
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
- Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - E Alonso
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - J Marcelino
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - F Cabral Duarte
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - N P Fernandes
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - M Neto
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - E Pedro
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - M Branco Ferreira
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
- Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - A Spínola Santos
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
- Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Lisbon, Portugal
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Farkas H, Máj C, Kenessey I, Sebestyén A, Krencz I, Pápay J, Cervenak L. A novel pathogenetic factor of laryngeal attack in hereditary angioedema? Involvement of protease activated receptor 1. Allergy Asthma Clin Immunol 2022; 18:60. [PMID: 35787812 PMCID: PMC9254515 DOI: 10.1186/s13223-022-00699-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare, life-threatening disease. The knowledge about the molecular pathogenesis of HAE has derived mainly from investigating blood samples. However, limited data are available on the role of the molecular mechanisms in the affected tissues during HAE attack. OBJECTIVE The aim of our study was to explore the histological changes occurring in HAE attacks. METHODS Post mortem macro-, microscopic and immunohistological assessment of upper airway tissues of a patient with HAE due to C1 inhibitor deficiency (C1-INH-HAE) type 2 who died from laryngeal HAE attack was compared with a non-HAE patient who died from other condition without any signs of angioedema. RESULTS Compared to the control patient, we demonstrated stronger T cell/monocyte infiltration and a more intense C1-INH staining in the C1-INH-HAE patient. The expression of both bradykinin receptors (B1/B2) was observed with a slightly lower level in the C1-INH-HAE patient than in the control patient. PAR1 expression was strongly reduced in the C1-INH-HAE patient suggesting overactivation of this hyperpermeability inducing receptor. CONCLUSION Our unique case and novel results correspond to the knowledge about C1-INH and BDKRs observed in plasma; however, it revealed new information about the pathomechanism of HAE attack focusing on the potential involvement of PAR1 in edema formation. This observation, if it is verified by subcutaneous biopsy studies, may designate a new therapeutic target in HAE.
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Affiliation(s)
- Henriette Farkas
- Hungarian Angioedema Reference Center, Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary.,Department of Internal Medicine and Hematology, Semmelweis University, Szentkirályi u. 46, Budapest, 1088, Hungary
| | - Csilla Máj
- Department of Pathology, Szent György University Hospital, Székesfehérvár, Hungary
| | - István Kenessey
- 2nd Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Anna Sebestyén
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Ildikó Krencz
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Judit Pápay
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - László Cervenak
- Department of Internal Medicine and Hematology, Semmelweis University, Szentkirályi u. 46, Budapest, 1088, Hungary.
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5
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Valle SOR, Alonso MLO, Dortas Junior SD, Goudouris ES, de Carvalho ALRB, Capelo AV, Mansour E, Bernardes AF, Leite LFB, Giavina-Bianchi P, Aun MV, Ferriani MPL, Arruda LK, Grumach AS. Acquired Angioedema due to C1-Inhibitor Deficiency: A Challenging Condition. Int Arch Allergy Immunol 2022; 183:572-577. [PMID: 35325890 DOI: 10.1159/000521646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acquired deficiency of C1 inhibitor (AAE-C1-INH) is a very rare cause of recurrent angioedema, with few cases reported in the literature. We aimed to describe a series of patients with AAE-C1-INH who were diagnosed and received care at angioedema reference centers in Brazil, affiliated to the Brazilian Group of Studies on Hereditary Angioedema. METHODS Fourteen patients from 8 Brazilian Angioedema Reference Centers, diagnosed with AAE-C1-INH, were included in this study. Clinical data collected included sex, date of birth, date of onset of symptoms, date of diagnosis, plasma levels of antigenic and/or functional C1-INH, levels of C4 and C1q, location and treatment of angioedema attacks, long-term prophylaxis, associated diseases, and definitive treatment. RESULTS Fourteen patients were identified with AAE-C1-INH. Most patients (10/14; 71.4%) were female. The median age at onset of symptoms was 56.5 years (range, 14-74 years; interquartile range [IQR], 32-64 years), and median age at diagnosis was 58.0 years (range, 20-76 years; IQR, 38-65 years), with a median time until diagnosis of 2 years (range, 0-6 years; IQR, 1-3 years). The most common manifestations were cutaneous (face, eyelids, lips, trunk, hands, feet, and genitals). Most patient had low levels of C4 (13/14; 92.8%) and of antigenic C1-INH (8/14; 57.1%). Four had decreased functional activity of C1-INH (4/7; 57.1%) and C1q levels were low in 5 patients (5/12; 41.6%). Underlying diseases were identified in all 14 patients, with lymphoma of the splenic marginal zone and monoclonal gammopathy of undetermined significance being the most frequent. Nine patients (64.2%) needed long-term prophylactic treatment for recurrent angioedema and 5 patients (46.7%) required treatment for angioedema attacks. Most of them (12/14; 85.7%) had resolution of angioedema. CONCLUSION Therapy of AAE-C1-INH aims to control symptoms; however, diagnosis and treatment of the underlying disease, when present, should be an important target and may lead to the resolution of angioedema in patients with AAE-C1-INH.
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Affiliation(s)
- Solange Oliveira Rodrigues Valle
- Immunology Service, Department of Internal Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Maria Luiza Oliva Alonso
- Immunology Service, Department of Internal Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil,
| | - Sérgio Duarte Dortas Junior
- Immunology Service, Department of Internal Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Ekaterini Simões Goudouris
- Departamento de Pediatria da Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Ana Luiza Ribeiro Bard de Carvalho
- Immunology Service, Department of Internal Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Albertina Varandas Capelo
- Hospital Universitário Gaffrée e Guinle (HUGG) da Universidade Federal do Estado do RJ (UNIRIO), Rio de Janeiro, Brazil
| | - Eli Mansour
- Allergy and Immunology, Department of Internal Medicine, School of Medical Sciences, University of Campinas/UNICAMP, Campinas, Brazil
| | - Ana Flávia Bernardes
- Allergy and Immunology, Department of Internal Medicine, School of Medical Sciences, University of Campinas/UNICAMP, Campinas, Brazil
| | - Luiz Fernando Bacarini Leite
- Immunodeficiency and Allergy Unit, Pediatrics Department, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Pedro Giavina-Bianchi
- Clinical Immunology and Allergy Division of Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo Vivolo Aun
- Clinical Immunology and Allergy Division of Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Luisa Karla Arruda
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Balla Z, Andrási N, Pólai Z, Visy B, Czaller I, Temesszentandrási G, Csuka D, Varga L, Farkas H. The characteristics of upper airway edema in hereditary and acquired angioedema with C1-inhibitor deficiency. Clin Transl Allergy 2021; 11:e12083. [PMID: 34962723 PMCID: PMC8805691 DOI: 10.1002/clt2.12083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/02/2021] [Accepted: 11/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background Angioedemas localized in the upper airway are potentially life threatening, and without proper treatment, they may lead to death by suffocation. Upper airway edemas (UAE) in bradykinin‐mediated angioedemas can even be the first symptoms of the disease. Methods Our survey was performed with a retrospective long‐term follow‐up method from the medical history of 197 hereditary (C1‐INH‐HAE) and 20 acquired C1‐inhibitor deficiency (C1‐INH‐AAE), 3 factor XII and 3 plasminogen gene mutation (FXII‐HAE, PLG‐HAE) patients treated at our center between 1990 and 2020. The UAE group included edemas localized to the mesopharynx, hypopharynx, and larynx, as narrowing of these anatomical regions can lead to suffocation. Results 98/197 C1‐INH‐HAE (47 families) and 13/20 C1‐INH‐AAE, 1/3 PLG‐HAE, 1/3 FXII‐HAE patients had experienced UAE at least once according to their medical history. In case of C1‐INH‐HAE patients, in 6/47 families who had undiagnosed ancestors had 13 members who died of suffocation. After the diagnosis, 1‐1 member of two families died of UAE. 44/64 C1‐INH‐HAE patients did not smoke, 20/64 did. The occurrence of UAE was significantly higher in smoker patients. We analyzed 7607 HAE attacks of 56/98 patients. Out of all attacks, the incidence of UAE in the C1‐INH‐HAE group was 4%, and 9.5% in the C1‐INH‐AAE group, respectively. Conclusion Early diagnosis is key in bradykinin‐mediated angioedemas cases, since the patient must be provided with adequate treatment; and also it is essential to inform patients about the importance of avoiding the trigger factors and the early symptoms of UAE, as these measures could significantly decrease the incidence of lethal UAEs.
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Affiliation(s)
- Zsuzsanna Balla
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary.,School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Noémi Andrási
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary.,School of PhD Studies, Semmelweis University, Budapest, Hungary.,2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Zsófia Pólai
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary.,School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Beáta Visy
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary.,Heim Pál Children's Hospital, Budapest, Hungary
| | - Ibolya Czaller
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | | | - Dorottya Csuka
- Research Laboratory, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Lilian Varga
- 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
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Piotrowicz-Wójcik K, Bulanda M, Juchacz A, Jamróz-Brzeska J, Gocki J, Kuziemski K, Pawłowicz R, Porebski G. Clinical Characteristics and Management of Angioedema Attacks in Polish Adult Patients with Hereditary Angioedema Due to C1-Inhibitor Deficiency. J Clin Med 2021; 10:jcm10235609. [PMID: 34884311 PMCID: PMC8658320 DOI: 10.3390/jcm10235609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
Hereditary angioedema (HAE) due to C1-inhibitor (C1-INH) deficiency is a rare disease characterized by recurrent swellings. This study aims to determine (i) the clinical characteristics of the HAE patient population from Poland, and (ii) real-life patients' treatment practices. A cross-sectional study involved 138 adult HAE patients (88 females, 50 males) treated in six regional HAE centers in Poland. Consecutive patients during routine follow-up visits underwent a structured medical interview on the clinical characteristics of the course and treatment of HAE attacks within the last six months. A total of 118 of 138 patients was symptomatic. They reported in total 2835 HAE attacks predominantly peripheral and abdominal, treated with plasma-derived C1-INH (61.4%), icatibant (36.7%) and recombinant C1-INH (1.9%). An amount of 116 patients carried the rescue medication with them while traveling, and 74 patients self-administrated on demand treatment. There were twice as many symptomatic women (n = 78) as there were men (n = 40). Women treated their HAE attacks significantly more often than men. Older patients (≥65 years) reported a longer delay in diagnosis, and practiced the self-administration of rescue medication less frequently in comparison to other patients. Clinical features of the surveyed population are similar to other European, but not Asian, HAE patient groups. Self-administration still remains an unmet medical need. Some distinct HAE patients may require special attention due to the severe course of the disease (females) or a delay in diagnosis (the elderly).
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Affiliation(s)
- Katarzyna Piotrowicz-Wójcik
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland; (K.P.-W.); (M.B.)
| | - Małgorzata Bulanda
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland; (K.P.-W.); (M.B.)
| | - Aldona Juchacz
- Greater Poland Center of Pulmonology and Thoracic Surgery, Szamarzewskiego 62, 60-569 Poznan, Poland;
| | - Joanna Jamróz-Brzeska
- Department of Immunology and Allergy, Medical University of Lodz, Tadeusza Kościuszki 4, 90-419 Lodz, Poland;
| | - Jacek Gocki
- Specialist Clinical Practice Allergoderm, Jagiellońska 111/3, 85-027 Bydgoszcz, Poland;
| | - Krzysztof Kuziemski
- Department of Pulmonology and Allergology, Faculty of Medicine, Medical University of Gdansk, Smoluchowskiego 17, 80-214 Gdansk, Poland;
| | - Robert Pawłowicz
- Department and Clinic of Internal Medicine Pneumology and Allergology, Wroclaw Medical University, Marii Skłodowskiej-Curie 66, 50-369 Wrocław, Poland;
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland; (K.P.-W.); (M.B.)
- Correspondence: ; Tel.: +48-12-424-8638
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8
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Balla Z, Ignácz B, Varga L, Kőhalmi KV, Farkas H. How Angioedema Quality of Life Questionnaire Can Help Physicians in Treating C1-Inhibitor Deficiency Patients? Clin Rev Allergy Immunol 2021; 61:50-59. [PMID: 33660212 PMCID: PMC8282561 DOI: 10.1007/s12016-021-08850-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 11/29/2022]
Abstract
The Angioedema Quality of Life Questionnaire (AE-QoL) is an angioedema (AE)-specific validated questionnaire, which surveys the quality of life of diagnosed patients. The questionnaire has been used in multiple clinical trials. Our aim was to investigate how the questionnaire can assist physicians in the everyday practice of following up and managing C1-inhibitor deficiency patients. In a prospective trial conducted in our center between 2016 and 2018, 125 hereditary angioedema and 10 diagnosed with acquired angioedema completed an AE-QoL during their annual follow-up visit. Laboratory indices (i.e., complement levels) were obtained for each patient. Statistical analysis comparing clinical data with QoL parameters was performed. Results of the analysis show that AE-QoL total score and number of AE attacks per year correlated well (r = 0.47; p < 0.0001). Women reached higher AE-QoL total score values than men, over a 3-year period (p = 0.0014). The highest AE-QoL total scores were reached by the 41–60-year age group; we obtained a similar result, when analyzing the four domains. No correlation was found between the AE-QoL total score and complement parameters. Patients with a negative correlation between AE-QoL total score and number of AE attacks had a positive correlation with psychologic attributes like fatigue/mood and fears/shame domains. Patients that acquired HAE showed a significant correlation between the annual number of AE attacks and the AE-QoL total scores (r = 0.46; p < 0.0001). The study establishes the use of AE-QoL as a clinical tool for follow-up which can help in the complex assessment of both hereditary and acquired HAE patients, and help to develop better therapeutic strategies.
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Affiliation(s)
- Zsuzsanna Balla
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
- School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Bettina Ignácz
- Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
| | - Lilian Varga
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Kinga Viktória Kőhalmi
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
- Department of Rheumatology and Clinical Immunology, Semmelweis University, Budapest, Hungary
- Department of Rheumatology, Hospital of the Hospitaller Brothers of Saint John of God, Budapest, Hungary
| | - Henriette Farkas
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.
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9
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Germenis AE, Rijavec M, Veronez CL. Leveraging Genetics for Hereditary Angioedema: A Road Map to Precision Medicine. Clin Rev Allergy Immunol 2021; 60:416-428. [PMID: 33507496 DOI: 10.1007/s12016-021-08836-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 12/25/2022]
Abstract
Biochemical studies performed during the last decades resulted in the development of various innovative medicinal products for hereditary angioedema (HAE). These therapeutic agents target the production or the function of bradykinin-the main mediator of HAE due to C1-inhibitor (C1-INH) deficiency. However, despite these remarkable achievements, current knowledge cannot provide convincing explanations for the clinical variability of the disease. As a consequence, treatment indications apply for drugs available for C1-INH deficiency. The advent of high-throughput next-generation sequencing technologies may assist in covering the missing part of our understanding of HAE pathogenesis. During the last 3 years alone, several new entities were added to the already described genotypes. The recent discovery of four novel target genes expands our understanding of other causes which may explain recurrent angioedema in individuals and families with normal C1-INH activity. Furthermore, new genetic technologies allowed the recognition of deep intronic variants associated with the disease, and elegant functional studies characterized new variants for the C1-INH gene. Thus, evidence has been provided regarding pathogenetic aspects remaining obscure for many years, such as the defective intracellular transport of mutant C1-INH, and environmental effect on the disease expression. Therefore, it seems that the stage for Precision Medicine era in HAE management is ready. Disease endotypes are expected to be uncovered and specified targets for therapeutic intervention will be detected, promising a more effective, individualized management of the disease.
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Affiliation(s)
- Anastasios E Germenis
- Department of Immunology and Histocompatibility, School of Medicine, University of Thessaly, 3 Panepistimiou Street, GR-41500, Biopolis Larissa, Greece.
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Camila Lopes Veronez
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, University of California San Diego, San Diego, CA, USA.,Research Service, San Diego Veterans Affairs Healthcare, San Diego, CA, USA
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10
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Vatsiou S, Zamanakou M, Loules G, Psarros F, Parsopoulou F, Csuka D, Valerieva A, Staevska M, Porebski G, Obtulowicz K, Magerl M, Maurer M, Speletas M, Farkas H, Germenis AE. A novel deep intronic SERPING1 variant as a cause of hereditary angioedema due to C1-inhibitor deficiency. Allergol Int 2020; 69:443-449. [PMID: 31959500 DOI: 10.1016/j.alit.2019.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/29/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In about 5% of patients with hereditary angioedema due to C1-inhibitor deficiency (C1-INH-HAE) no mutation in the SERPING1 gene is detected. METHODS C1-INH-HAE cases with no mutation in the coding region of SERPING1 after conventional genotyping were examined for defects in the intronic or untranslated regions of the gene. Using a next-generation sequencing (NGS) platform targeting the entire SERPING1, 14 unrelated C1-INH-HAE patients with no detectable mutations in the coding region of the gene were sequenced. Detected variants with a global minor allele frequency lower than the frequency of C1-INH-HAE (0.002%), were submitted to in silico analysis using ten different bioinformatics tools. Pedigree analysis and examination of their pathogenic effect on the RNA level were performed for filtered in variants. RESULTS In two unrelated patients, the novel mutation c.-22-155G > T was detected in intron 1 of the SERPING1 gene by the use NGS and confirmed by Sanger sequencing. All bioinformatics tools predicted that the variant causes a deleterious effect on the gene and pedigree analysis showed its co-segregation with the disease. Degradation of the mutated allele was demonstrated by the loss of heterozygosity on the cDNA level. According to the American College of Medical Genetics and Genomics 2015 guidelines the c.-22-155G > T was curated as pathogenic. CONCLUSIONS For the first time, a deep intronic mutation that was detected by NGS in the SERPING1 gene, was proven pathogenic for C1-INH-HAE. Therefore, advanced DNA sequencing methods should be performed in cases of C1-INH-HAE where standard approaches fail to uncover the genetic alteration.
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Affiliation(s)
- Sofia Vatsiou
- CeMIA SA, Larissa, Greece; Department of Immunology & Histocompatibility, University of Thessaly, School of Health Sciences, Faculty of Medicine, Larissa, Greece
| | | | | | - Fotis Psarros
- Department of Allergology, Navy Hospital, Athens, Greece
| | - Faidra Parsopoulou
- CeMIA SA, Larissa, Greece; Department of Immunology & Histocompatibility, University of Thessaly, School of Health Sciences, Faculty of Medicine, Larissa, Greece
| | - Dorottya Csuka
- Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Anna Valerieva
- Clinic of Allergy and Asthma, Medical University of Sofia, Sofia, Bulgaria
| | - Maria Staevska
- Clinic of Allergy and Asthma, Medical University of Sofia, Sofia, Bulgaria
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Krystyna Obtulowicz
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Markus Magerl
- Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus Maurer
- Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthaios Speletas
- Department of Immunology & Histocompatibility, University of Thessaly, School of Health Sciences, Faculty of Medicine, Larissa, Greece
| | - Henriette Farkas
- Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Anastasios E Germenis
- CeMIA SA, Larissa, Greece; Department of Immunology & Histocompatibility, University of Thessaly, School of Health Sciences, Faculty of Medicine, Larissa, Greece.
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11
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Veronez CL, Campos RA, Constantino-Silva RN, Nicolicht P, Pesquero JB, Grumach AS. Hereditary Angioedema-Associated Acute Pancreatitis in C1-Inhibitor Deficient and Normal C1-Inhibitor Patients: Case Reports and Literature Review. Front Med (Lausanne) 2019; 6:80. [PMID: 31058156 PMCID: PMC6478673 DOI: 10.3389/fmed.2019.00080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/01/2019] [Indexed: 12/12/2022] Open
Abstract
Abdominal pain due to intestinal swellings is one of the most common manifestations in hereditary angioedema (HAE). Bowel swellings can cause severe abdominal pain, nausea, vomiting, and diarrhea, which may lead to misdiagnosis of gastrointestinal disorders. In rare cases, HAE abdominal attacks can be accompanied by acute pancreatitis. Here, we report 3 patients with HAE and acute pancreatitis and present a literature review of similar cases. Patients with confirmed diagnosis of HAE secondary to C1-inhibitor (C1-INH) deficiency (n = 2) and HAE with normal C1-INH and F12 mutation (F12-HAE) (n = 1) were included. Pancreatitis was diagnosed based on clinical symptoms and high lipase and amylase levels. Three HAE patients were diagnosed with acute pancreatitis based on increased amylase levels during severe abdominal swelling episodes. Two were previously diagnosed with HAE type I and one with F12-HAE. Pancreatitis was efficiently treated in two patients using Icatibant, with pain relief within hours. When conservatively treated, pancreatitis pain took longer time to resolve. Eighteen pancreatitis cases in HAE with C1-INH deficiency were previously reported and none in F12-HAE. Most patients (12/18) underwent invasive procedures and/or diagnostic methods. Although rare, severe abdominal HAE attacks could cause pancreatitis; HAE-specific treatments may be efficient for HAE-associated pancreatitis. HAE should be considered as a differential diagnosis of acute idiopathic pancreatitis. To our knowledge, this is the first report of HAE-associated pancreatitis in a F12-HAE patient treated with Icatibant.
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Affiliation(s)
| | | | | | - Priscila Nicolicht
- Department of Biophysics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - João Bosco Pesquero
- Department of Biophysics, Universidade Federal de São Paulo, São Paulo, Brazil
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12
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Bork K, Staubach-Renz P, Hardt J. Angioedema due to acquired C1-inhibitor deficiency: spectrum and treatment with C1-inhibitor concentrate. Orphanet J Rare Dis 2019; 14:65. [PMID: 30866985 PMCID: PMC6417199 DOI: 10.1186/s13023-019-1043-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 03/05/2019] [Indexed: 11/23/2022] Open
Abstract
Background Acquired angioedema due to C1-inhibitor (C1-INH) deficiency (AAE-C1-INH) is a serious condition that may result in life-threatening asphyxiation due to laryngeal edema. It is associated with malignant B-cell lymphoma and other disorders. The purpose of this study was to describe the characteristics and associated disorders of patients with AAE-C1-INH and assess the efficacy of plasma-derived C1-INH concentrate (pdC1-INH) in the treatment of AAE-C1-INH. Forty-four patients with AAE-C1-INH from the Angioedema Outpatient Service of Mainz were assessed for associated disorders. In 32 of these patients, the duration of swelling attacks was measured before and after treatment with pdC1-INH (Berinert® (CSL Behring, Marburg, Germany)). The time between injection and complete resolution of symptoms and treatment effectiveness was provided by the patients. Results The following underlying disorders were present: monoclonal gammopathy of undetermined significance (47.7%), non-Hodgkin lymphoma (27.3%), anti-C1-INH autoantibodies alone (11.4%), and other conditions (4.5%). In 9.1% patients, no associated disorder could be found. AAE-C1-INH led to the detection of lymphoma in 75% of patients with the malignancy. Treatment with pdC1-INH shortened attacks by an average (SD) 54.4 (± 32.8) hours (P < 0.0001). The earlier the attack was treated, the shorter the time between injection and resolution of symptoms (P = 0.0149). A total of 3553 (97.7%) of the 3636 attacks were effectively treated with pdC1-INH as assessed by the patient. The mean (SD) dose per-attack was 787 (± 442) U. pdC1-INH was effective in 1246 (93.8%) of 1329 attacks in 8 patients with anti-C1-INH autoantibodies and in 344 (99.4%) of 346 attacks in 6 patients without autoantibodies. The average (SD) dose per effectively treated attack was 1238.4 (± 578.2) U in patients with anti-C1-INH autoantibodies and 510.2 (± 69.1) U in patients without autoantibodies. Conclusions pdC1-INH is highly effective in treating AAE-C1-INH patients and is also effective in the vast majority of attacks in patients with anti-C1-INH autoantibodies. It is fast-acting and reduces attack duration.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Petra Staubach-Renz
- Department of Dermatology, Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Jochen Hardt
- Department of Medical Psychology and Medical Sociology, Johannes Gutenberg University, Mainz, Germany
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13
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Bernstein JA, Li HH, Craig TJ, Manning ME, Lawo JP, Machnig T, Krishnarajah G, Fridman M. Indirect comparison of intravenous vs. subcutaneous C1-inhibitor placebo-controlled trials for routine prevention of hereditary angioedema attacks. Allergy Asthma Clin Immunol 2019; 15:13. [PMID: 30899278 PMCID: PMC6407188 DOI: 10.1186/s13223-019-0328-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/17/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction For prophylaxis of hereditary angioedema (HAE) attacks, replacement therapy with human C1-inhibitor (C1-INH) treatment is approved and available as intravenous [C1-INH(IV)] (Cinryze®) and subcutaneous [C1-INH(SC)] HAEGARDA® preparations. In the absence of a head-to-head comparative study of the two treatment modalities, an indirect comparison of data from 2 independent but similar clinical trials was undertaken. Methods Two similar randomized, double-blind, placebo-controlled, crossover studies were identified which evaluated either C1-INH(SC) (COMPACT; NCT01912456; 16 weeks) or C1-INH(IV) (CHANGE; NCT01005888; 14 weeks) vs. placebo (on-demand treatment only) for routine prevention of HAE attacks. Individual patient data from each trial were used to conduct an indirect comparison of treatment effects. Attack reductions (absolute and percent of mean/median number of monthly HAE attacks reduction over placebo) were compared between the two C1-INH formulations at approved/recommended doses: C1-INH(SC) 60 IU/kg twice weekly (n = 45) and 1000 U of C1-INH(IV) twice weekly (n = 22). Point estimates were adjusted using mixed and quantile regression models that controlled for study design. Results The absolute mean monthly numbers of HAE attack reductions were 3.6 (95% CI 2.9, 4.2) for C1-INH(SC) 60 IU/kg vs. placebo and 2.3 (1.4, 3.3) for C1-INH(IV) vs. placebo; between-product difference, 1.3 (0.1, 2.4; P = 0.034). The mean percent reduction in monthly attack rate was significantly greater with C1-INH(SC) as compared with C1-INH(IV) (84% vs. 51%; P < 0.001). The percentages of subjects experiencing ≥ 50%, ≥ 70%, and ≥ 90% reductions in monthly HAE attack rates versus placebo were significantly higher with C1-INH(SC) 60 IU/kg as compared to C1-INH(IV) 1000 U (≥ 50% reduction: 91% vs. 50%, odds ratio [OR] = 10.33, P = 0.003; ≥ 70% reduction: 84% vs. 46%, OR = 6.19, P = 0.005; ≥ 90% reduction: 57% vs. 18%, OR = 6.04, P = 0.007). Conclusion Within the limitations of an indirect study comparison, this analysis suggests greater attack reduction with twice-weekly C1-INH(SC) 60 IU/kg as compared to twice-weekly C1-INH(IV) 1000 U for the routine prevention of HAE attacks.
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Affiliation(s)
- Jonathan A Bernstein
- 1University of Cincinnati College of Medicine and Bernstein Clinical Research Center, 231 Albert Sabin Way ML #563, Cincinnati, OH 45267-0563 USA
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14
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Valerieva A, Cicardi M, Baraniuk J, Staevska M. The physician and hereditary angioedema friend or foe: 62-year diagnostic delay and iatrogenic procedures. Allergy Asthma Clin Immunol 2018; 14:75. [PMID: 30386388 PMCID: PMC6201585 DOI: 10.1186/s13223-018-0275-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is a rare autosomal dominant disease characterized by episodes of acute subcutaneous swelling, and/or recurrent severe abdominal pain. The disease is potentially fatal if the upper-airway is involved. Iatrogenic harm can occur if HAE is not considered in the differential diagnosis, the specialists are not aware of the natural history, diagnosis and treatment of HAE, or as a result of unnecessary surgical and other iatrogenic interventions. Case presentation We present the case of a 72-year-old man who began suffering recurrent abdominal pain at the age of 8 years. The pain led to frequent emergency department visits, three emergency surgical interventions, and 5 endoscopies before C1-INH-HAE was diagnosed at the age of 70. Infrequent subcutaneous swellings were attributed to unknown allergic reactions that were not related to the primary diagnosis of abdominal pain. Family history was positive for recurrent abdominal pain and angioedema but was ignored until the propositus’ grandson developed recurrent severe oro-facial edema attacks. The boy’s mother searched the worldwide web and found educational materials on a patient association website. She suggested complement C4 and C1-INH testing that led to the appropriate diagnosis of C1-INH-HAE type 1 in her son and his grandfather. Conclusion This report emphasizes the importance of accurately evaluating personal and family history in patients with a long history of recurrent, acute, severe but medically unexplained abdominal pain and cutaneous swellings. Here, the diagnosis of HAE was overlooked for 62 years and the focus on abdominal complaints led to numerous surgical interventions without consideration of the full differential diagnosis. Screening family members from all generations for unrecognized angioedema, abdominal pain, and measurement of C1-INH and C4 are essential for accurate and timely diagnosis of HAE.
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Affiliation(s)
- Anna Valerieva
- 1Clinical Center of Allergology, Clinic of Allergy and Asthma, University Hospital "Alexandrovska", Medical University of Sofia, 1, Georgi Sofiiski Str., 1431 Sofia, Bulgaria
| | - Marco Cicardi
- 2Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital-Polo Ospedaliero, University of Milan, Milan, Italy
| | - James Baraniuk
- 3Division of Rheumatology, Immunology and Allergy, Department of Medicine, Georgetown University, Washington, DC USA
| | - Maria Staevska
- 1Clinical Center of Allergology, Clinic of Allergy and Asthma, University Hospital "Alexandrovska", Medical University of Sofia, 1, Georgi Sofiiski Str., 1431 Sofia, Bulgaria
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15
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Longhurst HJ, Dempster J, Lorenzo L, Buckland M, Grigoriadou S, Symons C, Bethune C, Fabien V, Bangs C, Garcez T. Real-world outcomes in hereditary angioedema: first experience from the Icatibant Outcome Survey in the United Kingdom. Allergy Asthma Clin Immunol 2018; 14:28. [PMID: 30127805 PMCID: PMC6091163 DOI: 10.1186/s13223-018-0253-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 04/09/2018] [Indexed: 12/16/2022] Open
Abstract
Background Hereditary angioedema (HAE) is a potentially life-threatening, bradykinin-mediated disease, often misdiagnosed and under-treated, with long diagnostic delays. There are limited real-world data on best-practice management of HAE in the UK. Objectives To characterize the clinical profile, management and outcomes of patients with HAE type I and II from three specialist centres in the UK using data from the Icatibant Outcome Survey (IOS; Shire, Zug, Switzerland), an international observational study monitoring safety and effectiveness of icatibant, a selective bradykinin B2 receptor antagonist. Methods We performed retrospective analyses of IOS data for patients with HAE type I and II from three centres in the UK and compared UK data with pooled IOS data from 10 countries (48 centres). Results Analyses included 73 UK and 579 non-UK patients with HAE type I or II. Median diagnostic delay was 6.2 and 5.9 years, respectively. Analysis of data collected from February 2008 to July 2016 included 286 icatibant-treated attacks in 58 UK patients and 2553 icatibant-treated attacks in 436 non-UK patients (median of 3.0 attacks per patient in both groups). More attacks were treated by icatibant self-administration in UK patients (95.8%) than in non-UK patients (86.8%, p < 0.001). Time to icatibant treatment, time to resolution and attack duration were not significantly different in the UK versus non-UK patients. Conclusion UK patients from the specialist centres studied report similar diagnostic delay and similar icatibant treatment outcomes to their non-UK counterparts. However, improvements in the timely diagnosis of HAE are still required. Trial registration ClinicalTrials.gov NCT01034969
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Affiliation(s)
- Hilary J Longhurst
- 1Department of Clinical Biochemistry and Immunology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John Dempster
- 2Department of Immunology, Barts Health NHS Trust, London, UK
| | - Lorena Lorenzo
- 2Department of Immunology, Barts Health NHS Trust, London, UK
| | | | | | - Christine Symons
- 3Department of Immunology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Claire Bethune
- 3Department of Immunology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | | | - Catherine Bangs
- Department of Immunology, Central Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Tomaz Garcez
- Department of Immunology, Central Manchester University Hospital NHS Foundation Trust, Manchester, UK
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Savarese L, Bova M, De Falco R, Guarino MD, De Luca Picione R, Petraroli A, Senter R, Traverso C, Zabotto M, Zanichelli A, Zito E, Alessio M, Cancian M, Cicardi M, Franzese A, Perricone R, Marone G, Valerio P, Freda MF. Emotional processes and stress in children affected by hereditary angioedema with C1-inhibitor deficiency: a multicenter, prospective study. Orphanet J Rare Dis 2018; 13:115. [PMID: 30005674 PMCID: PMC6043996 DOI: 10.1186/s13023-018-0871-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/06/2018] [Indexed: 12/16/2022] Open
Abstract
Background Hereditary angioedema with C1-inhibitor deficiency (C1-INH-HAE) is characterized by recurrent edema of unpredictable frequency and severity. Stress, anxiety, and low mood are among the triggering factors most frequently reported. Impaired regulation and processing of emotions, also known as alexithymia, may influence outcomes. The aim of this study was to confirm the presence of alexithymia and stress in children with C1-INH-HAE, to determine whether they are also present in children affected by other chronic diseases, and to investigate their relationship with C1-INH-HAE severity. Data from children with C1-INH-HAE (n = 28) from four reference centers in Italy were compared with data from children with type 1 diabetes (T1D; n = 23) and rheumatoid arthritis (RA; n = 25). Alexithymia was assessed using the Alexithymia Questionnaire for Children scale; perceived stress was assessed using the Coddington Life Event Scale for Children (CLES-C). Results Mean age (standard deviation [SD]) in the C1-INH-HAE, T1D, and RA groups was 11.8 (3.3), 11.7 (2.9), and 11.1 (2.6) years, respectively. Mean C1-INH-HAE severity score was 5.9 (2.1), indicating moderate disease. Alexithymia scores were similar among disease groups and suggestive of difficulties in identifying and describing emotions; CLES-C scores tended to be worse in C1-INH-HAE children. C1-INH-HAE severity was found to correlate significantly and positively with alexithymia (p = 0.046), but not with perceived stress. Alexithymia correlated positively with perceived stress. Conclusions Alexithymia is common in children with chronic diseases. In C1-INH-HAE, it may result in increased perceived stress and act as a trigger of edema attacks. Comprehensive management of C1-INH-HAE children should consider psychological factors. Electronic supplementary material The online version of this article (10.1186/s13023-018-0871-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Livia Savarese
- Department of Humanities, University Federico II, via Porta di Massa 1, 80133, Naples, Italy.
| | - Maria Bova
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Raffaella De Falco
- Department of Clinical Neuroscience, Anesthesiology and Drug Administration, University Federico II, Naples, Italy
| | - Maria Domenica Guarino
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Rome, Italy
| | | | - Angelica Petraroli
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | | | - Claudia Traverso
- Department of Pediatrics, Rheumatology Unit, University Federico II, Naples, Italy
| | - Matteo Zabotto
- Department of Psychiatry, "Luigi Sacco" Hospital, University of Milan, Milan, Italy
| | - Andrea Zanichelli
- ASST Fatebenefratelli Sacco, Department of Biomedical and Clinical Sciences, "Luigi Sacco" Hospital, University of Milan, Milan, Italy
| | - Eugenio Zito
- Department of Social Sciences, University Federico II, Naples, Italy
| | - Maria Alessio
- Department of Pediatrics, Rheumatology Unit, University Federico II, Naples, Italy
| | - Mauro Cancian
- Department of Medicine, University of Padua, Padua, Italy
| | - Marco Cicardi
- ASST Fatebenefratelli Sacco, Department of Biomedical and Clinical Sciences, "Luigi Sacco" Hospital, University of Milan, Milan, Italy
| | - Adriana Franzese
- Department of Social Sciences, University Federico II, Naples, Italy
| | - Roberto Perricone
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Rome, Italy
| | - Gianni Marone
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Paolo Valerio
- Department of Clinical Neuroscience, Anesthesiology and Drug Administration, University Federico II, Naples, Italy
| | - Maria Francesca Freda
- Department of Humanities, University Federico II, via Porta di Massa 1, 80133, Naples, Italy
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17
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Farkas H, Kőhalmi KV. Icatibant for the treatment of hereditary angioedema with C1-inhibitor deficiency in adolescents and in children aged over 2 years. Expert Rev Clin Immunol 2018; 14:447-460. [PMID: 29757016 DOI: 10.1080/1744666x.2018.1476851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Hereditary angioedema (HAE) due to C1-inhibitor deficiency (C1-INH-HAE) is a rare disorder with life-threatening complications if untreated. It begins during childhood, and reduces the patient's quality of life. Therefore, the availability of an easily administered agent to relieve unpredictable HAE episodes is indispensable for this age group. Areas covered: Randomized, double-blind, placebo-controlled, open-label extensions and prospective observational studies have proven the safety and efficacy of the subcutaneously administered bradykinin B2 receptor antagonist, icatibant, in the acute treatment of HAE episodes in adult C1-INH-HAE patients. Recently, a Phase 3, multicenter, open-label, non-randomized, single-arm study demonstrated the efficacy, safety, and tolerability of icatibant as an acute treatment for pediatric patients aged 2 years to less than 18 years. Expert commentary: The clinical study in pediatric patients showed that icatibant undergoes rapid absorption, reaches a therapeutic level, and promptly relieves the symptoms. It is well tolerated, and the subcutaneous preparation, presented in a pre-filled syringe, ensures ease of use. It can be administered anytime, anywhere, and instantly - even by the patients themselves, or - in the case of children and adolescents - by a caregiver. Icatibant may greatly contribute to the improvement of the quality of life of pediatric patients.
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Affiliation(s)
- Henriette Farkas
- a Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
| | - Kinga Viktória Kőhalmi
- a Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
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Jacquin-Porretaz C, Castelain F, Daguindau E, Seilles E, Nardin C, Aubin F, Pelletier F. [Acquired C1 esterase inhibitor deficiency via bradykinin-mediated angioedema: Four cases]. Ann Dermatol Venereol 2018; 145:598-602. [PMID: 29673745 DOI: 10.1016/j.annder.2018.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 09/25/2017] [Accepted: 02/13/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acquired C1-esterase inhibitor (C1-INH) deficiency angioedema (C1-INH-AAE) is a form of bradykinin-mediated angioedema. This rare disorder is due to acquired consumption of C1-INH, hyperactivation of the classic pathway of human complement, and potentially fatal recurrent angioedema symptoms. Clinical symptoms of C1-INH-AAE are very similar to those of hereditary angioedema (HAE) but usually appear after the fourth decade of life and induce abdominal pain less frequently. Laboratory tests are essential in establishing the diagnosis with low levels or abnormal structure and function of C1-INH. Most patients present C1-INH autoantibodies. Furthermore, C1q is reduced in AAE, contrary to HAE. The long-term prognosis is determined by associated hematologic malignancies. PATIENTS AND METHODS We report 4 cases of C1-INH-AAE associated with lymphoproliferative disorders referred to the Reference Centre for Angioedema of Besançon, France. The patients were aged between 60 and 77 years. C1 INH antibodies were found in three patients. Symptoms were triggered by angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) in 3 patients. Hematologic malignancy was present at diagnosis (one case of chronic lymphoid leukemia) or was diagnosed during follow-up (one case of indolent marginal zone non-Hodgkin lymphoma and two cases of monoclonal gammopathy). DISCUSSION C1-INH-AAE induced by ACE inhibitors or ARBs may be associated with hematologic malignancies. This form of revelation does not necessarily indicate a diagnosis of ACE or ARBs angioedema, and screening should therefore be performed for C1 Inh and C1q. An underlying hematologic malignancy should be routinely sought and the long-term prognosis determined.
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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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Demirturk M, Akpinar TS, Kose M, Gelincik A, Colakoğlu B, Buyukozturk S. Endocan: A Novel Marker of Endothelial Dysfunction in C1-Inhibitor-Deficient Hereditary Angioedema. Int Arch Allergy Immunol 2017; 174:104-107. [PMID: 29059678 DOI: 10.1159/000481256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/04/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hereditary angioedema (HAE) related to C1-inhibitor deficiency is a rare autosomal dominant disorder. Vascular cell adhesion molecules (VCAM) are known as endothelial activation markers. Endocan (also called ESM-1) is proposed as an endothelial dysfunction indicator. We aimed to investigate endothelial activation in attack-free periods in HAE patients by measuring their levels of endocan and VCAM-1. METHODS Twenty-six HAE patients (22 female, mean age 40 ± 13 years) and 38 healthy control patients (13 female, mean age 36.9 ± 12 years) were included in the study. Peripheral blood samples were collected from HAE patients during symptom-free periods and control subjects. Endocan and VCAM-1 levels were measured using the enzyme-linked immunosorbent assay method. RESULTS The median serum levels of endocan (647 ± 101 ng/mL) and VCAM-1 (500 ± 79 ng/mL) in the HAE patients were significantly higher than in the control patients (391 ± 41 and 325 ± 4; p < 0.001 for both). CONCLUSION The increased endocan and VCAM-1 levels may reflect an endothelial activation even in attack-free periods in HAE patients.
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Affiliation(s)
- Mustafa Demirturk
- Immunology and Allergy Unit, Yedikule Education and Training Hospital, Istanbul University, Istanbul, Turkey
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Kőhalmi KV, Veszeli N, Cervenak L, Varga L, Farkas H. A novel prophylaxis with C1-inhibitor concentrate in hereditary angioedema during erythema marginatum. Immunol Lett 2017; 189:90-3. [PMID: 28577900 DOI: 10.1016/j.imlet.2017.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 05/26/2017] [Accepted: 05/28/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hereditary angioedema with C1-inhibitor deficiency (C1-INH-HAE) is a rare, autosomal dominant disorder. The characteristic episodes of subcutaneous/submucosal edema formation may be preceded by erythema marginatum (EM) - the occurrence of a 'map-like' pattern on the skin. EM can occur as an isolated finding or accompanying a hereditary angiooedema (HAE) attack as well. Nevertheless, it is unknown whether a HAE attack can be prevented by the proper prophylactic treatment during EM. OBJECTIVES Our aim was to assess the prevalence of EM in the Hungarian C1-INH-HAE population and to introduce a safe and effective novel prophylactic treatment during EM in patients who's HAE attacks are preceded by EM in a considerable proportion of the cases. RESULTS Based on the data of the Hungarian HAE Registry, 49 among 173 C1-INH-HAE patients (28.3%) from 32 families had EM in their life. According to the clinical data and the patient's HAE diaries, two patients (Patient #1, Patient #2) were selected who frequently had EM as a prodromal symptom. Both patients were instructed to administer plasma-derived C1-inhibitor concentrate (pdC1-INH) as soon as possible after the onset of EM, in order to prevent the development of HAE attack. Interestingly, HAE attacks never developed if pdC1-INH was administered within 6h from the occurrence of EM in both patients. In contrast, without pdC1-INH treatment, in Patient 1 and Patient 2, 97.0% and 44.3% of the EM were followed by a HAE attack, respectively (p<0.0001, Fisher's exact test). CONCLUSIONS As a novel prophylaxis in C1-INH-HAE, intravenous administration of pdC1-INH concentrate during EM might be an effective, individual therapeutic strategy in those patients who's HAE attacks are often preceded by EM. Besides it can improve the quality of life of these selected patients, pdC1-INH administration during EM provides the lowest effective dose for the prophylaxis of their HAE attacks.
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Zotter Z, Nagy Z, Patócs A, Csuka D, Veszeli N, Kőhalmi KV, Farkas H. Glucocorticoid receptor gene polymorphisms in hereditary angioedema with C1-inhibitor deficiency. Orphanet J Rare Dis 2017; 12:5. [PMID: 28069032 PMCID: PMC5223456 DOI: 10.1186/s13023-016-0552-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/09/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Hereditary angioedema caused by C1-inhibitor deficiency (C1-INH-HAE) is a rare, autosomal dominant disorder. C1-INH-HAE is characterized by edema-formation, which may occur in response to stress. The individual's response to stress stimuli is partly genetically determined. Activation of the hypothalamic-pituitary-adrenal axis results in the release of cortisol. In turn, the secreted gluco- and mineralocorticoids affect the metabolism, as well as the cardiovascular and immune systems. We hypothesized that changes in serum cortisol level and polymorphisms of the glucocorticoid receptor (GR) modify the individual sensitivity to stressor stimuli of C1-INH-HAE patients. RESULTS We compared the response to stress with Rahe's Brief Stress and Coping Inventory of 43 C1-INH-HAE patients, 18 angioedema patients and 13 healthy controls. 139 C1-INH-HAE patients and 160 healthy controls were genotyped for glucocorticoid receptor polymorphisms BclI, N363S and A3669G. Serum cortisol levels were determined during attacks and during symptom-free periods in 36 C1-INH-HAE patients. The relationships between clinical, laboratory data and GR SNPs (Single Nucleotide Polymorphisms) were assessed using ANOVA. C1-INH-HAE patients have decreased coping capabilities compared to healthy controls. Cortisol levels were significantly higher during attacks than in symptom-free periods (p = 0.004). The magnitude of the elevation of cortisol levels did not show a significant correlation with any clinical or laboratory data. Among the C1-INH-HAE patients, the carriers of the A3669G allele had significantly lower cortisol levels, and increased body mass index compared with non-carriers. CONCLUSIONS The higher cortisol level observed during attacks may reflect the effect of a stressful situation (such as of the attack itself), on the patients' neuroendocrine system. In A3669G carriers, the lower cortisol levels might reflect altered feedback to the hypothalamic-pituitary-adrenal axis, due to decreased sensitivity to glucocorticoids.
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Affiliation(s)
- Zsuzsanna Zotter
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary.,Department of Urology, Medical Center, Hungarian Defence Forces, Budapest, Hungary
| | - Zsolt Nagy
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.,HAS-SE "Lendület" Hereditary Endocrine Tumors Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - Attila Patócs
- HAS-SE "Lendület" Hereditary Endocrine Tumors Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - Dorottya Csuka
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary
| | - Nóra Veszeli
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary
| | - Kinga Viktória Kőhalmi
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary
| | - Henriette Farkas
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary.
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Zotter Z, Veszeli N, Kőhalmi KV, Varga L, Imreh É, Kovács G, Nallbani M, Farkas H. Bacteriuria increases the risk of edematous attacks in hereditary angioedema with C1-inhibitor deficiency. Allergy 2016; 71:1791-1793. [PMID: 27548887 DOI: 10.1111/all.13034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2016] [Indexed: 11/30/2022]
Abstract
Urinary tract infections are considered among the most common infectious disorders in humans. Various infections may have a role in inducing HAE attacks. Our study intended to evaluate bacteriuria in the urinalysis of patients with C1-INH-HAE. Urine specimens contributed by 139 patients with C1-INH-HAE at the annual control visits were studied retrospectively for microorganisms. We analyzed the presence of bacteriuria in relation to the clinical symptoms. Taking into account three randomly selected urine specimens, we found that the cumulative number of edematous attacks was higher in patients with bacteriuria than in those without (P = 0.019, P = 0.022, P = 0.014). Considering the same patients, attack number was significantly higher (14.51 vs 8.63) in patients with bacteriuria than in those without (P < 0.0001). In patients with bacteriuria, we found a higher incidence of edema formation during the year before evaluation, which may suggest the triggering role of bacteriuria in the occurrence of edematous episodes.
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Affiliation(s)
- Z. Zotter
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
- Urology Department; Medical Center; Hungarian Defence Forces; Budapest Hungary
| | - N. Veszeli
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - K. V. Kőhalmi
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - L. Varga
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - É. Imreh
- Department of Laboratory Medicine; Semmelweis University; Budapest Hungary
| | - G. Kovács
- Urology Department; Medical Center; Hungarian Defence Forces; Budapest Hungary
| | - M. Nallbani
- Urology Department; Medical Center; Hungarian Defence Forces; Budapest Hungary
| | - H. Farkas
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
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Abstract
Hereditary angioedema (HAE) patients experience recurrent local swelling in various parts of the body including painful swelling of the intestine and life-threatening laryngeal oedema. Most HAE literature is about attacks located in one anatomical site, though it is mentioned that HAE attacks may also involve multiple anatomical sites simultaneously. A detailed description of such multi-location attacks is currently lacking. This study investigated the occurrence, severity and clinical course of HAE attacks with multiple anatomical locations. HAE patients included in a clinical database of recombinant human C1-inhibitor (rhC1INH) studies were evaluated. Visual analog scale scores filled out by the patients for various symptoms at various locations and investigator symptoms scores during the attack were analysed. Data of 219 eligible attacks in 119 patients was analysed. Thirty-three patients (28%) had symptoms at multiple locations in anatomically unrelated regions at the same time during their first attack. Up to five simultaneously affected locations were reported. The observation that severe HAE attacks often affect multiple sites in the body suggests that HAE symptoms result from a systemic rather than from a local process as is currently believed.
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Squeglia V, Barbarino A, Bova M, Gravante C, Petraroli A, Spadaro G, Triggiani M, Genovese A, Marone G. High attack frequency in patients with angioedema due to C1-inhibitor deficiency is a major determinant in switching to home therapy: a real-life observational study. Orphanet J Rare Dis 2016; 11:133. [PMID: 27686124 PMCID: PMC5043538 DOI: 10.1186/s13023-016-0518-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 09/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hereditary angioedema with C1-inhibitor deficiency (C1-INH-HAE) is characterized by recurrent attacks of swelling that affect various body sites. Such attacks are a frequent cause of visits to the emergency department and are often treated in the hospital. In recent years, self-administration of C1-inhibitor (C1-INH) concentrates at home has become an increasingly used option, with a positive impact on patient outcomes and quality of life. METHODS This was an observational study of 6 months' duration in 56 patients with C1-INH-HAE referred to a HAE center in southern Italy. The patients received three types of treatment for their swelling attacks: C1-INH concentrates administered at home (n = 25); icatibant administered at home (n = 12); and C1-INH concentrates administered in the hospital (n = 19). The objectives of this observational study were to compare therapy compliance (defined as the proportion of treated attacks) and quality of life in home- and hospital-treated patients, and to identify factors associated with the decision to use home therapy. RESULTS Overall, 918 attacks were reported over 6 months, of which 544 (59.2 %) were treated. Total number of reported attacks and the mean (±SD) number of attacks per patient, respectively, in the three groups were: 611 and 24.4 (±26.1) for home-based C1-INH; 191 and 15.9 (±12.0) for home-based icatibant; 166 and 6.1 (±6.5) for hospital-based C1-INH. Differences in attack frequency between home- and hospital-based treatments were statistically significant (p = 0.002), while patient demographic characteristics and the disease severity score did not correlate with the use of home therapy. Compliance with therapy was significantly better with home-based therapy (71.2 % of treated attacks with C1-INH and 44.0 % with icatibant) than with hospital-based therapy (21.6 %, p = 0.003). Quality of life showed an opposite trend, with patients on hospital-based treatment reporting the highest quality of life. CONCLUSIONS Home-based therapy was associated with better compliance compared with hospital-based therapy. The choice to adopt home-based therapy appeared to correlate with a high attack frequency. Home-based therapy is a valid treatment option for patients with C1-INH-HAE and should be offered to all such patients, and especially to those with high attack frequency.
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Affiliation(s)
- Veronica Squeglia
- Dipartimento di Science Mediche Traslazionali, Università degli Studi di Napoli Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Alessandro Barbarino
- Department of Public Health, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Maria Bova
- Dipartimento di Science Mediche Traslazionali, Università degli Studi di Napoli Federico II, Via S. Pansini 5, 80131, Naples, Italy.
| | - Carmela Gravante
- Dipartimento di Science Mediche Traslazionali, Università degli Studi di Napoli Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Angelica Petraroli
- Dipartimento di Science Mediche Traslazionali, Università degli Studi di Napoli Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Giuseppe Spadaro
- Dipartimento di Science Mediche Traslazionali, Università degli Studi di Napoli Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Massimo Triggiani
- Department of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Arturo Genovese
- Dipartimento di Science Mediche Traslazionali, Università degli Studi di Napoli Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Gianni Marone
- Dipartimento di Science Mediche Traslazionali, Università degli Studi di Napoli Federico II, Via S. Pansini 5, 80131, Naples, Italy.
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Speletas M, Szilágyi Á, Csuka D, Koutsostathis N, Psarros F, Moldovan D, Magerl M, Kompoti M, Varga L, Maurer M, Farkas H, Germenis AE. F12-46C/T polymorphism as modifier of the clinical phenotype of hereditary angioedema. Allergy 2015; 70:1661-4. [PMID: 26248961 DOI: 10.1111/all.12714] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2015] [Indexed: 11/29/2022]
Abstract
The factors influencing the heterogeneous clinical manifestation of hereditary angioedema due to C1-INH deficiency (C1-INH-HAE) represent one of the oldest unsolved problems of the disease. Considering that factor XII (FXII) levels may affect bradykinin production, we investigated the contribution of the functional promoter polymorphism F12-46C/T in disease phenotype. We studied 258 C1-INH-HAE patients from 113 European families, and we explored possible associations of F12-46C/T with clinical features and the SERPING1 mutational status. Given that our cohort consisted of related subjects, we implemented generalized estimating equations (GEEs), an extension of the generalized linear model accounting for the within-subject correlation. F12-46C/T carriers exhibited a significantly delayed disease onset (P < 0.001) and did not need long-term treatment (P = 0.02). In a GEE linear regression model, the presence of F12-46C/T was significantly associated with a 7-year delay in disease onset (P < 0.0001) regardless of SERPING1 mutational status. It is concluded that F12-46C/T carriage acts as an independent modifier of C1-INH-HAE severity.
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Affiliation(s)
- M. Speletas
- Department of Immunology & Histocompatibility; School of Health Sciences; Faculty of Medicine; University of Thessaly; Larissa Greece
| | - Á. Szilágyi
- 3rd Department of Internal Medicine; Hungarian Angioedema Center; Semmelweis University; Budapest Hungary
| | - D. Csuka
- 3rd Department of Internal Medicine; Hungarian Angioedema Center; Semmelweis University; Budapest Hungary
| | - N. Koutsostathis
- Department of Immunology & Histocompatibility; School of Health Sciences; Faculty of Medicine; University of Thessaly; Larissa Greece
| | - F. Psarros
- Department of Allergology; Navy Hospital; Athens Greece
| | - D. Moldovan
- Department of Allergy-Immunology; University of Medicine and Pharmacy; Mures County Hospital; Tîrgu Mureș Romania
| | - M. Magerl
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - M. Kompoti
- Department of Immunology & Histocompatibility; School of Health Sciences; Faculty of Medicine; University of Thessaly; Larissa Greece
| | - L. Varga
- 3rd Department of Internal Medicine; Hungarian Angioedema Center; Semmelweis University; Budapest Hungary
| | - M. Maurer
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - H. Farkas
- 3rd Department of Internal Medicine; Hungarian Angioedema Center; Semmelweis University; Budapest Hungary
| | - A. E. Germenis
- Department of Immunology & Histocompatibility; School of Health Sciences; Faculty of Medicine; University of Thessaly; Larissa Greece
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Malbrán A, Riedl M, Ritchie B, Smith WB, Yang W, Banerji A, Hébert J, Gleich GJ, Hurewitz D, Jacobson KW, Bernstein JA, Khan DA, Kirkpatrick CH, Resnick D, Li H, Fernández Romero DS, Lumry W. Repeat treatment of acute hereditary angioedema attacks with open-label icatibant in the FAST-1 trial. Clin Exp Immunol 2014; 177:544-53. [PMID: 24749847 DOI: 10.1111/cei.12358] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2014] [Indexed: 11/30/2022] Open
Abstract
Hereditary angioedema (HAE) is characterized by potentially life-threatening recurrent episodes of oedema. The open-label extension (OLE) phase of the For Angioedema Subcutaneous Treatment (FAST)-1 trial (NCT00097695) evaluated the efficacy and safety of repeated icatibant exposure in adults with multiple HAE attacks. Following completion of the randomized, controlled phase, patients could receive open-label icatibant (30 mg subcutaneously) for subsequent attacks. The primary end-point was time to onset of primary symptom relief, as assessed by visual analogue scale (VAS). Descriptive statistics were reported for cutaneous/abdominal attacks 1-10 treated in the OLE phase and individual laryngeal attacks. Post-hoc analyses were conducted in patients with ≥ 5 attacks across the controlled and OLE phases. Safety was evaluated throughout. During the OLE phase, 72 patients received icatibant for 340 attacks. For cutaneous/abdominal attacks 1-10, the median time to onset of primary symptom relief was 1·0-2·0 h. For laryngeal attacks 1-12, patient-assessed median time to initial symptom improvement was 0·3-1·2 h. Post-hoc analyses showed the time to onset of symptom relief based on composite VAS was consistent across repeated treatments with icatibant. One injection of icatibant was sufficient to treat 88·2% of attacks; rescue medication was required in 5·3% of attacks. No icatibant-related serious adverse events were reported. Icatibant provided consistent efficacy and was well tolerated for repeated treatment of HAE attacks.
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Affiliation(s)
- A Malbrán
- Hospital Británico de Buenos Aires, Buenos Aires, Argentina
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Aygören‐Pürsün E, Martinez Saguer I, Kreuz W, Klingebiel T, Schwabe D. Risk of angioedema following invasive or surgical procedures in HAE type I and II--the natural history. Allergy 2013; 68:1034-9. [PMID: 23968383 PMCID: PMC4223932 DOI: 10.1111/all.12186] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2013] [Indexed: 01/28/2023]
Abstract
Background Hereditary angioedema (HAE), caused by deficiency in C1-inhibitor (C1-INH), leads to unpredictable edema of subcutaneous tissues with potentially fatal complications. As surgery can be a trigger for edema episodes, current guidelines recommend preoperative prophylaxis with C1-INH or attenuated androgens in patients with HAE undergoing surgery. However, the risk of an HAE attack in patients without prophylaxis has not been quantified. Objectives This analysis examined rates of perioperative edema in patients with HAE not receiving prophylaxis. Methods This was a retrospective analysis of records of randomly selected patients with HAE type I or II treated at the Frankfurt Comprehensive Care Centre. These were examined for information about surgical procedures and the presence of perioperative angioedema. Results A total of 331 patients were included; 247 underwent 700 invasive procedures. Of these procedures, 335 were conducted in 144 patients who had not received prophylaxis at the time of surgery. Categories representing significant numbers of procedures were abdominal (n = 113), ENT (n = 71), and gynecological (n = 58) procedures. The rate of documented angioedema without prophylaxis across all procedures was 5.7%; in 24.8% of procedures, the presence of perioperative angioedema could not be excluded, leading to a maximum potential risk of 30.5%. Predictors of perioperative angioedema could not be identified. Conclusion The risk of perioperative angioedema in patients with HAE type I or II without prophylaxis undergoing surgical procedures ranged from 5.7% to 30.5% (CI 3.5–35.7%). The unpredictability of HAE episodes supports current international treatment recommendations to consider short-term prophylaxis for all HAE patients undergoing surgery.
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Affiliation(s)
- E. Aygören‐Pürsün
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
| | - I. Martinez Saguer
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
| | - W. Kreuz
- Internationales Forschungsinstitut für Gerinnungsstörungen und Immundefekte Mörfelden‐Walldorf Germany
| | - T. Klingebiel
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
| | - D. Schwabe
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
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Castelli R, Zanichelli A, Cicardi M, Cugno M. Acquired C1-inhibitor deficiency and lymphoproliferative disorders: a tight relationship. Crit Rev Oncol Hematol 2013; 87:323-32. [PMID: 23490322 DOI: 10.1016/j.critrevonc.2013.02.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/11/2013] [Accepted: 02/14/2013] [Indexed: 11/18/2022] Open
Abstract
Angioedema due to the acquired deficiency of C1-inhibitor is a rare disease known as acquired angioedema (AAE), which was first described in a patient with high-grade lymphoma and is frequently associated with lymphoproliferative diseases, including expansion of B cell clones producing anti-C1-INH autoantibodies, monoclonal gammopathy of uncertain significance (MGUS) and non-Hodgkin lymphoma (NHL). AAE is clinically similar to hereditary angioedema (HAE), and is characterized by recurrent episodes of sub-cutaneous and sub-mucosal edema. It may affect the face, tongue, extremities, trunk and genitals. The involvement of the gastrointestinal tract causes bowel sub-occlusion with severe pain, vomiting and diarrhea, whereas laryngeal edema can be life-threatening. Unlike those with HAE, AAE patients usually have late-onset symptoms, do not have a family history of angioedema and present variable response to treatment due to the hyper-catabolism of C1-inhibitor. Reduced C1-inhibitor function leads to activation of the classic complement pathway with its consumption and activation of the contact system leading to the generation of the vasoactive peptide bradykinin, which increases vascular permeability and induces angioedema. Lymphoprolipherative diseases and AAE are tightly linked with either angioedema or limphoprolyferation being the first symptom. Experimental data indicate that neoplastic tissue and/or anti-C1-inhibitor antibodies induce C1-inhibitor consumption, and this is further supported by the observation that cytotoxic treatment of the lymphoproliferative diseases associated with AAE variably reverses the complement impairment and leads to a clinical improvement in angioedema symptoms.
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Affiliation(s)
- Roberto Castelli
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, Italy
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Farkas H, Varga L. Human Plasma-Derived, Nanofiltered, C1-Inhibitor Concentrate (Cinryze®), a Novel Therapeutic Alternative for the Management of Hereditary Angioedema Resulting from C1-Inhibitor Deficiency. Biol Ther 2012; 2:2. [PMID: 24490128 DOI: 10.1007/s13554-012-0002-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Indexed: 01/18/2023]
Abstract
Hereditary angioedema resulting from the deficiency of the C1 inhibitor (HAE-C1-INH) is a rare, but potentially life-threatening disorder characterized by paroxysmal episodes of subcutaneous or submucosal edema. Early diagnosis is essential. Management is aimed at the prompt elimination of full-fledged attacks, as well as at the prevention of edematous episodes. The most straightforward means for therapy is supplementation with the deficient C1-INH protein. Placebo-controlled and open clinical studies have established that nanofiltered, human C1-INH concentrate, Cinryze® (ViroPharma Inc., Exton, PA, USA) (C1-INHCi), administered in 1,000 U doses is an effective and safe remedy for edematous episodes of HAE-C1-INH, regardless of the localization of the attack. Clinical manifestations rapidly improve and then resolve completely following treatment with this medicinal product. Additionally, C1-INHCi is also appropriate for pre-procedural or for routine prophylaxis. The administration of 1,000 U C1-INHCi before the (dental, surgical, or interventional diagnostic) procedure reduced the incidence of edematous episodes compared with placebo, and this reduction proved significant during routine prophylaxis with the administration of this dose every 3–4 days. Relapses did not occur, and repeated dosing had no influence on the efficacy of the preparation. Patients also tolerated treatment with C1-INHCi well. The safety of this preparation was confirmed by the absence of viral transmission as well as by the lack of antibody formation against C1-INH during treatment. Nowadays, C1-INHCi for intravenous use is the only medicinal product indicated both for the prevention and management of edematous attacks.
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Farkas H, Varga L. Ecallantide is a novel treatment for attacks of hereditary angioedema due to C1 inhibitor deficiency. Clin Cosmet Investig Dermatol 2011; 4:61-8. [PMID: 21760740 PMCID: PMC3133501 DOI: 10.2147/ccid.s10322] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Indexed: 11/23/2022]
Abstract
Hereditary angioedema (HAE) resulting from the deficiency of the C1 inhibitor protein is a rare disease, characterized by paroxysms of edema formation in the subcutis and in the submucosa. Edema can cause obstruction of the upper airway, which may lead to suffocation. Prompt elimination of edema is necessary to save patients from this life-threatening condition. Essentially, these edematous attacks are related to the activation of the kinin-kallikrein system and the consequent release of bradykinin. Ecallantide (known as DX-88 previously), a potent and specific inhibitor of plasma kallikrein is an innovative medicinal product. This is the only agent approved recently by the FDA for all localizations of edematous HAE attacks. Its advantages include no risk of viral contamination, high selectivity, very rapid onset of action, good tolerability, and straightforward subcutaneous administration. Owing to the risk of anaphylaxis, ecallantide should be administered by a health care professional. A postmarketing survey to improve risk-assessment and risk-minimization has been launched. The results of these studies may lead to the approval of ecallantide for self-administration.
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Affiliation(s)
- Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
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