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Beard N, Frese M, Smertina E, Mere P, Katelaris C, Mills K. Interventions for the long-term prevention of hereditary angioedema attacks. Cochrane Database Syst Rev 2022; 11:CD013403. [PMID: 36326435 PMCID: PMC9632406 DOI: 10.1002/14651858.cd013403.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a serious and potentially life-threatening condition that causes acute attacks of swelling, pain and reduced quality of life. People with Type I HAE (approximately 80% of all HAE cases) have insufficient amounts of C1 esterase inhibitor (C1-INH) protein; people with Type II HAE (approximately 20% of all cases) may have normal C1-INH concentrations, but, due to genetic mutations, these do not function properly. A few people, predominantly females, experience HAE despite having normal C1-INH levels and C1-INH function (rare Type III HAE). Several new drugs have been developed to treat acute attacks and prevent recurrence of attacks. There is currently no systematic review and meta-analysis that included all preventive medications for HAE. OBJECTIVES To assess the benefits and harms of interventions for the long-term prevention of HAE attacks in people with Type I, Type II or Type III HAE. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 3 August 2021. SELECTION CRITERIA We included randomised controlled trials in children or adults with HAE that used medications to prevent HAE attacks. The comparators could be placebo or active comparator, or both; approved and experimental drug trials were eligible for inclusion. There were no restrictions on dose, frequency or intensity of treatment. The minimum length of four weeks of treatment was required for inclusion; this criterion excluded the acute treatment of HAE attacks. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. HAE attacks (number of attacks per person, per population) and change in number of HAE attacks; 2. mortality and 3. serious adverse events (e.g. hepatic dysfunction, hepatic toxicity and deleterious changes in blood tests). Our secondary outcomes were 4. quality of life; 5. severity of breakthrough attacks; 6. disability and 7. adverse events (e.g. weight gain, mild psychological changes and body hair). We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We identified 15 studies (912 participants) that met the inclusion criteria. The studies included people with Type I and II HAE. The studies investigated avoralstat, berotralstat, subcutaneous C1-INH, plasma-derived C1-INH, nanofiltered C1-INH, recombinant human C1-INH, danazol, and lanadelumab for the prevention of HAE attacks. We did not find any studies on the use of tranexamic acid for prevention of HAE attacks. All drugs except avoralstat reduced the number of HAE attacks compared with placebo. For breakthrough attacks that occurred despite prophylactic treatment, intravenous and subcutaneous forms of C1-INH and lanadelumab reduced attack severity. It is not known whether other drugs have a similar effect, as the severity of breakthrough attacks in people taking drugs other than C1-INH and lanadelumab was not reported. For quality of life, avoralstat, berotralstat, C1-INH (all forms) and lanadelumab increased quality of life compared with placebo; there were no data for danazol. Four studies reported on changes in disability during treatment with C1-INH, berotralstat and lanadelumab; all three drugs decreased disability compared with placebo. Adverse events, including serious adverse events, did not occur at a rate higher than placebo. However, serious adverse event data and other adverse event data were not available for danazol, which prevented us from drawing conclusions about the absolute or relative safety of this drug. No deaths were reported in the included studies. The analysis was limited by the small number of studies, the small number of participants in each study and the lack of data on older drugs, therefore the certainty of the evidence is low. Given the rarity of HAE, it is not surprising that drugs were rarely directly compared, which does not allow conclusions on the comparative efficacy of the various drugs for people with HAE. Finally, we did not identify any studies that included people with Type III HAE. Therefore, we cannot draw any conclusions about the efficacy or safety of any drug in people with this form of HAE. AUTHORS' CONCLUSIONS The available data suggest that berotralstat, C1-INH (subcutaneous, plasma-derived, nanofiltered and recombinant), danazol and lanadelumab are effective in lowering the risk or incidence (or both) of HAE attacks. In addition, C1-INH and lanadelumab decrease the severity of breakthrough attacks (data for other drugs were not available). Avoralstat, berotralstat, C1-INH (all forms) and lanadelumab increase quality of life and do not increase the risk of adverse events, including serious adverse events. It is possible that danazol, subcutaneous C1-INH and recombinant human C1-INH are more effective than berotralstat and lanadelumab in reducing the risk of breakthrough attacks, but the small number of studies and the small size of the studies means that the certainty of the evidence is low. This and the lack of head-to-head trials prevented us from drawing firm conclusions on the relative efficacy of the drugs.
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Affiliation(s)
- Nicole Beard
- Faculty of Science and Technology, University of Canberra, Bruce, Australia
| | - Michael Frese
- Faculty of Science and Technology, University of Canberra, Bruce, Australia
| | - Elena Smertina
- Faculty of Science and Technology, University of Canberra, Bruce, Australia
| | - Peter Mere
- Department of Mathematics and Statistics, Macquarie University, Macquarie Park, Australia
| | - Constance Katelaris
- Department of Medicine, Campbelltown Hospital and Western Sydney University, Campbelltown, Australia
| | - Kerry Mills
- Faculty of Science and Technology, University of Canberra, Bruce, Australia
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Maurer M, Magerl M, Betschel S, Aberer W, Ansotegui IJ, Aygören-Pürsün E, Banerji A, Bara NA, Boccon-Gibod I, Bork K, Bouillet L, Boysen HB, Brodszki N, Busse PJ, Bygum A, Caballero T, Cancian M, Castaldo AJ, Cohn DM, Csuka D, Farkas H, Gompels M, Gower R, Grumach AS, Guidos-Fogelbach G, Hide M, Kang HR, Kaplan AP, Katelaris CH, Kiani-Alikhan S, Lei WT, Lockey RF, Longhurst H, Lumry W, MacGinnitie A, Malbran A, Martinez Saguer I, Matta Campos JJ, Nast A, Nguyen D, Nieto-Martinez SA, Pawankar R, Peter J, Porebski G, Prior N, Reshef A, Riedl M, Ritchie B, Sheikh FR, Smith WB, Spaeth PJ, Stobiecki M, Toubi E, Varga LA, Weller K, Zanichelli A, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema – The 2021 revision and update. World Allergy Organ J 2022; 15:100627. [PMID: 35497649 PMCID: PMC9023902 DOI: 10.1016/j.waojou.2022.100627] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/05/2021] [Accepted: 12/21/2021] [Indexed: 12/21/2022] Open
Abstract
Hereditary Angioedema (HAE) is a rare and disabling disease for which early diagnosis and effective therapy are critical. This revision and update of the global WAO/EAACI guideline on the diagnosis and management of HAE provides up-to-date guidance for the management of HAE. For this update and revision of the guideline, an international panel of experts reviewed the existing evidence, developed 28 recommendations, and established consensus by an online DELPHI process. The goal of these recommendations and guideline is to help physicians and their patients in making rational decisions in the management of HAE with deficient C1-inhibitor (type 1) and HAE with dysfunctional C1-inhibitor (type 2), by providing guidance on common and important clinical issues, such as: 1) How should HAE be diagnosed? 2) When should HAE patients receive prophylactic on top of on-demand treatment and what treatments should be used? 3) What are the goals of treatment? 4) Should HAE management be different for special HAE patient groups such as children or pregnant/breast feeding women? 5) How should HAE patients monitor their disease activity, impact, and control? It is also the intention of this guideline to help establish global standards for the management of HAE and to encourage and facilitate the use of recommended diagnostics and therapies for all patients.
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Oral Surgery Procedures in a Patient Affected by Hereditary Angioedema Type I. Case Rep Dent 2022; 2022:6602411. [PMID: 35132366 PMCID: PMC8817880 DOI: 10.1155/2022/6602411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/19/2022] [Indexed: 11/17/2022] Open
Abstract
Hereditary Angioedema (HAE) is a rare disease characterized by a deficiency or a reduced function of the plasma protein C1 esterase inhibitor (C1-INH), which is involved in the downregulation of several inflammatory pathways. Patients affected by HAE suffer from episodic swellings of subcutaneous or submucosal tissues. Swellings can be caused by stress or dental and surgical procedures and can be life-threatening if the airways are involved. We have reported a clinical case of a patient affected by HAE type I who underwent oral surgery procedures under a short-term prophylaxis with C1-INH plasma-derived concentrate. The patient underwent a cyst removal, multiple tooth extractions, and an excisional biopsy with a prophylaxis with C1-INH plasma-derived concentrate and was hospitalized for 36 hours after the surgery to be monitored for possible HAE attacks. During the hospitalization, the patient did not show signs of swelling nor of HAE attacks. At 14 and 28 days after the surgery, the patient presented a good surgical healing. The prophylactic intravenous infusion of C1-INH concentrate was successful in preventing acute HAE attacks after oral surgery procedures.
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Maurer M, Magerl M, Aygören-Pürsün E, Bork K, Farkas H, Longhurst H, Kiani-Alikhan S, Bouillet L, Boccon-Gibod I, Cancian M, Zanichelli A, Launay D. Attenuated androgen discontinuation in patients with hereditary angioedema: a commented case series. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:4. [PMID: 35027083 PMCID: PMC8759255 DOI: 10.1186/s13223-021-00644-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/26/2021] [Indexed: 11/16/2022]
Abstract
Background Hereditary angioedema (HAE) is characterized by potentially severe and life-threatening attacks of localized swelling. Prophylactic therapies are available, including attenuated androgens. Efficacy of attenuated androgens has not been assessed in large, randomized, placebo-controlled trials and can be associated with frequent, and sometimes severe, side effects. As better tolerated targeted therapies become available, attenuated androgen withdrawal is increasingly considered by physicians and their patients with HAE. Attenuated androgens withdrawal has not been systematically studied in HAE, although examination of other disorders indicates that attenuated androgen withdrawal may result in mood disturbances and flu-like symptoms. Standardized protocols for attenuated androgen discontinuation that continue to provide control of attacks while limiting potential attenuated androgen withdrawal symptoms are not established as the outcomes of different withdrawal strategies have not been compared. We aim to describe the challenges of attenuated androgen discontinuation in patients with HAE and how these may continue into the post-androgen period. Case presentation We present a retrospective case series of 10 patients with confirmed type I HAE who have discontinued prophylactic treatment with attenuated androgens. The most common reason for attenuated androgen discontinuation was side effects. Attenuated androgens were either immediately withdrawn, tapered and/or overlapped with another treatment. The major challenge of discontinuation was the management of an increased frequency and severity of HAE attacks in some patients. Conclusions Healthcare teams need to undertake careful planning and monitoring after attenuated androgens discontinuation, and modify treatment strategies if HAE control is destabilized with an increased number of attacks. Discontinuation of attenuated androgens is definitively an option in an evolving HAE treatment landscape, and outcomes can be favourable with additional patient support and education. Supplementary Information The online version contains supplementary material available at 10.1186/s13223-021-00644-0.
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Affiliation(s)
- Marcus Maurer
- Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Angioedema Center of Reference and Excellence (ACARE), Dermatological Allergology, Allergie-Centrum-Charité, Berlin, Germany.
| | - Markus Magerl
- Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Angioedema Center of Reference and Excellence (ACARE), Dermatological Allergology, Allergie-Centrum-Charité, Berlin, Germany
| | | | - Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Mainz, Germany
| | - Henriette Farkas
- Hungarian Angioedema Center of Excellence and Reference (ACARE), Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Hilary Longhurst
- Auckland District Health Board and University of Auckland, Auckland, New Zealand
| | - Sorena Kiani-Alikhan
- Angioedema Center of Reference and Excellence (ACARE), Barts Health NHS Trust, London, UK
| | - Laurence Bouillet
- French National Center of Reference and Excellence for Angioedema, Grenoble Alpes University Hospital, Grenoble, France
| | - Isabelle Boccon-Gibod
- French National Center of Reference and Excellence for Angioedema, Grenoble Alpes University Hospital, Grenoble, France
| | - Mauro Cancian
- Italian Network for Hereditary and Acquired Angioedema (ITACA), Interregional Center of Reference for Angioedema, University of Padova, Padova, Italy
| | - Andrea Zanichelli
- Italian National Center of Reference for Angiodema, Department of Internal Medicine, ASST Fatebenefratelli Sacco, Ospedale Luigi Sacco - Università degli Studi di Milano, Milan, Italy
| | - David Launay
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, French National Center of Reference for Angioedema, 59000, Lille, France
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Maurer M, Magerl M, Betschel S, Aberer W, Ansotegui IJ, Aygören‐Pürsün E, Banerji A, Bara N, Boccon‐Gibod I, Bork K, Bouillet L, Boysen HB, Brodszki N, Busse PJ, Bygum A, Caballero T, Cancian M, Castaldo A, Cohn DM, Csuka D, Farkas H, Gompels M, Gower R, Grumach AS, Guidos‐Fogelbach G, Hide M, Kang H, Kaplan AP, Katelaris C, Kiani‐Alikhan S, Lei W, Lockey R, Longhurst H, Lumry WB, MacGinnitie A, Malbran A, Martinez Saguer I, Matta JJ, Nast A, Nguyen D, Nieto‐Martinez SA, Pawankar R, Peter J, Porebski G, Prior N, Reshef A, Riedl M, Ritchie B, Rafique Sheikh F, Smith WR, Spaeth PJ, Stobiecki M, Toubi E, Varga LA, Weller K, Zanichelli A, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema-The 2021 revision and update. Allergy 2022; 77:1961-1990. [PMID: 35006617 DOI: 10.1111/all.15214] [Citation(s) in RCA: 131] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 12/11/2022]
Abstract
Hereditary angioedema (HAE) is a rare and disabling disease for which early diagnosis and effective therapy are critical. This revision and update of the global WAO/EAACI guideline on the diagnosis and management of HAE provides up-to-date guidance for the management of HAE. For this update and revision of the guideline, an international panel of experts reviewed the existing evidence, developed 28 recommendations, and established consensus by an online DELPHI process. The goal of these recommendations and guideline is to help physicians and their patients in making rational decisions in the management of HAE with deficient C1 inhibitor (type 1) and HAE with dysfunctional C1 inhibitor (type 2), by providing guidance on common and important clinical issues, such as: (1) How should HAE be diagnosed? (2) When should HAE patients receive prophylactic on top of on-demand treatment and what treatments should be used? (3) What are the goals of treatment? (4) Should HAE management be different for special HAE patient groups such as children or pregnant/breast-feeding women? and (5) How should HAE patients monitor their disease activity, impact, and control? It is also the intention of this guideline to help establish global standards for the management of HAE and to encourage and facilitate the use of recommended diagnostics and therapies for all patients.
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Affiliation(s)
- Marcus Maurer
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | - Markus Magerl
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | | | - Werner Aberer
- Department of Dermatology Medical University of Graz Graz Austria
| | | | - Emel Aygören‐Pürsün
- Center for Children and Adolescents University Hospital Frankfurt Frankfurt Germany
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology Massachusetts General Hospital Boston Massachusetts USA
| | - Noémi‐Anna Bara
- Romanian Hereditary Angioedema Expertise CentreMediquest Clinical Research Center Sangeorgiu de Mures Romania
| | - Isabelle Boccon‐Gibod
- National Reference Center for Angioedema (CREAK) Angioedema Center of Reference and Excellence (ACARE) Grenoble Alpes University Hospital Grenoble France
| | - Konrad Bork
- Department of Dermatology University Medical CenterJohannes Gutenberg University Mainz Germany
| | - Laurence Bouillet
- National Reference Center for Angioedema (CREAK) Angioedema Center of Reference and Excellence (ACARE) Grenoble Alpes University Hospital Grenoble France
| | | | - Nicholas Brodszki
- Department of Pediatric Immunology Childrens HospitalSkåne University Hospital Lund Sweden
| | | | - Anette Bygum
- Clinical Institute University of Southern Denmark Odense Denmark
- Department of Clinical Genetics Odense University Hospital Odense Denmark
| | - Teresa Caballero
- Allergy Department Hospital Universitario La PazIdiPaz, CIBERER U754 Madrid Spain
| | - Mauro Cancian
- Department of Systems Medicine University Hospital of Padua Padua Italy
| | | | - Danny M. Cohn
- Department of Vascular Medicine Amsterdam UMC/University of Amsterdam Amsterdam The Netherlands
| | - Dorottya Csuka
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Henriette Farkas
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Mark Gompels
- Clinical Immunology North Bristol NHS Trust Bristol UK
| | - Richard Gower
- Marycliff Clinical ResearchPrinciple Research Solutions Spokane Washington USA
| | | | | | - Michihiro Hide
- Department of Dermatology Hiroshima Citizens Hospital Hiroshima Japan
- Department of Dermatology Hiroshima University Hiroshima Japan
| | - Hye‐Ryun Kang
- Department of Internal Medicine Seoul National University College of Medicine Seoul Korea
| | - Allen Phillip Kaplan
- Division of Pulmonary, Critical Care, Allergy and Immunology Medical university of South Carolina Charleston South Carolina USA
| | - Constance Katelaris
- Department of Medicine Campbelltown Hospital and Western Sydney University Sydney NSW Australia
| | | | - Wei‐Te Lei
- Division of Allergy, Immunology, and Rheumatology Department of Pediatrics Mackay Memorial Hospital Hsinchu Taiwan
| | - Richard Lockey
- Division of Allergy and Immunology Department of Internal Medicine Morsani College of MedicineUniversity of South Florida Tampa Florida USA
| | - Hilary Longhurst
- Department of Immunology Auckland District Health Board and Department of MedicineUniversity of Auckland Auckland New Zealand
| | - William B. Lumry
- Internal Medicine Allergy Division University of Texas Health Science Center Dallas Texas USA
| | - Andrew MacGinnitie
- Division of Immunology Department of Pediatrics Boston Children's HospitalHarvard Medical School Boston Massachusetts USA
| | - Alejandro Malbran
- Unidad de Alergia, Asma e Inmunología Clínica Buenos Aires Argentina
| | | | | | - Alexander Nast
- Department of Dermatology, Venereology and Allergology Division of Evidence‐Based Medicine Charité ‐ Universitätsmedizin Berlincorporate member of Free University of BerlinHumboldt University of Berlin, and Berlin Institute of Health Berlin Germany
| | - Dinh Nguyen
- Respiratory, Allergy and Clinical Immunology Unit Internal Medicine Department Vinmec Healthcare System College of Health SciencesVinUniversity Hanoi Vietnam
| | | | - Ruby Pawankar
- Department of Pediatrics Nippon Medical School Tokyo Japan
| | - Jonathan Peter
- Division of Allergy and Clinical Immunology University of Cape Town Cape Town South Africa
- Allergy and Immunology Unit University of Cape Town Lung Institute Cape Town South Africa
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology Jagiellonian University Medical College Krakow Poland
| | - Nieves Prior
- Allergy Hospital Universitario Severo Ochoa Madrid Spain
| | - Avner Reshef
- Angioderma CenterBarzilai University Medical Center Ashkelon Israel
| | - Marc Riedl
- Division of Rheumatology, Allergy and Immunology University of California San Diego La Jolla California USA
| | - Bruce Ritchie
- Departments of Medicine and Medical Oncology University of Alberta Edmonton AB Canada
| | - Farrukh Rafique Sheikh
- Section of Adult Allergy & Immunology Department of Medicine King Faisal Specialist Hospital & Research Centre Riyadh Saudi Arabia
| | - William R. Smith
- Clinical Immunology and Allergy Royal Adelaide Hospital Adelaide SA Australia
| | - Peter J. Spaeth
- Institute of PharmacologyUniversity of Bern Bern Switzerland
| | - Marcin Stobiecki
- Department of Clinical and Environmental Allergology Jagiellonian University Medical College Krakow Poland
| | - Elias Toubi
- Division of Allergy and Clinical Immunology Bnai Zion Medical CenterAffiliated with Rappaport Faculty of MedicineTechnion‐Israel Institute of Technology Haifa Israel
| | - Lilian Agnes Varga
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Karsten Weller
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | - Andrea Zanichelli
- Department of Internal Medicine ASST Fatebenefratelli Sacco Ospedale Luigi Sacco‐University of Milan Milan Italy
| | - Yuxiang Zhi
- Department of Allergy and Clinical Immunology Bejing Union Medical College Hospital & Chinese Academy of Medical Sciences Bejing China
| | - Bruce Zuraw
- University of California, San Diego San Diego California USA
| | - Timothy Craig
- Departments of Medicine and Pediatrics Penn State University Hershey Pennsylvania USA
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Sugar Matters: Improving In Vivo Clearance Rate of Highly Glycosylated Recombinant Plasma Proteins for Therapeutic Use. Pharmaceuticals (Basel) 2021; 14:ph14010054. [PMID: 33440845 PMCID: PMC7826800 DOI: 10.3390/ph14010054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 11/17/2022] Open
Abstract
Correct glycosylation of proteins is essential for production of therapeutic proteins as glycosylation is important for protein solubility, stability, half-life and immunogenicity. The heavily glycosylated plasma protein C1-inhibitor (C1-INH) is used in treatment of hereditary angioedema attacks. In this study, we used C1-INH as a model protein to propose an approach to develop recombinant glycoproteins with the desired glycosylation. We produced fully functional recombinant C1-INH in Chinese hamster ovary (CHO) cells. In vivo we observed a biphasic clearance, indicating different glycosylation forms. N-glycan analysis with mass spectrometry indeed demonstrated heterogeneous glycosylation for recombinant C1-INH containing terminal galactose and terminal sialic acid. Using a Ricinus Communis Agglutinin I (RCA120) column, we could reduce the relative abundance of terminal galactose and increase the relative abundance of terminal sialic acid. This resulted in a fully active protein with a similar in vivo clearance rate to plasmaderived C1-INH. In summary, we describe the development of a recombinant human glycoprotein using simple screening tools to obtain a product that is similar in function and in vivo clearance rate to its plasma-derived counterpart. The approach used here is of potential use in the development of other therapeutic recombinant human glycoproteins.
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Masa I, Casado-Sánchez C, Crespo-Lora V, Ballestín A. Effects of Ischemic Preconditioning and C1 Esterase Inhibitor Administration following Ischemia-Reperfusion Injury in a Rat Skin Flap Model. J Reconstr Microsurg 2020; 37:242-248. [PMID: 32971547 DOI: 10.1055/s-0040-1717102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Ischemia-reperfusion (I/R) injury is a serious condition that can affect the success rate of microsurgical reconstructions of ischemic amputated limbs and complex tissue defects requiring free tissue transfers. The purpose of this study was to evaluate the effects of ischemic preconditioning (IPC) and C1 esterase inhibitor (C1-Inh) intravenous administration following I/R injury in a rat skin flap model. METHODS Superficial caudal epigastric skin flaps (3 cm × 7 cm) were performed on 50 Wistar rats that were randomly divided into five groups. Ischemia was not induced in the control group. All other flaps underwent 8 hours of ischemia prior to revascularization: I/R control group (8-hour ischemia), IPC group (preconditioning protocol + 8-hour ischemia), C1-Inh group (8-hour ischemia + C1-Inh), and IPC + C1-Inh group (preconditioning protocol + 8-hour ischemia + C1-Inh). Survival areas were macroscopically assessed after 1 week of surgery, and histopathological and biochemical evaluations were also measured. RESULTS There were no significant differences in flap survival between the treatment groups that were suffering 8 hours of ischemia and the control group. A significant increase in neovascularization and lower edema formation were observed in the IPC group compared with that in the I/R group. Biochemical parameters did not show any significant differences. CONCLUSION Intravenous administration of C1-Inh did not significantly modulate I/R-related damage in this experimental model, but further research is needed. On the other hand, IPC reduces tissue damage and improves neovascularization, confirming its potential protective effects in skin flaps following I/R injury.
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Affiliation(s)
- Inmaculada Masa
- Department of Plastic and Reconstructive Surgery, University Hospital Clínico San Carlos, Madrid, Spain
| | - César Casado-Sánchez
- Department of Plastic and Reconstructive Surgery, University Hospital La Paz, Madrid, Spain
| | | | - Alberto Ballestín
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
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Longhurst H, Farkas H. Biological therapy in hereditary angioedema: transformation of a rare disease. Expert Opin Biol Ther 2020; 20:493-501. [PMID: 31994957 DOI: 10.1080/14712598.2020.1724280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Hereditary angioedema, a disabling condition, with high mortality when untreated, is caused by C1 inhibitor deficiency and other regulatory disorders of bradykinin production or metabolism. This review covers the remarkable progress made in biological therapies for this rare disorder.Areas covered: Over the past 10 years, several evidence-based parenteral treatments have been licensed, including two plasma-derived C1 inhibitor replacement therapies and one recombinant C1 inhibitor replacement for acute treatment of angioedema attacks and synthetic peptides for inhibition of kallikrein or bradykinin B2 receptors, with oral small molecule treatments currently in clinical trial. Moreover, recent advances in prophylaxis by subcutaneous C1 inhibitor to restore near-normal plasma function or by humanized antibody inhibition of kallikrein have resulted in freedom from symptoms for a high proportion of those treated.Expert opinion: This plethora of treatment possibilities has come about as a result of recent scientific advances. Collaboration between patient groups, basic and clinical scientists, physicians, nurses, and the pharmaceutical industry has underpinned this translation of basic science into treatments and protocols. These in their turn have brought huge improvements in prognosis, quality of life and economic productivity to patients, their families, and the societies in which they live.
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Affiliation(s)
- Hilary Longhurst
- Department of Clinical Immunology, Addenbrooke's Hospital, Cambridge and University College Hospitals, London, UK
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
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Abstract
Angioedema is a localized swelling of the skin and submucosal tissues and is generally benign and self-limiting. However, it can be life threatening if angioedema involves the upper airway, resulting in airway obstruction. Airway protection would be critical and lifesaving in patients with angioedema irrespective of the underlying etiology. Detailed history and physical examination can help identify the underlying mechanism of angioedema in an individual patient (ie, mast-cell versus bradykinin-mediated angioedema). Treatment of angioedema depends on the underlying etiology. Mast cell-mediated angioedema is generally responsive to steroids, antihistamines, and epinephrine (when indicated), unlike bradykinin-mediated disease. [Pediatr Ann. 2019;48(12):e473-e478.].
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Betschel S, Badiou J, Binkley K, Borici-Mazi R, Hébert J, Kanani A, Keith P, Lacuesta G, Waserman S, Yang B, Aygören-Pürsün E, Bernstein J, Bork K, Caballero T, Cicardi M, Craig T, Farkas H, Grumach A, Katelaris C, Longhurst H, Riedl M, Zuraw B, Berger M, Boursiquot JN, Boysen H, Castaldo A, Chapdelaine H, Connors L, Fu L, Goodyear D, Haynes A, Kamra P, Kim H, Lang-Robertson K, Leith E, McCusker C, Moote B, O'Keefe A, Othman I, Poon MC, Ritchie B, St-Pierre C, Stark D, Tsai E. The International/Canadian Hereditary Angioedema Guideline. Allergy Asthma Clin Immunol 2019; 15:72. [PMID: 31788005 PMCID: PMC6878678 DOI: 10.1186/s13223-019-0376-8] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/10/2019] [Indexed: 12/20/2022] Open
Abstract
This is an update to the 2014 Canadian Hereditary Angioedema Guideline with an expanded scope to include the management of hereditary angioedema (HAE) patients worldwide. It is a collaboration of Canadian and international HAE experts and patient groups led by the Canadian Hereditary Angioedema Network. The objective of this guideline is to provide evidence-based recommendations, using the GRADE system, for the management of patients with HAE. This includes the treatment of attacks, short-term prophylaxis, long-term prophylaxis, and recommendations for self-administration, individualized therapy, quality of life, and comprehensive care. New to the 2019 version of this guideline are sections covering the diagnosis and recommended therapies for acute treatment in HAE patients with normal C1-INH, as well as sections on pregnant and paediatric patients, patient associations and an HAE registry. Hereditary angioedema results in random and often unpredictable attacks of painful swelling typically affecting the extremities, bowel mucosa, genitals, face and upper airway. Attacks are associated with significant functional impairment, decreased health-related quality of life, and mortality in the case of laryngeal attacks. Caring for patients with HAE can be challenging due to the complexity of this disease. The care of patients with HAE in Canada, as in many countries, continues to be neither optimal nor uniform. It lags behind some other countries where there are more organized models for HAE management, and greater availability of additional licensed therapeutic options. It is anticipated that providing this guideline to caregivers, policy makers, patients, and advocates will not only optimize the management of HAE, but also promote the importance of individualized care. The primary target users of this guideline are healthcare providers who are managing patients with HAE. Other healthcare providers who may use this guideline are emergency and intensive care physicians, primary care physicians, gastroenterologists, dentists, otolaryngologists, paediatricians, and gynaecologists who will encounter patients with HAE and need to be aware of this condition. Hospital administrators, insurers and policy makers may also find this guideline helpful.
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Affiliation(s)
| | | | | | | | - Jacques Hébert
- 4Department of Medicine, Laval University, Quebec City, QC Canada
| | - Amin Kanani
- 5Division of Allergy and Clinical Immunology, St. Paul's Hospital, Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Paul Keith
- 6Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Gina Lacuesta
- 7Department of Medicine, Dalhousie University, Halifax, NS Canada
| | - Susan Waserman
- 6Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Bill Yang
- 8University of Ottawa Medical School, Ottawa, ON Canada
| | | | - Jonathan Bernstein
- 10Department of Internal Medicine, University of Cincinnati, Cincinnati, OH USA
| | - Konrad Bork
- 11Department of Dermatology, University Hospital of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | | | - Marco Cicardi
- Department of Internal Medicine, Universita degli Studi di Milano, Ospedale L. Sacco, Milan, Italy
| | - Timothy Craig
- 14Departments of Medicine and Pediatrics, Penn State University, Hershey, PA USA
| | - Henriette Farkas
- 153rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Anete Grumach
- Laboratory of Clinical Immunology, Faculdade de Medicine ABC, Sao Paulo, Brazil
| | - Connie Katelaris
- 17Campbelltown Hospital, Western Sydney University, New South Wales, Australia
| | - Hilary Longhurst
- 18Addenbrooke's Hospital, Cambridge and University College Hospital, London, England UK
| | - Marc Riedl
- 19University of California, San Diego, San Diego, CA USA
| | - Bruce Zuraw
- 19University of California, San Diego, San Diego, CA USA
| | | | - Jean-Nicolas Boursiquot
- 21Division of Allergy and Clinical Immunology, Centre hospitalier universitaire de Québec, Laval University, Quebec City, QC Canada
| | | | | | - Hugo Chapdelaine
- 24Institut de recherches cliniques de Montréal, Montreal, QC Canada
| | - Lori Connors
- 7Department of Medicine, Dalhousie University, Halifax, NS Canada
| | - Lisa Fu
- Toronto Allergy Group, Toronto, ON Canada
| | - Dawn Goodyear
- 26Southern Alberta Rare Blood and Bleeding Disorders Program, Foothills Medical Centre, University of Calgary, Calgary, AB Canada
| | - Alison Haynes
- 27Division of Pediatrics, Faculty of Medicine, Memorial University, St John's, NF Canada
| | - Palinder Kamra
- 28Janeway Children's Health and Rehabilitation Centre, Memorial University, St John's, NF Canada
| | - Harold Kim
- 29Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada.,30Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON Canada
| | | | - Eric Leith
- 31Department of Medicine, University of Toronto, Oakville, ON Canada
| | - Christine McCusker
- 32Department of Immunology, McGill University Health Centre, Montreal, QC Canada
| | - Bill Moote
- 33Department of Medicine, Western University, London, ON Canada
| | - Andrew O'Keefe
- 27Division of Pediatrics, Faculty of Medicine, Memorial University, St John's, NF Canada
| | - Ibraheem Othman
- 34College of Medicine, University of Saskatchewan, Regina, SK Canada
| | - Man-Chiu Poon
- 35Departments of Medicine, Pediatrics and Oncology, University of Calgary Cumming School of Medicine, Calgary, AB Canada
| | - Bruce Ritchie
- 36Departments of Medicine and Medical Oncology, University of Alberta, Edmonton, AB Canada
| | | | - Donald Stark
- 38Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Ellie Tsai
- 39Department of Internal Medicine, Queen's University, Kingston, ON Canada
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11
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Maurer M, Magerl M, Ansotegui I, Aygören-Pürsün E, Betschel S, Bork K, Bowen T, Balle Boysen H, Farkas H, Grumach AS, Hide M, Katelaris C, Lockey R, Longhurst H, Lumry WR, Martinez-Saguer I, Moldovan D, Nast A, Pawankar R, Potter P, Riedl M, Ritchie B, Rosenwasser L, Sánchez-Borges M, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema-The 2017 revision and update. Allergy 2018; 73:1575-1596. [PMID: 29318628 DOI: 10.1111/all.13384] [Citation(s) in RCA: 298] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 12/25/2022]
Abstract
Hereditary Angioedema (HAE) is a rare and disabling disease. Early diagnosis and appropriate therapy are essential. This update and revision of the global guideline for HAE provides up-to-date consensus recommendations for the management of HAE. In the development of this update and revision of the guideline, an international expert panel reviewed the existing evidence and developed 20 recommendations that were discussed, finalized and consented during the guideline consensus conference in June 2016 in Vienna. The final version of this update and revision of the guideline incorporates the contributions of a board of expert reviewers and the endorsing societies. The goal of this guideline update and revision is to provide clinicians and their patients with guidance that will assist them in making rational decisions in the management of HAE with deficient C1-inhibitor (type 1) and HAE with dysfunctional C1-inhibitor (type 2). The key clinical questions covered by these recommendations are: (1) How should HAE-1/2 be defined and classified?, (2) How should HAE-1/2 be diagnosed?, (3) Should HAE-1/2 patients receive prophylactic and/or on-demand treatment and what treatment options should be used?, (4) Should HAE-1/2 management be different for special HAE-1/2 patient groups such as pregnant/lactating women or children?, and (5) Should HAE-1/2 management incorporate self-administration of therapies and patient support measures?
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Affiliation(s)
- M. Maurer
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - M. Magerl
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - I. Ansotegui
- Department of Allergy and Immunology; Hospital Quironsalud Bizkaia; Bilbao Spain
| | - E. Aygören-Pürsün
- Center for Children and Adolescents; University Hospital Frankfurt; Frankfurt Germany
| | - S. Betschel
- Division of Clinical Immunology and Allergy; St. Michael's Hospital; University of Toronto; Toronto ON Canada
| | - K. Bork
- Department of Dermatology; Johannes Gutenberg University Mainz; Mainz Germany
| | - T. Bowen
- Department of Medicine and Pediatrics; University of Calgary; Calgary AB Canada
| | | | - H. Farkas
- Hungarian Angioedema Center; 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - A. S. Grumach
- Clinical Immunology; Faculdade de Medicina ABC; São Paulo Brazil
| | - M. Hide
- Department of Dermatology; Hiroshima University; Hiroshima Japan
| | - C. Katelaris
- Department of Medicine; Campbelltown Hospital and Western Sydney University; Sydney NSW Australia
| | - R. Lockey
- Department of Internal Medicine; University of South Florida Morsani College of Medicine; Tampa FL USA
| | - H. Longhurst
- Department of Clinical Biochemistry and Immunology; Addenbrooke's Hospital; Cambridge University Hospitals NHS Foundation Trust; UK
| | - W. R. Lumry
- Department of Internal Medicine; Allergy/Immunology Division; Southwestern Medical School; University of Texas; Dallas TX USA
| | | | - D. Moldovan
- University of Medicine and Pharmacy; Tîrgu Mures Romania
| | - A. Nast
- Berlin Institute of Health; Department of Dermatology, Venereology und Allergy; Division of Evidence based Medicine (dEBM); Corporate Member of Freie Universität Berlin; Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - R. Pawankar
- Department of Pediatrics; Nippon Medical School; Tokyo Japan
| | - P. Potter
- Department of Medicine; University of Cape Town; Cape Town South Africa
| | - M. Riedl
- Department of Medicine; University of California-San Diego; La Jolla CA USA
| | - B. Ritchie
- Division of Hematology; University of Alberta; Edmonton AB Canada
| | - L. Rosenwasser
- Allergy and Immunology Department; University of Missouri at Kansas City School of Medicine; Kansas City MO USA
| | - M. Sánchez-Borges
- Allergy and Clinical Immunology Department; Centro Medico Docente La Trinidad; Caracas Venezuela
| | - Y. Zhi
- Department of Allergy; Peking Union Medical College Hospital and Chinese Academy of Medical Sciences; Beijing China
| | - B. Zuraw
- Department of Medicine; University of California-San Diego; La Jolla CA USA
- San Diego VA Healthcare; San Diego CA USA
| | - T. Craig
- Department of Medicine and Pediatrics; Penn State University; Hershey PA USA
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Efficacy of C1 inhibitor concentrate in hereditary angioedema with C1 inhibitor deficiency: Analysis in a French cohort. Ann Allergy Asthma Immunol 2018; 121:506-508. [PMID: 29964227 DOI: 10.1016/j.anai.2018.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 11/22/2022]
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13
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Longhurst H. Optimum Use of Acute Treatments for Hereditary Angioedema: Evidence-Based Expert Consensus. Front Med (Lausanne) 2018; 4:245. [PMID: 29594115 PMCID: PMC5857575 DOI: 10.3389/fmed.2017.00245] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 12/18/2017] [Indexed: 11/13/2022] Open
Abstract
Acute treatment of hereditary angioedema due to C1 inhibitor deficiency has become available in the last 10 years and has greatly improved patients’ quality of life. Two plasma-derived C1 inhibitors (Berinert and Cinryze), a recombinant C1 inhibitor (Ruconest/Conestat alpha), a kallikrein inhibitor (Ecallantide), and a bradykinin B2 receptor inhibitor (Icatibant) are all effective. Durably good response is maintained over repeated treatments and several years. All currently available prophylactic agents are associated with breakthrough attacks, therefore an acute treatment plan is essential for every patient. Experience has shown that higher doses of C1 inhibitor than previously recommended may be desirable, although only recombinant C1 inhibitor has been subject to full dose–response evaluation. Treatment of early symptoms of an attack, with any licensed therapy, results in milder symptoms, more rapid resolution and shorter duration of attack, compared with later treatment. All therapies have been shown to be well-tolerated, with low risk of serious adverse events. Plasma-derived C1 inhibitors have a reassuring safety record regarding lack of transmission of virus or other infection. Thrombosis has been reported in association with plasma-derived C1 inhibitor in some case series. Ruconest was associated with anaphylaxis in a single rabbit-allergic volunteer, but no further anaphylaxis has been reported in those not allergic to rabbits despite, in a few cases, prior IgE sensitization to rabbit or milk protein. Icatibant is associated with high incidence of local reactions but not with systemic effects. Ecallantide may cause anaphylactoid reactions and is given under supervision. For children and pregnant women, plasma-derived C1 inhibitor has the best evidence of safety and currently remains first-line treatment.
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Affiliation(s)
- Hilary Longhurst
- Honorary Consultant Immunologist, Department of Clinical Biochemistry and Immunology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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14
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Maurer M, Magerl M, Ansotegui I, Aygören-Pürsün E, Betschel S, Bork K, Bowen T, Boysen HB, Farkas H, Grumach AS, Hide M, Katelaris C, Lockey R, Longhurst H, Lumry WR, Martinez-Saguer I, Moldovan D, Nast A, Pawankar R, Potter P, Riedl M, Ritchie B, Rosenwasser L, Sánchez-Borges M, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema – the 2017 revision and update. World Allergy Organ J 2018. [DOI: 10.1186/s40413-017-0180-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
The purpose of this article is to review the current available material pertaining to atopic dermatitis, contact dermatitis, urticaria, and angioedema. This article focuses on each disease process's clinical presentation, diagnosis, and management. Although atopic dermatitis and contact dermatitis are similar, their development is different and can affect a patient's quality of life. Urticaria and angioedema are also similar, but the differentiation of the two processes is crucial in that they have significant morbidity and mortality, each with a different prognosis.
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Affiliation(s)
- Van Nguyen
- Department of Family Medicine, Loma Linda University, 25455 Barton Road, Suite 209B, Loma Linda, CA 92354, USA.
| | - Lauren Simon
- Department of Family Medicine, Loma Linda University, 25455 Barton Road, Suite 209B, Loma Linda, CA 92354, USA
| | - Ecler Jaqua
- Department of Family Medicine, Loma Linda University, 25455 Barton Road, Suite 209B, Loma Linda, CA 92354, USA
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17
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Abstract
Remarkable progress in understanding the pathophysiology and underlying mechanisms of hereditary angioedema has led to the development of effective treatment for this disorder. Progress in three separate areas has catalyzed our understanding of hereditary angioedema. The first is the recognition that HAE type I and type II result from a deficiency in the plasma level of functional C1 inhibitor. This observation has led to a detailed understanding of the SERPING1 mutations responsible for this deficiency as well as the molecular regulation of C1 inhibitor expression and function. The second is that the fundamental cause of swelling is enhanced contact system activation leading to increased generation of bradykinin. Substantial progress has been made in defining the parameters regulating bradykinin generation and catabolism as well as the receptors that transduce the biologic effects of kinins. The third is the understanding that tissue swelling in hereditary angioedema primarily involves the function of endothelial cell adherens junctions. This knowledge is driving increased attention to the role of endothelial biology in determining disease activity in hereditary angioedema. While there has been considerable progress made, large gaps still remain in our knowledge. Important areas that remain poorly understood include the factors that lead to very low plasma functional C1 inhibitor levels, the triggers of contact system activation in hereditary angioedema, and the role of the bradykinin B1 receptor. The phenotypic variability of hereditary angioedema has been extensively documented but never understood. The mechanisms discussed in this chapter likely contribute to this variability. Future progress in understanding these mechanisms should provide new means to improve the diagnosis and treatment of hereditary angioedema.
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Shih AR, Murali MR. Laboratory tests for disorders of complement and complement regulatory proteins. Am J Hematol 2015; 90:1180-6. [PMID: 26437749 DOI: 10.1002/ajh.24209] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 09/30/2015] [Indexed: 12/25/2022]
Abstract
The complement pathway is a cascade of proteases that is involved in immune surveillance and innate immunity, as well as adaptive immunity. Dysfunction of the complement cascade may be mediated by aberrations in the pathways of activation, complement regulatory proteins, or complement deficiencies, and has been linked to a number of hematologic disorders, including paroxysmal noctural hemoglobinuria (PNH), hereditary angioedema (HAE), and atypical hemolytic-uremic syndrome (aHUS). Here, current laboratory tests for disorders of the complement pathway are reviewed, and their utility and limitations in hematologic disorders and systemic diseases are discussed. Current therapeutic advances targeting the complement pathway in treatment of complement-mediated hematologic disorders are also reviewed.
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Affiliation(s)
- Angela R. Shih
- Department of Pathology; Massachusetts General Hospital; Boston Massachusetts 02114
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20
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Nasr IH, Manson AL, Al Wahshi HA, Longhurst HJ. Optimizing hereditary angioedema management through tailored treatment approaches. Expert Rev Clin Immunol 2015; 12:19-31. [PMID: 26496459 DOI: 10.1586/1744666x.2016.1100963] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hereditary angioedema (HAE) is a rare but serious and potentially life threatening autosomal dominant condition caused by low or dysfunctional C1 esterase inhibitor (C1-INH) or uncontrolled contact pathway activation. Symptoms are characterized by spontaneous, recurrent attacks of subcutaneous or submucosal swellings typically involving the face, tongue, larynx, extremities, genitalia or bowel. The prevalence of HAE is estimated to be 1:50,000 without known racial differences. It causes psychological stress as well as significant socioeconomic burden. Early treatment and prevention of attacks are associated with better patient outcome and lower socioeconomic burden. New treatments and a better evidence base for management are emerging which, together with a move from hospital-centered to patient-centered care, will enable individualized, tailored treatment approaches.
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Affiliation(s)
- Iman H Nasr
- a Department of Immunology, Barts Health NHS Trust , London , UK
| | - Ania L Manson
- a Department of Immunology, Barts Health NHS Trust , London , UK
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Bork K, Craig TJ, Bernstein JA, Feuersenger H, Machnig T, Staubach P. Efficacy of C1 esterase inhibitor concentrate in treatment of cutaneous attacks of hereditary angioedema. Allergy Asthma Proc 2015; 36:218-24. [PMID: 25803207 DOI: 10.2500/aap.2015.36.3844] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although treatment with C1 esterase inhibitor (C1-INH) concentrate is well established for hereditary angioedema (HAE) attacks in general, data that assess its efficacy for cutaneous attack treatment are sparse. OBJECTIVE To assess efficacy of plasma-derived, nanofiltered C1-INH concentrate for cutaneous attack treatment by comparing treated attacks from the uncontrolled I.M.P.A.C.T.2 study with historical data for untreated attacks. METHODS Cutaneous attack data from patients with HAE who were treated for cutaneous edema with 20 IU/kg body weight C1-INH concentrate in the uncontrolled I.M.P.A.C.T.2 study (38 patients) were compared with data from untreated patients from an historical data base (46 patients) and included subset analyses for facial edema (treated group, 21 patients; untreated group, 33 patients) and peripheral edema (30 patients in each group). Average attack duration (AAD) per patient was the efficacy end point used to compare treated and untreated patients. Differences were assessed with a Wilcoxon test (primary analysis) and a log-rank test; AAD per patient was analyzed descriptively and graphically with Kaplan-Meier curves. RESULTS The AAD per patient of all cutaneous attacks or facial and peripheral cutaneous attack subsets was significantly faster with C1-INH treatment than without treatment (Wilcoxon and log-rank tests, both p < 0.0001 for all comparisons). Mean AADs per patient for all, facial, and peripheral attacks were 2.04, 1.45, and 2.16 days, respectively, in the C1-INH-treated group, and were 3.74, 4.45, and 2.98 days, respectively, in the untreated group. Kaplan-Meier curves corroborated the observed group differences. CONCLUSION Treatment of cutaneous HAE attacks (all attacks or facial and peripheral attack subsets) with 20 IU/kg C1-INH concentrate provided faster attack resolution compared with no treatment.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
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22
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Sabharwal G, Craig T. Recombinant human C1 esterase inhibitor for the treatment of hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE). Expert Rev Clin Immunol 2015; 11:319-27. [PMID: 25669442 DOI: 10.1586/1744666x.2015.1012502] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The lack of C1 inhibitor function that results in excessive production of bradykinin causing the angioedema seen in hereditary angioedema (HAE) is well established. Several drugs have been developed to treat and prevent attacks in patients suffering from HAE due to C1 inhibitor deficiency (C1-INH-HAE). Plasma-derived C1INH has been used to replace the deficiency of C1 inhibitor (C1INH) and has been approved for both treatment of attacks and for prophylactic therapy to prevent attacks. Plasma kallikrein inhibitor (ecallantide) and bradykinin receptor antagonist (icatibant) are both effective for treatment of acute attacks, but their short half-life limits the use for prophylaxis. Androgens, in particular danazol, are effective for long-term prophylaxis, but adverse event profile can limit its use. Recombinant C1 inhibitor derived from transgenic rabbits has recently been approved for use in treatment of C1-INH-HAE attacks and is effective and appears safe with minimal adverse event profile.
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Affiliation(s)
- Geetika Sabharwal
- Department of Pediatrics, Penn State University, 500 University Drive, 17033 Hershey, USA
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Betschel S, Badiou J, Binkley K, Hébert J, Kanani A, Keith P, Lacuesta G, Yang B, Aygören-Pürsün E, Bernstein J, Bork K, Caballero T, Cicardi M, Craig T, Farkas H, Longhurst H, Zuraw B, Boysen H, Borici-Mazi R, Bowen T, Dallas K, Dean J, Lang-Robertson K, Laramée B, Leith E, Mace S, McCusker C, Moote B, Poon MC, Ritchie B, Stark D, Sussman G, Waserman S. Canadian hereditary angioedema guideline. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2014; 10:50. [PMID: 25352908 PMCID: PMC4210625 DOI: 10.1186/1710-1492-10-50] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 09/10/2014] [Indexed: 11/26/2022]
Abstract
Hereditary angioedema (HAE) is a disease which is associated with random and often unpredictable attacks of painful swelling typically affecting the extremities, bowel mucosa, genitals, face and upper airway. Attacks are associated with significant functional impairment, decreased Health Related Quality of Life, and mortality in the case of laryngeal attacks. Caring for patients with HAE can be challenging due to the complexity of this disease. The care of patients with HAE in Canada is neither optimal nor uniform across the country. It lags behind other countries where there are more organized models for HAE management, and where additional therapeutic options are licensed and available for use. The objective of this guideline is to provide graded recommendations for the management of patients in Canada with HAE. This includes the treatment of attacks, short-term prophylaxis, long-term prophylaxis, and recommendations for self-administration, individualized therapy, quality of life, and comprehensive care. It is anticipated that by providing this guideline to caregivers, policy makers, patients and their advocates, that there will be an improved understanding of the current recommendations regarding management of HAE and the factors that need to be considered when choosing therapies and treatment plans for individual patients. The primary target users of this guideline are healthcare providers who are managing patients with HAE. Other healthcare providers who may use this guideline are emergency physicians, gastroenterologists, dentists and otolaryngologists, who will encounter patients with HAE and need to be aware of this condition. Hospital administrators, insurers and policy makers may also find this guideline helpful.
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Affiliation(s)
| | | | | | - Jacques Hébert
- />Department of Medicine, Laval University, Quebec City, Quebec Canada
| | - Amin Kanani
- />Department of Medicine, University of British Columbia, Vancouver, British Columbia Canada
| | - Paul Keith
- />Department of Medicine, McMaster University, Hamilton, Ontario Canada
| | - Gina Lacuesta
- />Department of Medicine, Dalhousie University, Halifax, Nova Scotia Canada
| | - Bill Yang
- />University of Ottawa Medical School, Ottawa, Ontario Canada
| | | | - Jonathan Bernstein
- />Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio USA
| | - Konrad Bork
- />Department of Dermatology, University Hospital of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | | | - Marco Cicardi
- />Department of Internal Medicine, UniversitadegliStudi di Milano, Ospedale L. Sacco, Milan, Italy
| | - Timothy Craig
- />Departments of Medicine and Pediatrics, Penn State University, Hershey, Pennsylvania USA
| | - Henriette Farkas
- />3rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Hilary Longhurst
- />Department of Immunology, Barts and the London NHS Trust, London, England, UK
| | - Bruce Zuraw
- />University of California, San Diego, San Diego, California USA
| | | | | | - Tom Bowen
- />Departments of Medicine and Paediatrics, University of Calgary, Calgary, Alberta Canada
| | - Karen Dallas
- />Saskatoon Health Region, Saskatoon, Saskatchewan Canada
| | - John Dean
- />BC Children’s Hospital, Vancouver, British Columbia Canada
| | | | - Benoît Laramée
- />Centre hospitalier de l’université de Montréal, Montréal, Quebec Canada
| | - Eric Leith
- />Department of Medicine, University of Toronto, Oakville, Ontario Canada
| | - Sean Mace
- />University of Toronto, Toronto, Ontario Canada
| | - Christine McCusker
- />Department of Immunology, McGill University Health Centre, Montreal, Quebec Canada
| | - Bill Moote
- />Department of Medicine, Western University, London, Ontario Canada
| | - Man-Chiu Poon
- />Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Calgary, Alberta Canada
| | - Bruce Ritchie
- />Departments of Medicine and Medical Oncology, University of Alberta, Edmonton, Alberta Canada
| | - Donald Stark
- />Department of Medicine, University of British Columbia, Vancouver, British Columbia Canada
| | | | - Susan Waserman
- />Department of Medicine, McMaster University, Hamilton, Ontario Canada
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Tradtrantip L, Asavapanumas N, Phuan PW, Verkman AS. Potential therapeutic benefit of C1-esterase inhibitor in neuromyelitis optica evaluated in vitro and in an experimental rat model. PLoS One 2014; 9:e106824. [PMID: 25191939 PMCID: PMC4156393 DOI: 10.1371/journal.pone.0106824] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 07/30/2014] [Indexed: 11/18/2022] Open
Abstract
Neuromyelitis optica (NMO) is an autoimmune demyelinating disease of the central nervous system in which binding of anti-aquaporin-4 (AQP4) autoantibodies (NMO-IgG) to astrocytes causes complement-dependent cytotoxicity (CDC) and inflammation resulting in oligodendrocyte and neuronal injury. There is compelling evidence for a central role of complement in NMO pathogenesis. Here, we evaluated the potential of C1-esterase inhibitor (C1-inh) for complement-targeted therapy of NMO. C1-inh is an anti-inflammatory plasma protein with serine protease inhibition activity that has a broad range of biological activities on the contact (kallikrein), coagulation, fibrinolytic and complement systems. C1-inh is approved for therapy of hereditary angioedema (HAE) and has been studied in a small safety trial in acute NMO relapses (NCT 01759602). In vitro assays of NMO-IgG-dependent CDC showed C1-inh inhibition of human and rat complement, but with predicted minimal complement inhibition activity at a dose of 2000 units in humans. Inhibition of complement by C1-inh was potentiated by ∼10-fold by polysulfated macromolecules including heparin and dextran sulfate. In rats, intravenous C1-inh at a dose 30-fold greater than that approved to treat HAE inhibited serum complement activity by <5%, even when supplemented with heparin. Also, high-dose C1-inh did not reduce pathology in a rat model of NMO produced by intracerebral injection of NMO-IgG. Therefore, although C1r and C1s are targets of C1-inh, our in vitro data with human serum and in vivo data in rats suggest that the complement inhibition activity of C1-inh in serum is too low to confer clinical benefit in NMO.
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Affiliation(s)
- Lukmanee Tradtrantip
- Departments of Medicine and Physiology, University of California San Francisco, San Francisco, California, United States of America
| | - Nithi Asavapanumas
- Departments of Medicine and Physiology, University of California San Francisco, San Francisco, California, United States of America
| | - Puay-Wah Phuan
- Departments of Medicine and Physiology, University of California San Francisco, San Francisco, California, United States of America
| | - A. S. Verkman
- Departments of Medicine and Physiology, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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Bork K. Human pasteurized C1-inhibitor concentrate for the treatment of hereditary angioedema due to C1-inhibitor deficiency. Expert Rev Clin Immunol 2014; 7:723-33. [DOI: 10.1586/eci.11.72] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Bork K. Pasteurized C1 inhibitor concentrate in hereditary angioedema: pharmacology, safety, efficacy and future directions. Expert Rev Clin Immunol 2014; 4:13-20. [DOI: 10.1586/1744666x.4.1.13] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Riedl MA, Bernstein JA, Li H, Reshef A, Lumry W, Moldovan D, Farkas H, Levy R, Baker J, Hardiman Y, Totoritis MC, Relan A, Cicardi M. Recombinant human C1-esterase inhibitor relieves symptoms of hereditary angioedema attacks: phase 3, randomized, placebo-controlled trial. Ann Allergy Asthma Immunol 2014; 112:163-169.e1. [PMID: 24468257 DOI: 10.1016/j.anai.2013.12.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 11/22/2013] [Accepted: 12/03/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE), caused by C1 inhibitor (C1INH) deficiency or dysfunction, is characterized by recurrent attacks of tissue swelling affecting multiple anatomic locations. Recombinant human C1INH (rhC1INH) has been shown effective for acute treatment of HAE attacks. OBJECTIVE To evaluate the efficacy and safety of rhC1INH (50 IU/kg to maximum 4,200 IU/treatment) vs placebo in a larger HAE population. METHODS Seventy-five patients experiencing peripheral, abdominal, facial, and/or oropharyngeal laryngeal attacks were randomized (3:2) to rhC1INH (n = 44) or placebo (saline; n = 31). Efficacy was assessed by patient responses on a Treatment Effect Questionnaire (TEQ) and visual analog scale (VAS). Safety also was evaluated. RESULTS Median (95% confidence interval) time to beginning of symptom relief at the primary attack location was 90 minutes (61-150) in rhC1INH-treated patients vs 152 minutes (93, not estimable) in placebo-treated patients (P = .031) based on the TEQ and 75 minutes (60-105) vs 303 minutes (81-720, P = .003) based on a VAS decrease of at least 20 mm. Median time to minimal symptoms was 303 minutes (240-720) in rhC1INH-treated patients vs 483 minutes (300-1,440) in placebo-treated patients based on the TEQ (P = .078) and 240 minutes (177-270) vs 362 minutes (240, not estimable; P = .005), based on an overall VAS less than 20 mm. Overall, rhC1INH was safe and well tolerated; no thromboembolic events, anaphylaxis, or neutralizing antibodies were observed. CONCLUSION Relief of symptoms of HAE attacks was achieved faster with rhC1INH compared with placebo as assessed by the TEQ and VAS, with a positive safety profile. Results are consistent with previous studies showing efficacy and safety of rhC1INH in patients with HAE.
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Affiliation(s)
- Marc A Riedl
- University of California, San Diego, California.
| | | | - Henry Li
- Institute for Asthma and Allergy, PC, Chevy Chase, Maryland
| | | | | | - Dumitru Moldovan
- University of Medicine and Pharmacy, Mures County Hospital, Tirgu Mures, Romania
| | - Henriette Farkas
- Hungarian Angioedema Center, Semmelweis University, Budapest, Hungary
| | - Robyn Levy
- Family Allergy and Asthma Center, Atlanta, Georgia
| | - James Baker
- Baker Allergy Asthma Dermatology, Lake Oswego, Oregon
| | | | | | - Anurag Relan
- Pharming Technologies BV, Leiden, The Netherlands
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Emmens RW, Naaijkens BA, Roem D, Kramer K, Wouters D, Zeerleder S, van Ham MS, Niessen HW, Krijnen PA. Evaluating the efficacy of subcutaneous C1-esterase inhibitor administration for use in rat models of inflammatory diseases. Drug Deliv 2013; 21:302-6. [DOI: 10.3109/10717544.2013.853211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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C1 esterase inhibitor reduces lower extremity ischemia/reperfusion injury and associated lung damage. PLoS One 2013; 8:e72059. [PMID: 23991040 PMCID: PMC3753343 DOI: 10.1371/journal.pone.0072059] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 07/05/2013] [Indexed: 12/13/2022] Open
Abstract
Background Ischemia/reperfusion injury of lower extremities and associated lung damage may result from thrombotic occlusion, embolism, trauma, or surgical intervention with prolonged ischemia and subsequent restoration of blood flow. This clinical entity is characterized by high morbidity and mortality. Deprivation of blood supply leads to molecular and structural changes in the affected tissue. Upon reperfusion inflammatory cascades are activated causing tissue injury. We therefore tested preoperative treatment for prevention of reperfusion injury by using C1 esterase inhibitor (C1 INH). Methods and Findings Wistar rats systemically pretreated with C1 INH (n = 6), APT070 (a membrane-targeted myristoylated peptidyl construct derived from human complement receptor 1, n = 4), vehicle (n = 7), or NaCl (n = 8) were subjected to 3h hind limb ischemia and 24h reperfusion. The femoral artery was clamped and a tourniquet placed under maintenance of a venous return. C1 INH treated rats showed significantly less edema in muscle (P<0.001) and lung and improved muscle viability (P<0.001) compared to controls and APT070. C1 INH prevented up-regulation of bradykinin receptor b1 (P<0.05) and VE-cadherin (P<0.01), reduced apoptosis (P<0.001) and fibrin deposition (P<0.01) and decreased plasma levels of pro-inflammatory cytokines, whereas deposition of complement components was not significantly reduced in the reperfused muscle. Conclusions C1 INH reduced edema formation locally in reperfused muscle as well as in lung, and improved muscle viability. C1 INH did not primarily act via inhibition of the complement system, but via the kinin and coagulation cascade. APT070 did not show beneficial effects in this model, despite potent inhibition of complement activation. Taken together, C1 INH might be a promising therapy to reduce peripheral ischemia/reperfusion injury and distant lung damage in complex and prolonged surgical interventions requiring tourniquet application.
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Craig TJ, Rojavin MA, Machnig T, Keinecke HO, Bernstein JA. Effect of time to treatment on response to C1 esterase inhibitor concentrate for hereditary angioedema attacks. Ann Allergy Asthma Immunol 2013; 111:211-5. [PMID: 23987198 DOI: 10.1016/j.anai.2013.06.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 06/17/2013] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND C1 esterase inhibitor (C1-INH) concentrate is well established as effective therapy for hereditary angioedema (HAE). It is thought that treatment of an acute HAE attack with C1-INH as early as possible improves efficacy, but there are limited data from prospective studies supporting this recommendation. OBJECTIVE To assess the effect of time to treatment (<6 vs ≥6 hours after start of an attack) with 20 U/kg of C1-INH concentrate on efficacy. METHODS A post hoc analysis of time to treatment after start of an attack was performed for 2 studies with C1-INH concentrate: International Multicenter Prospective Angioedema C1-INH Trial (IMPACT) 1 (randomized, placebo-controlled) and IMPACT 2 (open-label, uncontrolled extension). Because of differences in study design, the data sets were analyzed separately. IMPACT 1 data were analyzed using Cox regression with hazard ratios (HRs). For IMPACT 2 data, linear regression was applied to evaluate whether earlier treatment leads to faster recovery. Descriptive statistics for treatment response were calculated for both studies. RESULTS In IMPACT 1, treatment with C1-INH within less than 6 hours after start of an attack resulted in considerably shorter times to onset of symptom relief (HR, 3.36) and complete resolution (HR, 4.30) vs placebo. The benefit of C1-INH compared with placebo was reduced when administered after 6 or more hours (HRs, 1.18 for times to onset of symptom relief and 1.61 for complete resolution). Analysis of IMPACT 2 data indicated slower complete resolution of symptoms with later start of treatment. CONCLUSION Early treatment with C1-INH (<6 hours) provides a better treatment response than late treatment (≥6 hours), supporting the international recommendation to treat HAE attacks as early as possible. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT00168103 and NCT00292981.
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Affiliation(s)
- Timothy J Craig
- Penn State University College of Medicine, Hershey, Pennsylvania, USA.
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31
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Kawalec P, Holko P, Paszulewicz A. Cost-utility analysis of Ruconest(®) (conestat alfa) compared to Berinert(®) P (human C1 esterase inhibitor) in the treatment of acute, life-threatening angioedema attacks in patients with hereditary angioedema. Postepy Dermatol Alergol 2013; 30:152-8. [PMID: 24278067 PMCID: PMC3834719 DOI: 10.5114/pdia.2013.35616] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 03/15/2013] [Accepted: 04/24/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Administration of human C1 esterase inhibitor (Berinert(®) P) from target import is the most widespread treatment strategy for patients with hereditary angioedema (HAE). However, a therapeutic health program including Ruconest(®) (conestat alfa) could shorten a patient's expectancy for a life-saving treatment. AIM To evaluate the cost-utility of Ruconest(®) (conestat alfa) financed from public funds within the newly introduced therapeutic health program compared with Berinert(®) P (human C1 esterase inhibitor) in the treatment of acute angioedema attacks in adults with HAE. MATERIAL AND METHODS The cost-utility analysis from the Polish healthcare payer's perspective was performed for 1 year (2012). The costs and health outcomes were simulated for three pairs of eligible HAE patient groups (active treatment and corresponding placebo). The incremental costs of each intervention compared with placebo were listed together (direct or indirect comparisons between options were impossible due to limited clinical data available). RESULTS The incremental cost-utility ratios (ICURs) for the evaluated interventions compared with placebo were as follows: EUR 15,226 per QALY (Ruconest(®)) and EUR 27,786 per QALY (Berinert(®) P). The probability of cost-utility (ICUR < EUR 24,279 per QALY) assessed for Ruconest(®) administered in the case of acute angioedema attack was 61% and 41% for Berinert(®) P. CONCLUSIONS The administration of Ruconest(®) in acute life-threatening angioedema attacks is economically justified from the Polish healthcare payer's perspective, results in lower costs and is characterized by higher cost-utility probability compared with Berinert(®) P.
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Affiliation(s)
- Paweł Kawalec
- Drug Management Department, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University, Krakow, Poland. Head: Prof. Andrzej Pilc
- Centrum HTA, Krakow, Poland. Head: Dr. Paweł Kawalec
| | - Przemysław Holko
- Centrum HTA, Krakow, Poland. Head: Dr. Paweł Kawalec
- Department of General Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland. Head: Prof. Andrzej Klein
| | - Anna Paszulewicz
- Centrum HTA, Krakow, Poland. Head: Dr. Paweł Kawalec
- Laboratory of Cell Biophysics, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland. Head: Dr. Joanna Bereta
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Zuraw BL, Bernstein JA, Lang DM, Craig T, Dreyfus D, Hsieh F, Khan D, Sheikh J, Weldon D, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. A focused parameter update: Hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor–associated angioedema. J Allergy Clin Immunol 2013; 131:1491-3. [DOI: 10.1016/j.jaci.2013.03.034] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 03/11/2013] [Accepted: 03/14/2013] [Indexed: 11/26/2022]
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Lang DM, Aberer W, Bernstein JA, Chng HH, Grumach AS, Hide M, Maurer M, Weber R, Zuraw B. International consensus on hereditary and acquired angioedema. Ann Allergy Asthma Immunol 2013. [PMID: 23176876 DOI: 10.1016/j.anai.2012.10.008] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- David M Lang
- Allergy/Immunology, Respiratory Institute, Cleveland Clinic, Ohio, USA.
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Efficacy and safety of recombinant C1 inhibitor for the treatment of hereditary angioedema attacks: a North American open-label study. Ann Allergy Asthma Immunol 2013; 110:295-9. [PMID: 23535096 DOI: 10.1016/j.anai.2013.02.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 02/02/2013] [Accepted: 02/10/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND The efficacy of recombinant human C1 inhibitor (rhC1INH) for the treatment of patients with acute hereditary angioedema (HAE) attacks has been demonstrated in 2 randomized, double-blind, placebo-controlled studies. OBJECTIVE To assess the safety and efficacy of rhC1INH for repeated treatment of acute attacks of HAE. METHODS In this open-label extension study, patients with eligible HAE attacks were treated with an intravenous 50-U/kg dose of rhC1INH with an option for an additional dose of 50 U/kg based on clinical response. Time to beginning of relief was assessed by patients using a 100-mm visual analogue scale (VAS). Safety evaluation was based on the clinical laboratory results and adverse events. RESULTS Sixty-two patients were treated for 168 attacks (range, 1-8 attacks per patient). A total of 90% of the attacks were treated with a single 50-U/kg dose of rhC1INH. Median times to beginning of symptom relief for the first 5 attacks were 37 to 67 minutes. More than 90% of attacks responded within 4 hours after treatment with rhC1INH. There was no requirement for increased dosing with successive treatments. Thirty-nine patients (63%) reported at least 1 treatment-emergent adverse event, with most events rated mild to moderate. Seven severe treatment-emergent adverse events were reported, and all were considered to be unrelated to treatment with rhC1INH. CONCLUSION The results of this open-label extension support continued efficacy of rhC1INH after repeated treatments for subsequent HAE attacks. There was no increase in adverse event reporting after repeated exposure to rhC1INH.
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Abstract
Hereditary Angioedema (HAE) is a rare disease and for this reason proper diagnosis and appropriate therapy are often unknown or not available for physicians and other health care providers. For this reason we convened a group of specialists that focus upon HAE from around the world to develop not only a consensus on diagnosis and management of HAE, but to also provide evidence based grades, strength of evidence and classification for the consensus. Since both consensus and evidence grading were adhered to the document meets criteria as a guideline. The outcome of the guideline is to improve diagnosis and management of patients with HAE throughout the world and to help initiate uniform care and availability of therapies to all with the diagnosis no matter where the residence of the individual with HAE exists.
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Abstract
The 2 most commonly encountered primary immunodeficiency syndromes in adult practice are antibody deficiency disorders and hereditary angioedema.Immunologic therapy for these disorders has significantly improved patient management. Therapy with immunoglobulin leads to improvement in overall quality of life. With increasing survival rates and decreasing levels of life-threatening infections in patients with primary antibody deficiencies, disease complications are more commonly encountered. Treatment of these complications with monoclonal antibody therapy seems promising and is likely to increase in the future. More recently,several additional agents have become available, including novel drugs targeted at different elements of the disease process.
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MESH Headings
- Adrenergic beta-Antagonists/therapeutic use
- Anemia, Hemolytic, Autoimmune/therapy
- Angioedemas, Hereditary/therapy
- Bradykinin/analogs & derivatives
- Bradykinin/therapeutic use
- Complement C1 Inactivator Proteins/therapeutic use
- Complement C1 Inhibitor Protein/therapeutic use
- Cost-Benefit Analysis
- Delayed Diagnosis
- Disease Transmission, Infectious
- Filtration/methods
- Granuloma/therapy
- Home Infusion Therapy
- Humans
- Hypersensitivity, Delayed
- Hypersensitivity, Immediate
- Immunization, Passive
- Immunoglobulin G/blood
- Immunoglobulins/therapeutic use
- Immunologic Deficiency Syndromes/therapy
- Infections/epidemiology
- Kallikreins/antagonists & inhibitors
- Nanotechnology
- Peptides/therapeutic use
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Quality Control
- Quality of Life
- Recombinant Proteins/therapeutic use
- Self Administration
- Technology, Pharmaceutical
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Affiliation(s)
- Philip Wood
- Department of Clinical Immunology, St James's University Hospital, Beckett Wing, Leeds, Yorkshire LS9 7TF, UK.
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37
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Hofstra J, Budde IK, van Twuyver E, Choi G, Levi M, Leebeek F, de Monchy J, Ypma P, Keizer R, Huitema A, Strengers P. Treatment of hereditary angioedema with nanofiltered C1-esterase inhibitor concentrate (Cetor®): Multi-center phase II and III studies to assess pharmacokinetics, clinical efficacy and safety. Clin Immunol 2012; 142:280-90. [DOI: 10.1016/j.clim.2011.11.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 11/03/2011] [Accepted: 11/04/2011] [Indexed: 11/29/2022]
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Thomas MC, Shah S. New treatment options for acute edema attacks caused by hereditary angioedema. Am J Health Syst Pharm 2012; 68:2129-38. [PMID: 22058099 DOI: 10.2146/ajhp100718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE New treatment options for acute edema attacks caused by hereditary angioedema (HAE) are reviewed. SUMMARY HAE is characterized by mutations in the C1 inhibitor gene leading to either a reduced expression of C1 inhibitor in the plasma or expression of a functionally impaired C1 inhibitor. HAE is classified into two major types based on the cause of the C1 inhibitor deficiency. Type I HAE is defined by a reduced expression of C1 inhibitor in the plasma, whereas type II HAE is characterized by the expression of a dysfunctional C1 inhibitor protein. Clinical data were reviewed for C1 inhibitor, ecallantide, and icatibant in the treatment of acute edema attacks caused by HAE. C1 inhibitor leads to a faster onset of edema relief and is effective in decreasing the duration of edema. Dosing strategies include fixed dosing and weight-based dosing. Optimal dosing strategies have not been established, but fixed dosing (500-1000 units) or 20 units/kg has been effective in clinical trials and reports. No comparative trials suggest that one strategy is superior to another; however, the approved labeling for acute treatment is based on weight. Ecallantide is also efficacious for treating acute episodes; however, the available evidence is limited to a single published trial. Icatibant has shown variable effects in two trials with placebo and active controls. CONCLUSION In patients with HAE, most edema episodes only involve the skin and gastrointestinal tract, though airway obstruction caused by laryngeal angioedema is the most common cause of death. I.V. C1 inhibitor should be considered first-line treatment for acute edema attacks because of its fast onset of action and effectiveness, though it is not clear whether fixed or weight-based dosing is preferred. Ecallantide can be considered as a second-line treatment option.
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Affiliation(s)
- Michael C Thomas
- South University School of Pharmacy, 709 Mall Boulevard, Savannah, GA 31406, USA.
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Moldovan D, Reshef A, Fabiani J, Kivity S, Toubi E, Shlesinger M, Triggiani M, Montinaro V, Cillari E, Realdi G, Cancian M, Visscher S, Zanichelli A, Relan A, Cicardi M. Efficacy and safety of recombinant human C1-inhibitor for the treatment of attacks of hereditary angioedema: European open-label extension study. Clin Exp Allergy 2012; 42:929-35. [DOI: 10.1111/j.1365-2222.2012.03984.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- D. Moldovan
- Department of Allergology - Immunology; Mures County Hospital; University of Medicine and Pharmacy; Tîrgu-Mureş Romania
| | - A. Reshef
- The Allergy and Clinical Immunology Unit; The Chaim Sheba Medical Center; Tel Hashomer Israel
| | - J. Fabiani
- Argentine Institute of Allergy and Immunology; Lezica Capital Federal Argentina
| | - S. Kivity
- Allergy and Immunology Institute; Souraski MC; Tel-Aviv Israel
| | - E. Toubi
- Immunology and Allergy Institute; Bnei Zion Hospital; Haifa Israel
| | - M. Shlesinger
- Department of Immunology; The Barzilai M.C; Ashkelon Israel
| | - M. Triggiani
- Division of Allergy and Clinical Immunology; University of Naples Federico II; Naples Italy
| | - V. Montinaro
- Division of Nephrology; Azienda Ospedaliero-Universitaria “Consorziale Policlinico” Bari; Bari Italy
| | - E. Cillari
- Department of Clinical Pathology; Azienda Ospedaliera “V.Cervello”; Palermo Italy
| | - G. Realdi
- Department of Medical and Surgical Sciences; University of Padova; Italy
| | - M. Cancian
- Department of Medical and Surgical Sciences; University of Padova; Italy
| | - S. Visscher
- Pharming Technologies B.V; Leiden The Netherlands
| | - A. Zanichelli
- Dipartimento di Scienze Cliniche “Luigi Sacco”; Università di Milano; Milan Italy
| | - A. Relan
- Pharming Technologies B.V; Leiden The Netherlands
| | - M. Cicardi
- Dipartimento di Scienze Cliniche “Luigi Sacco”; Università di Milano; Milan Italy
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Abstract
Hereditary angio-oedema is caused by a heterozygous deficiency of C1 inhibitor. This inhibitor regulates several inflammatory pathways, and patients with hereditary angio-oedema have intermittent cutaneous or mucosal swellings because of a failure to control local production of bradykinin. Swellings typically evolve in several hours and persist for a few days. In addition to orofacial angio-oedema, painless swellings affect peripheries, which causes disfigurement or interference with work and other activities of daily living. Angio-oedema affecting the gastrointestinal tract or abdominal viscera causes severe pain often with vomiting due to oedematous bowel obstruction. About 2% of swellings involve the larynx and can be fatal if untreated. About 50% of patients have laryngeal swellings that are potentially fatal despite prophylaxis. In this Seminar we review the clinical features, diagnosis, and management of hereditary angio-oedema, with specific emphasis on the new treatments available for acute swellings.
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Affiliation(s)
- Hilary Longhurst
- Department of Immunology, Barts and The London National Health Service Trust, Whitechapel, London, UK.
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41
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Cicardi M, Bork K, Caballero T, Craig T, Li HH, Longhurst H, Reshef A, Zuraw B. Evidence-based recommendations for the therapeutic management of angioedema owing to hereditary C1 inhibitor deficiency: consensus report of an International Working Group. Allergy 2012; 67:147-57. [PMID: 22126399 DOI: 10.1111/j.1398-9995.2011.02751.x] [Citation(s) in RCA: 270] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Angioedema owing to hereditary deficiency of C1 inhibitor (HAE) is a rare, life-threatening, disabling disease. In the last 2 years, the results of well-designed and controlled trials with existing and new therapies for this condition have been published, and new treatments reached the market. Current guidelines for the treatment for HAE were released before the new trials and before the new treatments became available and were essentially based on observational studies and expert opinion. To provide evidence-based HAE treatment guidelines supported by the new studies, a conference was held in Gargnano del Garda, Italy, from September 26 to 29, 2010. The meeting hosted 58 experienced HAE expert physicians, representatives of pharmaceutical companies and representatives of HAE patients' associations. Here, we report the topics discussed during the meeting and evidence-based consensus about management approaches for HAE in adult/adolescent patients.
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Affiliation(s)
- M Cicardi
- Dipartimento di Scienze Cliniche "Luigi Sacco", Università di Milano, Ospedale L. Sacco, Milano, Italy.
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Hack CE, Relan A, van Amersfoort ES, Cicardi M. Target levels of functional C1-inhibitor in hereditary angioedema. Allergy 2012; 67:123-30. [PMID: 21923668 DOI: 10.1111/j.1398-9995.2011.02716.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a heterozygous deficiency of first component of complement-inhibitor (C1INH). Insufficient C1INH activity leads to uncontrolled activation of plasma cascade systems, which results in acute angioedema attacks in patients with HAE. Plasma-derived or recombinant C1INH products are approved for the treatment of such angioedema attacks. The target level of C1INH activity needed to achieve optimal efficacy, however, remains unknown. We determined the plasma level of C1INH associated with optimal clinical efficacy in the treatment of angioedema attacks. METHODS Efficacy and pharmacokinetic data were reviewed from recently published placebo-controlled randomized trials in the treatment of HAE with either plasma-derived or recombinant C1INH products, tested at various doses. RESULTS A dose-dependent effect was observed on time to the beginning of relief of symptoms, on time to resolution of symptoms, and on the response rate within 4 h. Optimal efficacy of C1INH therapy is achieved at doses ≥50 U/kg. This dose increases plasma C1INH activity in almost all patients to values ≥0.7 U/ml (70% of normal), the lower limit of the normal range. The differences in half-lives of the various C1INH products do not have an obvious effect on clinical efficacy. CONCLUSION A review of the efficacy and pharmacokinetic data from recently published controlled studies in the treatment of HAE attacks suggests that efficacy of C1INH therapy is optimal when C1INH activity levels are restored to the normal range.
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Affiliation(s)
- C E Hack
- Department of Dermatology/Allergology, Rheumatology and Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.
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43
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Tourangeau LM, Castaldo AJ, Davis DK, Koziol J, Christiansen SC, Zuraw BL. Safety and efficacy of physician-supervised self-managed C1 inhibitor replacement therapy. Int Arch Allergy Immunol 2011; 157:417-24. [PMID: 22123229 DOI: 10.1159/000329635] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 05/23/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND C1 inhibitor (C1INH) has recently been approved in the USA for the treatment of acute attacks in hereditary angioedema (HAE) patients. The literature suggests that treatment with C1INH is most effective when administered early in an attack. Home infusion of C1INH allows for the earliest possible intervention since patients can initiate therapy at the first sign of symptoms. METHODS We performed an observational, prospective study on 39 subjects with HAE utilizing two groups of patients: one receiving on-demand C1INH replacement therapy in a medical facility and the other self-managing on-demand C1INH replacement therapy in the home setting under the supervision of a treating physician. All subjects completed online questionnaires weekly for 8 weeks. RESULTS There were statistically significant decreases in attack duration (p < 0.0001), pain medication use (p < 0.0001) and graded attack severity (p < 0.005) in the subjects who received C1INH in the home setting versus the clinic-based group. Attack frequency was similar between the groups. The home group experienced more frequent injection-related side effects; however, the clinic group noted more severe adverse events from C1INH. CONCLUSION Physician-supervised self-managed C1INH replacement therapy is a safe and effective treatment for patients with HAE with potential benefits in diminishing attack duration and attack severity.
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Christiansen SC, Zuraw BL. Hereditary Angioedema: Management of Laryngeal Attacks. Am J Rhinol Allergy 2011; 25:379-82. [DOI: 10.2500/ajra.2011.25.3670] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Hereditary angioedema (HAE) patients suffering from laryngeal attacks in the United States faced severely limited treatment options until 2008. These potentially life-threatening episodes occur in over one-half of the patients affected by HAE during their lifetimes. Acute therapy had been relegated to supportive care, intubation, and consideration of fresh frozen plasma (FFP)–-the latter with the potential for actually accelerating the speed and severity of the swelling. Methods In this article we will review the recently approved and emerging HAE treatments that have evolved from the recognition that bradykinin generation is the fundamental abnormality leading to attacks of angioedema. Results Acute therapy for laryngeal attacks will be discussed including purified plasma–derived C1 inhibitor (C1INH), recombinant C1INH, an inhibitor of plasma kallikrein (ecallantide), and a B2 receptor antagonist (icatibant). Prophylactic care has also been transformed from a reliance on attenuated androgens with their attendant side effects to C1INH replacement. Conclusion The arrival of these novel therapies promises to transform the future management of HAE.
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Affiliation(s)
- Sandra C. Christiansen
- Department of Allergy, Kaiser Permanente and University of California, San Diego, California
| | - Bruce L. Zuraw
- Department of Medicine, University of California San Diego and San Diego Veteran's Affairs Medical Center, La Jolla, California
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Valle SOR, França AT, Campos RA, Grumach AS. C1 Esterase Inhibitor (Human) for the Treatment of Acute Hereditary Angioedema. ACTA ACUST UNITED AC 2011. [DOI: 10.4137/cmbd.s4090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hereditary angioedema (HAE) is a relatively rare disease characterized by acute episodes of swelling. These swellings can be disfiguring, painful and life-threatening. Since the symptoms occur in different areas and most patients experience a delay in their diagnosis, resulting in unnecessary suffering and dangerous situations. HAE can have a tremendous impact on the quality of life. The major genetic deficiency in this disorder is either an absent or nonfunctional C1INH which regulates the complement, fibrinolitic, kalikrein and plasmin pathways.
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Affiliation(s)
- Solange Oliveira Rodrigues Valle
- Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Regis A. Campos
- Department of Internal Medicine, Federal University of Bahia, Salvador, BA, Brazil
- Edgar Santos University Hospital, Salvador, BA, Brazil
- Contribution: Conception and design of the study, preparation and critical revision of the manuscript
| | - Anete Sevciovic Grumach
- University of São Paulo, SP, Brazil
- São Paulo City, SP, Brazil
- Contribution: Conception and design of the study, preparation and critical revision of the manuscript
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46
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Prematta MJ, Prematta T, Craig TJ. Treatment of hereditary angioedema with plasma-derived C1 inhibitor. Ther Clin Risk Manag 2011; 4:975-82. [PMID: 19209279 PMCID: PMC2621399 DOI: 10.2147/tcrm.s3172] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Plasma-derived C1 inhibitor (C1-INH) concentrate is a treatment option for acute hereditary angioedema (HAE) attacks and is considered the standard-of-care in many countries, although it is not yet available in the United States. Studies are still being conducted to establish its safety and efficacy as required by the FDA. OBJECTIVE To review the medical literature to determine if C1-INH concentrate is a safe and effective treatment for acute HAE attacks. METHODS THE FOLLOWING KEYWORDS WERE SEARCHED IN PUBMED AND OVID: C1 esterase inhibitor, C1-inhibitor, C1 inhibitor, and hereditary angioedema treatment. English-language articles were searched from 1966 to the present to look for studies demonstrating the efficacy and the safety of C1-INH concentrate. RESULTS The English-language literature search revealed several studies showing significantly improved relief of HAE symptoms with the administration of C1-INH concentrate - many studies demonstrated some improvement of symptoms within 30 minutes. Side effects have been similar to placebo, and no proven cases of viral transmission have occurred in over 20 years. CONCLUSION C1-INH concentrate appears to be a very safe and effective treatment option for HAE.
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Affiliation(s)
- Michael J Prematta
- Section of Allergy and Immunology, Penn State University, Milton S. Hershey Medical Center, PA, USA
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Bowen T. Hereditary angioedema: beyond international consensus - circa December 2010 - The Canadian Society of Allergy and Clinical Immunology Dr. David McCourtie Lecture. Allergy Asthma Clin Immunol 2011; 7:1. [PMID: 21310025 PMCID: PMC3048557 DOI: 10.1186/1710-1492-7-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 02/10/2011] [Indexed: 11/19/2022] Open
Abstract
Background The 2010 International Consensus Algorithm for the Diagnosis, Therapy and Management of Hereditary Angioedema was published earlier this year in this Journal (Bowen et al. Allergy, Asthma & Clinical Immunology 2010, 6:24 - http://www.aacijournal.com/content/6/1/24). Since that publication, there have been multiple phase III clinical trials published on either prophylaxis or therapy of hereditary angioedema and some of these products have changed approval status in various countries. This manuscript was prepared to review and update the management of hereditary angioedema. Objective To review approaches for the diagnosis and management of hereditary angioedema (HAE) circa December 2010 and present thoughts on moving from HAE management from international evidence-based consensus to facilitate more local health unit considerations balancing costs, efficacies of treatments, and risk benefits. Thoughts will reflect Canadian and international experiences. Methods PubMed searches including hereditary angioedema and diagnosis, therapy, management and consensus were reviewed as well as press releases from various pharmaceutical companies to early December 2010. Results The 2010 International Consensus Algorithms for the Diagnosis, Therapy and Management of Hereditary Angioedema is reviewed in light of the newly published phase III Clinical trials for prevention and therapy of HAE. Management approaches and models are discussed. Conclusions Consensus approach and double-blind placebo controlled trials are only interim guides to a complex disorder such as HAE and should be replaced as soon as possible with large phase IV clinical trials, meta analyses, data base registry validation of approaches including quality of life and cost benefit analyses, safety, and head-to-head clinical trials investigating superiority or non-inferiority comparisons of available approaches. Since not all therapeutic products are available in all jurisdictions and since health care delivery approaches and philosophy vary between countries, each health care delivery sector will likely devise their own algorithms based on local practicalities for implementing evidence-based guidelines and standards for HAE disease management. Quality-of-life and cost affordability benefit conclusions will likely vary between countries and health care units. Data base registries for rare disorders like HAE should be used to detect early adverse events for new therapies and to facilitate phase IV clinical trials and encourage superiority and non-inferiority comparisons of HAE management approaches.
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Affiliation(s)
- Tom Bowen
- Clinical Professor of Medicine and Paediatrics, University of Calgary, 705 South Tower 3031 Hospital Dr, NW, Calgary, Alberta, T2N 2T8, Canada.
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Jung M, Rice L. "Surgical" abdomen in a patient with chronic lymphocytic leukemia: a case of acquired angioedema. J Gastrointest Surg 2011; 15:2262-6. [PMID: 21997434 PMCID: PMC3220812 DOI: 10.1007/s11605-011-1718-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 02/23/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Acquired angioedema (AAE), an acquired deficiency of C1esterase inhibitor, is a medically treatable condition which can cause severe abdominal pain mimicking an acute surgical abdomen. This disorder is strongly associated with chronic lymphocytic leukemia (CLL) and other indolent lymphoplasmacytic disorders. DISCUSSION We describe a patient with known CLL who developed incapacitating, recurrent severe abdominal pains, culminating in partial bowel resection. Signs, symptoms, laboratory and pathologic findings demonstrated AAE. CONCLUSION Wider appreciation of the possibility of AAE, particularly in patients with lymphoproliferative disorders, could lead to preventive therapy and spare unnecessary surgery. This is more important now that more effective medical therapies are available.
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Affiliation(s)
- Moonjung Jung
- Department of Medicine, The Methodist Hospital, Weill Cornell Medical College, 6550 Fannin Street, #1001, Houston, TX 77030 USA
| | - Lawrence Rice
- Department of Medicine, The Methodist Hospital, Weill Cornell Medical College, 6550 Fannin Street, #1001, Houston, TX 77030 USA
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Cardona LP, Bellfill RL, Caus JM. Recent developments in the treatment of acute abdominal and facial attacks of hereditary angioedema: focus on human C1 esterase inhibitor. Appl Clin Genet 2010; 3:133-46. [PMID: 23776358 PMCID: PMC3681170 DOI: 10.2147/tacg.s9275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hereditary angioedema (HAE) is a potentially fatal genetic disorder typified by a deficiency (type I) or dysfunction (type II) of the C1-inhibitor (C1-INH) and characterized by swelling of the extremities, face, trunk, abdominal viscera, and upper airway. Type III is normal estrogen-sensitive C1-INH HAE. Bradykinin, the main mediator of HAE, binds to endothelial B2 receptors, increasing vascular permeability and resulting in edema. HAE management includes short- and long-term prophylaxis. For treating acute episodes, C1-INH concentrate is recommended with regression of symptoms achieved in 30-90 min. Infusions of 500-1000 U have been used in Europe for years. Two plasma-derived C1-INH concentrates have been licensed recently in the United States: Berinert(®) for treating acute attacks and Cinryze(®) for prophylaxis in adolescent/adult patients. A recombinant C1-INH that is being considered for approval (conestat alfa) exhibited significant superiority versus placebo. Ecallantide (Kalbitor(®)) is a selective kallikrein inhibitor recently licensed in the United States for treating acute attacks in patients aged >16 years. It is administered in three 10-mg subcutaneous injections with the risk of anaphylactic reactions. Icatibant (Firazyr(®)) is a bradykinin B2 receptor competitor. It is administered subcutaneously as a 30-mg injection and approved in Europe but not in the United States.
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Affiliation(s)
- Lourdes Pastó Cardona
- Pharmacy Service, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Ramon Lleonart Bellfill
- Allergy Unit, Internal Medicine Service, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Joaquim Marcoval Caus
- Dermatology Service, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
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Wasserman RL, Levy RJ, Bewtra AK, Hurewitz D, Craig TJ, Kiessling PC, Keinecke HO, Bernstein JA. Prospective study of C1 esterase inhibitor in the treatment of successive acute abdominal and facial hereditary angioedema attacks. Ann Allergy Asthma Immunol 2010; 106:62-8. [PMID: 21195947 DOI: 10.1016/j.anai.2010.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 09/30/2010] [Accepted: 10/12/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND hereditary angioedema (HAE) is a rare disorder characterized by a quantitative or functional deficiency of C1 esterase inhibitor (C1-INH), resulting in periodic attacks of acute edema at various body locations. The symptoms of these painful attacks can be treated effectively with C1-INH concentrate. OBJECTIVE to document the efficacy and safety of a weight-based dose of C1-INH concentrate in the treatment of successive HAE attacks at abdominal and facial locations. METHODS acute facial and abdominal attacks were each treated with C1-INH concentrate using a single intravenous dose of 20 U/kg body weight. Efficacy end points included patient-reported time to onset of symptom relief and time to complete resolution of all symptoms. Safety was assessed by monitoring adverse events and assaying for markers of viral infection. RESULTS we treated 663 abdominal attacks in 50 patients and 43 facial attacks in 16 patients (a total of 706 attacks in 53 patients). The median time to onset of relief for all attacks was 19.8 minutes, with a median time to complete resolution of 11.0 hours. The median time to onset of relief was 19.8 minutes for abdominal attacks and 28.2 minutes for facial attacks, indicating efficacy for both types of attack. No treatment-related serious adverse events occurred, and C1-INH concentrate was well tolerated. No human immunodeficiency virus, hepatitis virus, or parvovirus B19 infections arose during the study. CONCLUSION the C1-INH concentrate dose of 20 U/kg provides rapid, effective, and safe treatment for successive HAE attacks at abdominal and facial locations.
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