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Keskin S, Pak Y, Celestin J. What lessons are learned?: Our changing practice during 30 years of hereditary angioedema treatment. Ann Allergy Asthma Immunol 2024; 132:774-776. [PMID: 38403158 DOI: 10.1016/j.anai.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/11/2024] [Accepted: 02/09/2024] [Indexed: 02/27/2024]
Affiliation(s)
- Sevdenur Keskin
- Division of Allergy and Immunology, Department of Medicine, Albany Medical Center, Albany, New York
| | - Yosif Pak
- Department of Medicine, Albany Medical Center, Albany, New York
| | - Jocelyn Celestin
- Division of Allergy and Immunology, Department of Medicine, Albany Medical Center, Albany, New York.
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2
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Wilkerson RG, Winters ME. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. Immunol Allergy Clin North Am 2023; 43:513-532. [PMID: 37394257 DOI: 10.1016/j.iac.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Michael E Winters
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/critcareguys
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Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45267-0769, USA. https://twitter.com/edmojo
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Betschel SD, Banerji A, Busse PJ, Cohn DM, Magerl M. Hereditary Angioedema: A Review of the Current and Evolving Treatment Landscape. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2315-2325. [PMID: 37116793 DOI: 10.1016/j.jaip.2023.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/30/2023]
Abstract
Hereditary angioedema (HAE) is a rare disease characterized by sudden and often unprovoked episodes of swelling that can be potentially life-threatening when it involves the upper airway. The treatment options for both acute episodes of HAE and LTP, used to minimize the frequency and severity of angioedema attacks, were limited historically to very few options, had considerable side effects, and/or had considerable burden of treatment. Fortunately, through the elucidation of the pathophysiology of HAE, the development of newer targeted therapies has been possible both for acute therapy and long-term prophylaxis and even more are on the horizon. Because of the rapid development of these therapies, it can be challenging for clinicians to keep abreast of newer and developing treatments for HAE. This review article will outline the current and potential future treatments for HAE. It will also highlight important considerations when treating special HAE patient populations including women and pediatric patients.
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Affiliation(s)
- Stephen D Betschel
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Aleena Banerji
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Mass.
| | - Paula J Busse
- Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Danny M Cohn
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Markus Magerl
- Institute of Allergology, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin), Berlin, Germany; Department of Immunology and Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany
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5
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Raasch J, Glaum MC, O’Connor M. The multifactorial impact of receiving a hereditary angioedema diagnosis. World Allergy Organ J 2023; 16:100792. [PMID: 37448849 PMCID: PMC10336685 DOI: 10.1016/j.waojou.2023.100792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/08/2023] [Accepted: 05/24/2023] [Indexed: 07/15/2023] Open
Abstract
Hereditary angioedema (HAE) is a rare, chronic, debilitating genetic disorder characterized by recurrent, unpredictable, and potentially life-threatening episodes of swelling that typically affect the extremities, face, abdomen, genitals, and larynx. The most frequent cause of HAE is a mutation in the serpin family G member 1 (SERPING1) gene, which either leads to deficient plasma levels of the C1-esterase inhibitor (C1-INH) protein (type I HAE-C1-INH) or normal plasma levels of dysfunctional C1-INH protein (type II HAE-C1-INH). Mutations in SERPING1 are known to be associated with dysregulation of the kallikrein-bradykinin cascade leading to enhancement of bradykinin production and increased vascular permeability. However, some patients present with a third type of HAE (HAE-nl-C1-INH) that is characterized by normal plasma levels and functionality of the C1-INH protein. While mutations in the factor XII, angiopoietin-1, plasminogen, kininogen-1, myoferlin, and heparan sulfate-glucosamine 3-O-sulfotransferase-6 genes have been identified in some patients with HAE-nI-C1-INH, genetic cause remains unknown in many cases with further research required to fully elucidate the pathology of disease in these patients. Here we review the challenges that arise on the pathway to a confirmed diagnosis of HAE and explore the multifactorial impact of receiving a HAE diagnosis. We conclude that it is important to continue to raise awareness of HAE because delays to diagnosis have a direct impact upon patient suffering and quality of life. Since many patients will seek help from hospitals during their first swelling attack it is vital that emergency department staff are aware of the different pathological pathways that distinguish HAE from other forms of angioedema to ensure that the most appropriate treatment is administered. As disease awareness increases, it is hoped that patients will be diagnosed earlier and that pre-authorization and insurance coverage of HAE treatments will become easier to obtain, ultimately reducing the burden of treatment for these patients and their caregivers.
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Affiliation(s)
| | - Mark C Glaum
- Department of Internal Medicine, Division of Allergy and Immunology, University of South Florida, FL, USA
| | - Maeve O’Connor
- Allergy, Asthma & Immunology Relief of Charlotte, Charlotte, NC, USA
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6
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Li PH, Pawankar R, Thong BYH, Fok JS, Chantaphakul H, Hide M, Jindal AK, Kang HR, Abdul Latiff AH, Lobo RCM, Munkhbayarlakh S, Nguyen DV, Shyur SD, Zhi Y, Maurer M. Epidemiology, Management, and Treatment Access of Hereditary Angioedema in the Asia Pacific Region: Outcomes From an International Survey. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1253-1260. [PMID: 36584968 DOI: 10.1016/j.jaip.2022.12.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/25/2022] [Accepted: 12/18/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare genetic disease with significant morbidity and mortality for which early diagnosis and effective therapy are critical. Many Asia Pacific (AP) countries still lack access to diagnostic tests and evidence-based therapies. Epidemiologic data from the AP is needed to formulate regional guidelines to improve standards of care for HAE. OBJECTIVE To investigate the estimated minimal prevalence, needs, and potential interventions for the diagnosis and management of HAE in the AP. METHODS A structured questionnaire was distributed to representative experts from member societies of the Asia Pacific Association of Allergy, Asthma and Clinical Immunology. Patient profiles and the presence of diagnostic facilities or tests, regional and national HAE guidelines, and patient support groups were reported and compared. RESULTS Completed questionnaires were received from 14 representatives of 12 member countries and territories, representing 46% of the world population. Overall minimal prevalence of HAE in the AP region was 0.02/100,000 population, with significant heterogeneity across different centers. Only one-half and one-third had registered on-demand and prophylactic medications, respectively. Few had patient support groups (58%) or regional guidelines (33%), and their existence was associated with the availability of HAE-specific medications. Availability of C1-inhibitor level testing was associated with a lower age at HAE diagnosis (P = .017). CONCLUSIONS Hereditary angioedema in the AP differs from that in Western countries. Hereditary angioedema-specific medications were registered in only a minority of countries and territories, but those with patient support groups or regional guidelines were more likely to have better access. Asia Pacific-specific consensus and guidelines are lacking and urgently needed.
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Affiliation(s)
- Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong.
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan.
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy, and Immunology, Tan Tock Seng Hospital, Singapore
| | - Jie Shen Fok
- Department of Respiratory Medicine, Box Hill Hospital, Eastern Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Hiroshi Chantaphakul
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Michihiro Hide
- Department of Dermatology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ankur Kumar Jindal
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post-Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | | | - Rommel Crisenio M Lobo
- Philippine Children's Medical Center Hospital of Infant Jesus Medical Center, Fe del Mundo Medical Center, Quezon City, Philippines
| | - Sonomjamts Munkhbayarlakh
- Department of Pulmonology and Allergology, School of Medicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Dinh Van Nguyen
- Respiratory, Allergy, and Clinical Immunology Unit, Internal Medicine Department, Vinmec Times City International Hospital, Vinmec Healthcare System, Hanoi, Vietnam; College of Health Sciences, Vin University, Hanoi, Vietnam
| | | | - Yuxiang Zhi
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Marcus Maurer
- Angioedema Center of Reference and Excellence, Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
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7
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Sheikh F, Alajlan H, Albanyan M, Alruwaili H, Alawami F, Sumayli S, Al Gazlan S, Abu Awwad S, Al-Dhekri H, Al-Saud B, Arnaout R, Alrayes H, Sayes N, Al-Hamed MH, Al-Mousa H, AlShareef S, Alazami AM. Phenotypic and Genotypic Characterization of Hereditary Angioedema in Saudi Arabia. J Clin Immunol 2023; 43:479-484. [PMID: 36348183 DOI: 10.1007/s10875-022-01399-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
Abstract
Hereditary angioedema (HAE) is a potentially life-threatening autosomal dominant disorder affecting roughly 1:50,000 individuals. It is commonly characterized by swelling of the larynx, gastrointestinal tract, extremities, and skin. There is growing genetic heterogeneity associated with this disease but more than 95% of mutations are found in SERPING1, the gene which encodes complement 1 inhibitor (C1-INH). HAE cohorts from several populations have been published but no large scale study has been reported from the Arab world to date. Here we document the clinical and genetic findings of HAE patients from a single Saudi institution, which is a major referral center at the national level. A total of 51 patients across 17 unrelated families were recruited including two large multi-generational families, of which one contained an in-frame exonic deletion that was resolved through MLPA. Two cases were negative for all the genes we tested (including F12, PLG, ANGPT1, MYOF, KNG1, and HS3ST6). The predominant HAE subtype in our cohort was type I, at 76%. We were able to uncover a mutation in 49 patients (96%). No type III (normal C1-INH) patients were encountered in the clinic, suggesting that this subtype does not play a major role in HAE pathogenesis in Saudi Arabia. Additionally, the existence of four patients with consistently normal complement 4 (C4) levels alongside abnormal C1-INH profiles highlights the utility of dual screening for both proteins in suspected patients.
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Affiliation(s)
- Farrukh Sheikh
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Huda Alajlan
- Translational Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital & Research Centre, MBC 3, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Maram Albanyan
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hibah Alruwaili
- Translational Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital & Research Centre, MBC 3, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Fatimah Alawami
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Safia Sumayli
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sulaiman Al Gazlan
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sawsan Abu Awwad
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
| | - Hasan Al-Dhekri
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
| | - Bandar Al-Saud
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Rand Arnaout
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hassan Alrayes
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Najla Sayes
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Mohamed H Al-Hamed
- Clinical Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hamoud Al-Mousa
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
| | - Saad AlShareef
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Anas M Alazami
- Translational Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital & Research Centre, MBC 3, P.O. Box 3354, Riyadh, 11211, Saudi Arabia.
- Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia.
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8
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Pezeshki PS, Nowroozi A, Razi S, Rezaei N. Asthma and Allergy. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Petersen RS, Fijen LM, Levi M, Cohn DM. Hereditary Angioedema: The Clinical Picture of Excessive Contact Activation. Semin Thromb Hemost 2022. [PMID: 36417927 DOI: 10.1055/s-0042-1758820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hereditary angioedema is a rare, genetic disorder characterized by painful, debilitating and potentially life-threatening angioedema attacks in subcutaneous and submucosal tissue. While usually unpredictable, attacks can be provoked by a variety of triggers including physical injury and certain medication and are often preceded by prodromal symptoms. Hereditary angioedema has a profound influence on the patients' lives. The fundamental cause of hereditary angioedema in almost all patients is a mutation in the SERPING1 gene leading to a deficiency in C1-inhibitor. Subsequently, the contact activation cascade and kallikrein-kinin pathway are insufficiently inhibited, resulting in excessive bradykinin production triggering vascular leakage. While C1-inhibitor is an important regulator of the intrinsic coagulation pathway, fibrinolytic system and complement cascade, patients do not have an increased risk of coagulopathy, autoimmune conditions or immunodeficiency disorders. Hereditary angioedema is diagnosed based on C1-inhibitor level and function. Genetic analysis is only required in rare cases where hereditary angioedema with normal C1-inhibitor is found. In recent years, new, highly specific therapies have greatly improved disease control and angioedema-related quality of life. This article reviews the clinical picture of hereditary angioedema, the underlying pathophysiology, diagnostic process and currently available as well as investigational therapeutic options.
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Affiliation(s)
- Remy S Petersen
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Lauré M Fijen
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Marcel Levi
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Danny M Cohn
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
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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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11
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Norris M, Ashoor Z, Craig T. Management of pediatric hereditary angioedema types 1 and 2: A search for international consensus. Allergy Asthma Proc 2022; 43:388-396. [PMID: 36065112 DOI: 10.2500/aap.2022.43.220052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: The management of hereditary angioedema has rapidly changed over the past decade. With these changes there has been increased recognition of the unique challenges of diagnosing and managing hereditary angioedema in pediatric populations. The objective of this review was to identify and compare recently published consensus guidelines for the management of hereditary angioedema types 1 and 2 to identify areas of agreement and conflict. Methods: A MEDLINE database search was performed to identify guidelines that offered guidance on diagnosing or managing hereditary angioedema in pediatric populations. A limitation was placed on guidelines published in the past 5 years to reflect the most recent literature. Results: Six clinical practice guidelines were included in the analysis. Early detection of disease status, coordination with specialists, and empowering patients with self-administered medications are emphasized, with use of plasma derived C1 esterase inhibitor as first line therapy for aborting attacks. The guidelines are shifting away from attenuated androgens and tranexamic acid for long-term prophylaxis toward medications such as subcutaneous C1 esterase inhibitor, lanadelumab, and berotralstat. Conclusion: Although some differences exist based on geographic region and health system where an included guideline was published, they have very minimal differences on close review.
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Affiliation(s)
- Matthew Norris
- From the Department of Medicine, Penn State University, Hershey, Pennsylvania
| | - Zaynab Ashoor
- Cairo University School of Medicine, Cairo, Egypt; and
| | - Timothy Craig
- Department of Medicine, Pediatric and Biomedical Sciences, Penn State University, Hershey, Pennsylvania
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12
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Wong JC, Chiang V, Lam K, Tung E, Au EY, Lau CS, Li PH. Prospective Study on the Efficacy and Impact of Cascade Screening and Evaluation of Hereditary Angioedema (CaSE-HAE). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE 2022; 10:2896-2903.e2. [PMID: 35964924 DOI: 10.1016/j.jaip.2022.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/28/2022] [Accepted: 07/30/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Recommendations regarding family screening for hereditary angioedema (HAE) remain variable and mostly based on expert opinion. Studies evaluating its implementation and efficacy are lacking. OBJECTIVES A novel HAE screening program was established to evaluate the efficacy and impact of cascade family screening (CFS) for at-risk relatives. METHODS Potential HAE relatives were screened through the CFS approach. Prospective data on clinical, psychological, and HAE-related outcomes were collected at baseline and 1-year follow-up. Longitudinal outcomes were analyzed and compared between index patients and those given a diagnosis through CFS. RESULTS Of 179 relatives, 53% were contactable, 67% of whom consented to screening. Twenty-nine patients (46%) were newly given the diagnosis of HAE; half were symptomatic at baseline (52%). There was a stronger trend toward higher diagnostic yield among first-degree families, although this did not meet statistical significance (57.6% vs 33.3%; P = .077). Among symptomatic patients, there was a higher proportion with complete annual HAE remission (15% vs 46%; P = .021) and a reduction in annual HAE-related hospital admissions (1 vs 0; P = .016) and length of stay (3 vs 2 days; P = .001) after 1 year. Among all patients, there were reduced Hospital Anxiety and Depression Scale-anxiety (14.35 ± 6.32 vs 6.47 ± 4.14; P = .001) and improved Angioedema Quality of Life scores (55% vs 35%; P < .001). By extrapolation, CFS led to a reduction of at least HK $1,200 (US $153) in HAE-related costs per patient per year. Screening using a greater than suggested C4 cutoff of 22.9 mg/dL yielded superior sensitivity (100%) and specificity (77%). CONCLUSION Cascade family screening is an effective approach to family screening in HAE, improving clinical and psychological outcomes, and reducing disease-related costs.
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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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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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Anderson J, Maina N. Reviewing clinical considerations and guideline recommendations of C1 inhibitor prophylaxis for hereditary angioedema. Clin Transl Allergy 2022; 12:e12092. [PMID: 35079346 PMCID: PMC8764638 DOI: 10.1002/clt2.12092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/22/2021] [Accepted: 12/07/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hereditary angioedema (HAE), a rare disease that is characterized by painful and recurring non-allergic swelling episodes, is caused by the deficiency or dysfunction of C1 inhibitor (C1INH) protein. A comprehensive HAE management plan may require long-term prophylaxis (LTP) in addition to on-demand treatment to help "normalize" patients' lives so that they may fully engage in work, school, family, and leisure activities. AIM The main objective of this narrative review is to provide an overview of updated guideline recommendations specific to LTP of HAE and discuss clinical considerations and pharmacologic management options, with a focus on C1INH. MATERIALS AND METHODS The authors reviewed relevant HAE literature for current recommendations regarding LTP and the role of C1NH. RESULTS Acute HAE attacks are treated with on-demand medication; however, there is a consensus that LTP should routinely be considered for risk reduction and prevention of future episodes. The 2017 World Allergy Organization/European Academy of Allergy and Clinical Immunology guidelines recommend that all patients with HAE be evaluated for LTP routinely and the 2020 HAE Association (HAEA) guidelines emphasize that the decision to use LTP should not be based on rigid criteria, but rather should be based on individual patient needs. Both guidelines recommend C1INH as first-line/preferred therapy for LTP in a range of patient types including adults, children/adolescents, and pregnant/lactating patients. The HAEA also recommends the kallikrein inhibitor, lanadelumab, as a first-line option for LTP. HAE pathway-specific agents for LTP have not been associated with notable safety concerns. DISCUSSION Plasma-derived C1INH has been available for 40+ years in Europe and impacts multiple targets within the HAE pathway. C1INH has been used for on-demand treatment and LTP. A subcutaneous formulation of plasma-derived C1INH is approved for LTP and produces functional C1INH activity levels consistently above the threshold needed for protection from HAE attacks. Other pathway-specific options for LTP include the plasma kallikrein inhibitors, lanadelumab-flyo and berotralstat, approved for adults and pediatric patients aged ≥12 years. C1INH is approved for adults and pediatric patients aged ≥6 years. CONCLUSION Assessing the need for LTP is vital in the ongoing dialogue between clinicians and patients, as both disease-related factors and patient preferences may change over time. Among available options for LTP, plasma-derived C1INH is the broadly recommended first-line option for LTP in patients with HAE, including pregnant/lactating women and pediatric patients (≥6 years).
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Affiliation(s)
- John Anderson
- Clinical Research Center of Alabama, AllerVie HealthBirminghamAlabamaUSA
| | - Njeri Maina
- Alabama Allergy and Asthma Center, AllerVie HealthBirminghamAlabamaUSA
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Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45267-0769, USA. https://twitter.com/edmojo
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Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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Riedl MA, Johnston DT, Anderson J, Meadows JA, Soteres D, LeBlanc SB, Wedner HJ, Lang DM. Optimization of care for patients with hereditary angioedema living in rural areas. Ann Allergy Asthma Immunol 2021; 128:526-533. [PMID: 34628006 DOI: 10.1016/j.anai.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE People living in rural areas of the United States experience greater health inequality than individuals residing in urban or suburban locations and encounter several barriers to obtaining optimal health care. Health disparities are compounded for patients with rare diseases such as hereditary angioedema (HAE), an autosomal dominant genetic disorder characterized by recurrent, severe abdominal pain and lifethreatening oropharyngeal/laryngeal swelling. The objective of this review is to explore the challenges of managing HAE patients in rural areas and suggest possible improvements for optimizing care. DATA SOURCES PubMed was searched for articles on patient care management, treatment challenges, rural health, and HAE. STUDY SELECTIONS Relevant articles were selected and reviewed. RESULTS Challenges in managing HAE in the rural setting were identified including obtaining a diagnosis of HAE, easy access to a physician with expertise in HAE, continuity of care, availability of telemedicine services, access to approved HAE therapies, patient education, and economic barriers to treatment. Ways to improve HAE patient care in rural areas include health care provider recognition of the undiagnosed HAE patient, development of individualized management plans, expansion of telemedicine, effective care at the local level, appropriate access to HAE medication, and increased awareness of patient support and advocacy groups. CONCLUSION For HAE patients living in rural areas, optimal care is complicated by health disparities. Given the scarcity with which these topics have been covered in the literature to date, it is intended that this article will serve as the impetus for a range of further initiatives focused on improving access to care.
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Affiliation(s)
- Marc A Riedl
- Division of Rheumatology, Allergy & Immunology, University of California San Diego, San Diego, California.
| | | | - John Anderson
- Alabama Allergy & Asthma Center, Birmingham, Alabama
| | - J Allen Meadows
- Alabama College of Osteopathic Medicine, Montgomery, Alabama
| | - Daniel Soteres
- Asthma and Allergy Associates PC, Colorado Springs, Colorado
| | - Stephen B LeBlanc
- Division of Allergy & Immunology, University of Mississippi Medical Center, Jackson, Mississippi
| | - H James Wedner
- The Asthma & Allergy Center, Washington University School of Medicine, St Louis, Missouri
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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Powell J, Piszczatoski C, Rubido E. Orladeyo (Berotralstat): A Novel Oral Therapy for the Prevention of Hereditary Angioedema. Ann Pharmacother 2021; 56:488-493. [PMID: 34282650 DOI: 10.1177/10600280211032982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The purpose of this article is to review the available trials that led to the Food and Drug Administration (FDA) approval of berotralstat, an oral kallikrein inhibitor, for the prevention of hereditary angioedema (HAE) attacks. DATA SOURCES PubMed and ClincalTrials.gov were searched using key term berotralstat to identify phase III clinical trials related to the FDA approval of berotralstat from April 2018 to May 2021. STUDY SELECTION AND DATA EXTRACTION Trials selected were those that influenced the FDA approval of berotralstat or provided novel information regarding the safety and efficacy of this therapy in the treatment of HAE. DATA SYNTHESIS Both APeX-2 and ApeX-J found clinically significant benefit with berotralstat 150 mg daily for reduction in HAE attacks when compared with placebo (1.31 vs 2.35, P < 0.001, and 1.11 vs 2.18, P < 0.001, attacks in the APeX-2 and APeX-J trials, respectively). APeX-2 also showed a statistically significant benefit for berotralstat 110 mg daily (1.65 vs 2.35 attacks [1.65 attacks, P = 0.024]). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE An advantage berotralstat has over the other approved therapies is that it is administered orally, which may garner patient preference because of ease of administration. Berotralstat has also shown a potential benefit in reducing the need for standard-of-care treatment for HAE attacks, which has not been studied with alternative agents. CONCLUSIONS Berotralstat 150 mg daily has been proven safe and effective in clinical studies and appears to be a viable oral alternative to parenteral medications currently used in HAE prophylaxis.
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Affiliation(s)
- Jason Powell
- University of Florida Colleges of Pharmacy and Medicine, Gainesville, FL, USA
| | - Chris Piszczatoski
- University of Florida Colleges of Pharmacy and Medicine, Gainesville, FL, USA
| | - Eric Rubido
- University of Florida College of Pharmacy, Gainesville, FL, USA
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Jindal AK, Rawat A, Kaur A, Sharma D, Suri D, Gupta A, Garg R, Dogra S, Saikia B, Minz RW, Singh S. Novel SERPING1 gene mutations and clinical experience of type 1 hereditary angioedema from North India. Pediatr Allergy Immunol 2021; 32:599-611. [PMID: 33220126 DOI: 10.1111/pai.13420] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND There is paucity of literature on long-term follow-up of patients with hereditary angioedema (HAE) from developing countries. OBJECTIVE This study was carried out to analyze the clinical manifestations, laboratory features, and genetic profile of 32 patients (21 male and 11 female) from 23 families diagnosed with HAE between January 1996 and December 2019. METHODS Data were retrieved from medical records of Paediatric Immunodeficiency Clinic, Postgraduate Institute of Medical Education and Research, Chandigarh, India. RESULTS Median age at onset of symptoms was 6.25 years (range 1-25 years), and median age at diagnosis was 12 years (range 2-43 years). Serum complement C4 level was decreased in all patients. All patients had low C1-esterase inhibitor (C1-INH) quantitative level (type 1 HAE). SERPING1 gene sequencing could be carried out in 20 families. Of these, 11 were identified to have a pathogenic disease-causing variant in the SERPING1 gene. While 2 of these families had a previously reported mutation, remaining 9 families had novel pathogenic variants in SERPING1 gene. Because of non-availability of C1-INH therapy in India, all patients were given long-term prophylaxis (attenuated androgens or tranexamic acid (TA) or a combination of the 2). Life-threatening episodes of laryngeal edema were managed with fresh-frozen plasma (FPP) infusions. We recorded one disease-related mortality in our cohort. This happened in spite of long-term prophylaxis with stanozolol and TA. CONCLUSIONS We report largest single-center cohort of patients with HAE from India. Attenuated androgens, fibrinolytic agents, and FPP may be used for management of HAE in resource-limited settings.
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Affiliation(s)
- Ankur K Jindal
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anit Kaur
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dhrubajyoti Sharma
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anju Gupta
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravinder Garg
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Biman Saikia
- Department of Immunopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ranjana W Minz
- Department of Immunopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Hereditary angioedema: a disease seldom diagnosed by pediatricians. J Pediatr (Rio J) 2021; 97 Suppl 1:S10-S16. [PMID: 33271064 PMCID: PMC9432246 DOI: 10.1016/j.jped.2020.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To describe the hereditary angioedema to improve awareness of this condition and reduce diagnostic delay. DATA SOURCES Relevant articles in the MEDLINE database through PubMed. DATA SYNTHESIS Hereditary angioedema is rare and has an autosomal dominant pattern of inheritance. Its onset occurs mainly in childhood, but there is an important delay in the diagnosis. In the most frequent phenotype, there is a quantitative and/or functional deficiency in the C1esterase inhibitor protein, which regulates the activation of the complement, contact and fibrinolysis systems with greater formation of bradykinin, the main mediator of angioedema. There is a third type, the hereditary angioedema with a normal C1 inhibitor level, which is rare in children. Clinical manifestations are characterized by recurrent angioedema attacks, mainly in the extremities, abdomen and upper airways, which can progress to asphyxia and death. The main triggers are mechanical trauma, infections and stress. The diagnosis is attained by patient clinical picture and decreased serum levels of C4 and C1esterase inhibitor or its function. In hereditary angioedema with a normal C1 inhibitor, there is no change in these parameters, thus requiring a genetic study. Treatment is based on the use of attack medications and long and short-term prophylaxis. CONCLUSIONS Hereditary angioedema is little known by pediatricians due to the significant delay in diagnosis of this condition, whose onset usually begins in childhood. The presence of recurrent angioedema that does not respond to treatment with antihistamines, corticosteroids and adrenaline should increase the diagnostic suspicion.
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Porebski G, Kwitniewski M, Reshef A. Biomarkers in Hereditary Angioedema. Clin Rev Allergy Immunol 2021; 60:404-415. [PMID: 33560480 PMCID: PMC8272698 DOI: 10.1007/s12016-021-08845-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 12/20/2022]
Abstract
A biomarker is a defined characteristic measured as an indicator of normal, biologic, pathogenic processes, or biological responses to an exposure or intervention. Diagnostic biomarkers are used to detect a disease or a subtype of a disease; monitoring biomarkers are measured serially to assess a medical condition; response biomarkers are used to check biologic response following a medical intervention; predictive biomarkers are used to identify patients who are more likely to respond to a medical intervention; and prognostic biomarkers are used to assess the future likelihood of a clinical event. Although biomarkers have been extensively investigated and validated in many diseases and pathologies, very few are currently useful for the diagnosis, evaluation of disease activity, and treatment of hereditary angioedema (HAE). Pathophysiologic pathways involved in HAE reveal a plethora of molecules from the complement, coagulation, and fibrinolysis systems or from the vascular endothelium, which may serve as biomarkers. The most promising candidates, together with their laboratory readout systems, should be evaluated with regard to their analytical and clinical validity and utility. To be highly specific, such biomarkers should be linked to the pathomechanisms of HAE, particularly the bradykinin-generating cascade. Additionally, major advances in high-throughput omics-based technologies may facilitate the discovery of new candidate biomarkers in the future. This review will cover the existing as well as future potential biomarkers that will support the diagnosis, monitor disease activity, and can be used to assess the efficacy of new avenues of therapy of HAE and other forms of angioedema.
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Affiliation(s)
- Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland.
| | - Mateusz Kwitniewski
- Department of Immunology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Avner Reshef
- Barzilai University Medical Centre, Ashkelon, Israel
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23
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Veronez CL, Mendes AR, Leite CS, Gomes CP, Grumach AS, Pesquero JB. The Panorama of Primary Angioedema in the Brazilian Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:2293-2304.e5. [PMID: 33276216 DOI: 10.1016/j.jaip.2020.11.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary angioedema (PA) is a complex disorder, presenting multiple hereditary (hereditary angioedema) and acquired subtypes (acquired angioedema). Despite a very similar clinical presentation among subtypes, the differential diagnosis is limited by the difficulty to identify bradykinin-mediated PA and the lack of specific biomarkers. OBJECTIVES To report the clinical and genetic features of Brazilian patients with PA. METHODS Brazilian patients referred from 50 centers were diagnosed on the basis of clinical symptoms, C1 inhibitor (C1-INH) and C4 plasma measurements, and DNA sequencing of genes associated with hereditary angioedema. RESULTS We characterized 92 patients with acquired angioedema and 425 with HAE: 125 with C1-INH deficiency, 180 with F12 mutations, and 120 of unknown cause. Thirty-one different mutations were identified in SERPING1 and 2 in F12, in addition to 2 mutations of uncertain significance in the ANGPT1 gene. The molecular diagnosis was decisive for 34 patients with HAE without family history, and for 39% of patients with inconsistent biochemical measurements. The median delay in diagnosis was 10 years, with a maximum of 18 years for HAE with C1-INH deficiency. Androgens and tranexamic acid were the most used drugs for long-term prophylaxis in all the PA subtypes, and they were used on demand by 15% of patients. Only 10% of patients reported the use of specific medication for HAE during attacks. CONCLUSIONS Our analysis exposes a broad picture of PA diagnosis and management in a developing country. Complement measurements presented considerable inconsistencies, increasing the diagnosis delay, while patients with PA with normal C1-INH remain with an inaccurate diagnosis and unspecific treatment.
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Affiliation(s)
- Camila Lopes Veronez
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil; Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, Calif; Research Service, San Diego Veterans Affairs Healthcare, San Diego, Calif.
| | | | | | - Caio Perez Gomes
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
| | - Anete Sevciovic Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitário Saúde ABC, Santo Andre, Brazil
| | - João Bosco Pesquero
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
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24
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Rajan N, Sharma V, Patro SK, Goyal A. Acute Presentation of Undiagnosed Hereditary Angioedema of the Larynx: Averting Death. Turk Arch Otorhinolaryngol 2020; 58:279-281. [PMID: 33554204 PMCID: PMC7846295 DOI: 10.5152/tao.2020.5994] [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] [Received: 09/17/2020] [Accepted: 11/09/2020] [Indexed: 11/22/2022] Open
Abstract
Hereditary angioedema (HAE) differs from histamine-mediated angioedema in that it is resistant to steroids and antihistamines. Laryngeal attacks of this condition, if not diagnosed timely, carry a mortality rate up to 34%. Rarely, this disease goes undiagnosed until late adulthood and presents a life-threatening episode that poses a management challenge to the emergency physician. We report the case of a 48-year-old man who presented to the emergency department with progressive breathing difficulty two hours after consuming a carbonated drink. Clinical examination revealed supraglottic edema. He did not respond to steroids or antihistamines and required emergency tracheostomy to secure the airway due to failed intubation. Absence of symptoms such as itching or urticaria and inadequate response to steroids pointed to hereditary angioedema. Low complement factor 4 levels with low C1 esterase inhibitor functionality confirmed the diagnosis. This case report highlights the fact that delayed presentation of HAE can be life threatening and the diagnosis should be considered in all non-atopic adult patients with angioedema.
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Affiliation(s)
- Nikhil Rajan
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, India
| | - Vidhu Sharma
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, India
| | - Sourabha Kumar Patro
- Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Goyal
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, India
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25
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Nabilou S, Pak F, Alizadeh Z, Fazlollahi MR, Houshmand M, Ayazi M, Mohammadzadeh I, Bemanian MH, Fayezi A, Nabavi M, Saghafi S, Mohammadian S, Kokhaei P, Moin M, Pourpak Z. Genetic Study of Hereditary Angioedema Type I and Type II (First Report from Iranian Patients: Describing Three New Mutations). Immunol Invest 2020; 51:170-181. [PMID: 32896191 DOI: 10.1080/08820139.2020.1817068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hereditary Angioedema (HAE) is a rare autosomal dominant immunodeficiency disease with mutation in C1 inhibitor gene (SERPING1) which deficient and dysfunction of C1-INH protein result in HAE type I or type II, respectively. The present study aimed to define the genetic spectrum of HAE type I and type II among Iranian patients. METHODS Thirty-four patients with clinical phenotype of recurrent edematous attacks in face, upper and lower limbs, hands, and upper airway entered the study. Mutations in SERPING1 were analyzed using PCR and Sanger Sequencing. In addition, Multiplex Ligation-dependent Probe Amplification (MLPA) was performed to discover large deletions or duplications in negative screening samples by Sanger. RESULTS Twenty-three patients were diagnosed with HAE type I and 11 with HAE type II. Fourteen distinctive pathogenic variations including five frameshift (p.G217Vfs*, p.V454Gfs*18, p.S422Lfs*9, p.S36Ffs*21, p.L243Cfs*9), seven missense (p.A2V, p.G493R, p.V147E, p.G143R, p.L481P, p.P399H, p.R466C), one nonsense (p.R494*), and one splicing defect (C.51 + 2 T˃C), which three of these mutations were identified novel. However, no mutation was found in seven patients by Sanger sequencing and MLPA. CONCLUSION Final diagnosis with mutation analysis of HAE after clinical evaluation and assessment of C1INH level and function can prevent potential risks and life-threatening manifestations of the disorder. In addition, genetic diagnosis can play a significant role in facilitating early diagnosis, pre-symptomatic diagnosis, early diagnosis of children, asymptomatic cases, and those patients who have the borderline biochemical results of C1-INH deficiency and/or C4.
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Affiliation(s)
- Susan Nabilou
- Department of Immunology, Semnan University of Medical Sciences and Health Services, Semnan, Iran
| | - Fatemeh Pak
- Cancer Research Center, Semnan University of Medical Sciences and Health Services, Semnan, Iran.,Cancer Center Karolinska, Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Zahra Alizadeh
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Fazlollahi
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Houshmand
- Department of Medical Genetics, National Institute of Genetic Engineering and Biotechnology (NIGEB), Tehran, Iran
| | - Maryam Ayazi
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Iraj Mohammadzadeh
- Non-communicable Pediatric Diseases Research Center, Babol University of Medical Sciences, Babol, Iran
| | - Mohammad Hasan Bemanian
- Department of Allergy, Rasool-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Abbas Fayezi
- Division of Allergy and Immunology, School of Medicine, Ahvaz Jondishapour University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Nabavi
- Department of Allergy, Rasool-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shiva Saghafi
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sajedeh Mohammadian
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Parviz Kokhaei
- Cancer Research Center, Semnan University of Medical Sciences and Health Services, Semnan, Iran.,Cancer Center Karolinska, Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Mostafa Moin
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Immunology and Allergy, Tehran University of Medical Sciences Children Hospital, Tehran, Iran
| | - Zahra Pourpak
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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26
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Busse PJ, Christiansen SC, Riedl MA, Banerji A, Bernstein JA, Castaldo AJ, Craig T, Davis-Lorton M, Frank MM, Li HH, Lumry WR, Zuraw BL. US HAEA Medical Advisory Board 2020 Guidelines for the Management of Hereditary Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:132-150.e3. [PMID: 32898710 DOI: 10.1016/j.jaip.2020.08.046] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 08/28/2020] [Accepted: 08/29/2020] [Indexed: 01/29/2023]
Abstract
Scientific and clinical progress together with the development of effective novel therapeutic options has engendered multiple important changes in the diagnosis and management of hereditary angioedema (HAE). We now update and extend the 2013 United States Hereditary Angioedema Association Medical Advisory Board guidelines for the treatment and management of HAE. The guidelines are based on a comprehensive literature review with recommendations indicating both the strength of our recommendation and the quality of the underlying evidence. Guidelines are provided regarding the classification, diagnosis, on-demand treatment, prophylactic treatment, special considerations for women and children, development of a comprehensive management and monitoring plan, and assessment of burden of illness for both HAE due to C1 inhibitor deficiency and HAE with normal C1 inhibitor. Advances in HAE treatment now allow the development of management plans that can help many patients with HAE lead a normal life. Achieving this goal requires that physicians be familiar with the diagnostic and therapeutic transformations that have occurred in recent years.
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Affiliation(s)
- Paula J Busse
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Sandra C Christiansen
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, Calif
| | - Marc A Riedl
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, Calif
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Harvard Medical School, Boston, Mass
| | - Jonathan A Bernstein
- Division of Immunology, Rheumatology, and Allergy, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Timothy Craig
- Division of Allergy, Asthma, and Immunology, Department of Medicine, Pediatrics, and Graduate Studies, Pennsylvania State University, Hershey, Pa
| | - Mark Davis-Lorton
- Division of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, NYU Winthrop Hospital, Mineola, NY
| | - Michael M Frank
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - H Henry Li
- Medicine Service, Institute for Asthma and Allergy, Chevy Chase, Md
| | - William R Lumry
- Allergy and Asthma Research Associates Research Center, Dallas, Tex
| | - Bruce L Zuraw
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, Calif; San Diego Veterans Administration Healthcare, San Diego, Calif.
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27
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Angioedema without urticaria: novel findings which must be measured in clinical setting. Curr Opin Allergy Clin Immunol 2020; 20:253-260. [DOI: 10.1097/aci.0000000000000633] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Parallel comparison of three methodologies for measuring functional C1-inhibitor in Hereditary angioedema patients. Int Immunopharmacol 2020; 81:106348. [DOI: 10.1016/j.intimp.2020.106348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 02/18/2020] [Accepted: 02/23/2020] [Indexed: 11/17/2022]
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29
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Kaplan AP, Pawaskar D, Chiao J. C1 Inhibitor Activity and Angioedema Attacks in Patients with Hereditary Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:892-900. [DOI: 10.1016/j.jaip.2019.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 11/28/2022]
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30
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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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A hereditary angioedema screening in two villages, based on an index case, and identification of a novel mutation, "1033G>T", at the SERPING1 gene. Postepy Dermatol Alergol 2019; 36:403-411. [PMID: 31616213 PMCID: PMC6791162 DOI: 10.5114/ada.2018.78898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 05/01/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Hereditary angioedema (HAE) may be fatal and diagnosis can be delayed up to 10 years. We aimed to screen HAE in two villages based on an index case of HAE and to investigate for the mutation of the C1 esterase inhibitor (C1-INH) gene. Material and methods A total of 124 people were screened in two villages. The frequency and severity of symptoms were scored. C4, C1-INH levels and C1-INH activity were measured. We investigated for mutations of the C1-INH gene. Results Thirty-five cases of type I HAE and 7 cases of type II HAE were determined. Thirty-one (73.8%) patients diagnosed with HAE were 18 years old or younger. There was a positive correlation between C4 levels, C1-INH levels (p < 0.0001, r = 0.81), and C1-INH activity levels (p < 0.0001, r = 0.631) and between the age at diagnosis and severity score (p < 0.0001, r = 0.651). A positive correlation was found between the age at first symptom onset and C4 levels (p = 0.002, r = 0.774), and C1-INH levels (p = 0.006, r = 0.714). A marginally significant negative correlation was found between C1-INH activity levels and severity scores (p = 0.1, r = -0.515). We identified a novel heterozygous 1033G>T missense variant of the C1-INH gene, SERPING1, in patients with type I HAE. Conclusions There are long delay periods in the diagnosis of HAE and when the index case is present, family screening may be very important and even life-saving, in particular, in paediatric patients without symptoms. Furthermore, the present study provides evidence to link a novel mutation, c.1033G>T, to the development of HAE in a large HAE family from Turkey.
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Frese M, Beard N, Mere P, Katelaris C, Mills K. Interventions for the treatment of acute hereditary angioedema attacks. Hippokratia 2019. [DOI: 10.1002/14651858.cd013402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Michael Frese
- University of Canberra; Faculty of Science and Technology; Bruce ACT Australia 2617
| | - Nicole Beard
- University of Canberra; Faculty of Science and Technology; Bruce ACT Australia 2617
| | - Peter Mere
- Macquarie University; Department of Mathematics and Statistics; 12 Wally's Walk L6 Macquarie Park NSW Australia 2113
| | - Constance Katelaris
- Campbelltown Hospital; Department of Medicine; Therry Rd Campbelltown NSW Australia 2560
| | - Kerry Mills
- University of Canberra; Faculty of Science and Technology; Bruce ACT Australia 2617
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Abstract
Angioedema is a clinical entity defined as self-limiting edema localized in the deeper layers of the skin and mucosa and lasting for several days. Angioedema can be provoked by bradykinin and/or mast cell mediators, including histamine. Four types of acquired and three types of hereditary angioedema have been identified. The most obvious form of angioedema associated with other systemic disease is acquired angioedema due to C1-inhibitor deficiency. It is characterized by acquired consumption of C1 inhibitor and various underlying disorders, such as multiple myeloma, chronic lymphocytic leukemia, rectal carcinoma, and non-Hodgkin lymphoma. Suspected cases need an accurate differential diagnosis to exclude all other types of acquired and hereditary angioedema.
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Long BJ, Koyfman A, Gottlieb M. Evaluation and Management of Angioedema in the Emergency Department. West J Emerg Med 2019; 20:587-600. [PMID: 31316698 PMCID: PMC6625683 DOI: 10.5811/westjem.2019.5.42650] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 01/14/2023] Open
Abstract
Angioedema is defined by non-dependent, non-pitting edema that affects several different sites and is potentially life-threatening due to laryngeal edema. This narrative review provides emergency physicians with a focused overview of the evaluation and management of angioedema. Two primary forms include histamine-mediated and bradykinin-mediated angioedema. Histamine-mediated forms present similarly to anaphylaxis, while bradykinin-mediated angioedema presents with greater face and oropharyngeal involvement and higher risk of progression. Initial evaluation and management should focus on evaluation of the airway, followed by obtaining relevant historical features, including family history, medications, and prior episodes. Histamine-mediated angioedema should be treated with epinephrine intramuscularly, antihistaminergic medications, and steroids. These medications are not effective for bradykinin-mediated forms. Other medications include C1-INH protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists. Evidence is controversial concerning the efficacy of these medications in an acute episode, and airway management is the most important intervention when indicated. Airway intervention may require fiberoptic or video laryngoscopy, with preparation for cricothyrotomy. Disposition is dependent on patient's airway and respiratory status, as well as the sites involved.
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Affiliation(s)
- Brit Jeffrey Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Craig T, Zuraw B, Longhurst H, Cicardi M, Bork K, Grattan C, Katelaris C, Sussman G, Keith PK, Yang W, Hébert J, Hanzlikova J, Staubach-Renz P, Martinez-Saguer I, Magerl M, Aygören-Pürsün E, Farkas H, Reshef A, Kivity S, Neri S, Crisan I, Caballero T, Baeza ML, Hernandez MD, Li H, Lumry W, Bernstein JA, Hussain I, Anderson J, Schwartz LB, Jacobs J, Manning M, Levy D, Riedl M, Christiansen S, Feuersenger H, Pragst I, Mycroft S, Pawaskar D, Jacobs I. Long-Term Outcomes with Subcutaneous C1-Inhibitor Replacement Therapy for Prevention of Hereditary Angioedema Attacks. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:1793-1802.e2. [PMID: 30772477 DOI: 10.1016/j.jaip.2019.01.054] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/03/2019] [Accepted: 01/28/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND For the prevention of attacks of hereditary angioedema (HAE), the efficacy and safety of subcutaneous human C1-esterase inhibitor (C1-INH[SC]; HAEGARDA, CSL Behring) was established in the 16-week Clinical Study for Optimal Management of Preventing Angioedema with Low-Volume Subcutaneous C1-Inhibitor Replacement Therapy (COMPACT). OBJECTIVE To assess the long-term safety, occurrence of angioedema attacks, and use of rescue medication with C1-INH(SC). METHODS Open-label, randomized, parallel-arm extension of COMPACT across 11 countries. Patients with frequent angioedema attacks, either study treatment-naive or who had completed COMPACT, were randomly assigned (1:1) to 40 IU/kg or 60 IU/kg C1-INH(SC) twice per week, with conditional uptitration to optimize prophylaxis (ClinicalTrials.gov registration no. NCT02316353). RESULTS A total of 126 patients with a monthly attack rate of 4.3 in 3 months before entry in COMPACT were enrolled and treated for a mean of 1.5 years; 44 patients (34.9%) had more than 2 years of exposure. Mean steady-state C1-INH functional activity increased to 66.6% with 60 IU/kg. Incidence of adverse events was low and similar in both dose groups (11.3 and 8.5 events per patient-year for 40 IU/kg and 60 IU/kg, respectively). For 40 IU/kg and 60 IU/kg, median annualized attack rates were 1.3 and 1.0, respectively, and median rescue medication use was 0.2 and 0.0 times per year, respectively. Of 23 patients receiving 60 IU/kg for more than 2 years, 19 (83%) were attack-free during months 25 to 30 of treatment. CONCLUSIONS In patients with frequent HAE attacks, long-term replacement therapy with C1-INH(SC) is safe and exhibits a substantial and sustained prophylactic effect, with the vast majority of patients becoming free from debilitating disease symptoms.
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Affiliation(s)
- Timothy Craig
- Department of Medicine, Pediatrics and Graduate Studies, Penn State University Hershey Medical Center, Hershey, Pa.
| | - Bruce Zuraw
- Department of Medicine, University of California San Diego and San Diego VA Healthcare, La Jolla, Calif
| | - Hilary Longhurst
- Immunology Department, Barts Health NHS Trust, The Royal London Hospital, London, United Kingdom
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, "L. Sacco" University of Milan/ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Mainz, Germany
| | - Clive Grattan
- St John's Institute of Dermatology, Tower Wing Guy's Hospital, London, United Kingdom
| | - Constance Katelaris
- Department of Medicine, Immunology and Allergy, Campbelltown Hospital, Campbelltown, NSW, Australia
| | - Gordon Sussman
- Gordon Sussman Clinical Research, Inc, Toronto, ON, Canada
| | - Paul K Keith
- McMaster University Medical Center Site, Hamilton, ON, Canada
| | - William Yang
- Ottawa Allergy Research Corp, Ottawa, ON, Canada
| | - Jacques Hébert
- Clinique Specialisée en Allergie de la Capitale (CSAC), Québec, QC, Canada
| | - Jana Hanzlikova
- Fakultni nemocnice Plzen - Ustav Imunologie a Alergologie, Plzen, Czech Republic
| | - Petra Staubach-Renz
- Clinical Research Centre, Hautklinik und Poliklinik der Universitätsklinik Mainz, Mainz, Germany
| | | | - Markus Magerl
- Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Emel Aygören-Pürsün
- Klinikum der Johann Wolfgang-Goethe Universität, Klinik für Kinder- und Jugendmedizin, Frankfurt, Germany
| | - Henriette Farkas
- Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Avner Reshef
- Barzilai University Medical Center, Allergy, Immunology & Angioedema, Ashkelon, Israel
| | - Shmuel Kivity
- Tel Aviv Sourasky Medical Center, Allergy and Immunology Unit, Tel Aviv, Israel
| | - Sergio Neri
- Dipartimento di Medicina Interna, Azienda Ospedaliero - Universitaria "Policlinico - Vittorio Emanuele," Catania, Italy
| | - Ioana Crisan
- Spitalul Clinic Municipal Cluj, Cluj Napoca, Romania
| | - Teresa Caballero
- Servicio de Alergia, Hospital, La Paz Institute for Health Research (IdiPaz), Centro de Investigacion Biomédica en Red de Enfermedades Raras (CIBERER)-U754, Madrid, Spain
| | - Maria L Baeza
- Hospital General Universitario Gregorio Marañón, Servicio de Alergología, Instituto de Investigación Gregorio Marañón, Centro de Investigacion Biomédica en Red de Enfermedades Raras (CIBERER)-U761, Madrid, Spain
| | | | - Henry Li
- Institute for Asthma and Allergy, Chevy Chase, Md
| | | | | | | | - John Anderson
- Clinical Research Center of Alabama, Alabama Allergy & Asthma, Birmingham, Ala
| | - Lawrence B Schwartz
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Va
| | - Joshua Jacobs
- Allergy & Asthma Clinical Research, Walnut Creek, Calif
| | | | | | - Marc Riedl
- Clinical Allergy and Immunology Section, University of California San Diego School of Medicine, La Jolla, Calif
| | - Sandra Christiansen
- Clinical Allergy and Immunology Section, University of California San Diego School of Medicine, La Jolla, Calif
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Bygum A. Hereditary Angio-Oedema for Dermatologists. Dermatology 2019; 235:263-275. [PMID: 31167185 DOI: 10.1159/000500196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/08/2019] [Indexed: 11/19/2022] Open
Abstract
Among angio-oedema patients, hereditary angio-oedema (HAE) should not be overlooked. Besides skin swellings, these patients might have very painful abdominal attacks and potentially life-threatening angio-oedema of the upper airway. They will not respond to traditional anti-allergic therapy with antihistamines, corticosteroids, and adrenaline, and instead need specific drugs targeting the kallikrein-kinin pathway. Classically, patients with HAE have a quantitative or qualitative deficiency of the C1 inhibitor (C1INH) due to different mutations in SERPING1, although a new subtype with normal C1INH has been recognised more recently. This latter variant is diagnosed based on clinical features, family history, or molecular genetic testing for mutations in F12, ANGPT1,or PLG.The diagnosis of HAE is often delayed due to a general unfamiliarity with this orphan disease. However, undiagnosed patients are at an increased risk of unnecessary surgical interventions or life-threatening laryngeal swellings. Within the last decade, new and effective therapies have been developed and launched for acute and prophylactic therapy. Even more drugs are under evaluation in clinical trials. It is therefore of utmost importance that patients with HAE are diagnosed as soon as possible and offered relevant therapy with orphan drugs to reduce morbidity, prevent mortality, and improve quality of life.
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Affiliation(s)
- Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark,
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Tange CE, Johnson-Brett B, Cook A, Stordeur P, Brohet F, Jolles S, Steven R, Ponsford M, Roberts A, El-Shanawany T, Harding S, Wallis G, Parker AR. Quantification of human complement C2 protein using an automated turbidimetric immunoassay. Clin Chem Lab Med 2019; 56:1498-1506. [PMID: 29729138 DOI: 10.1515/cclm-2017-1068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/09/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND The measurement of complement components is clinically useful where a deficiency is suspected, or where excessive activation and consumption are present in disease. C2 deficiency carries an increased risk of developing systemic lupus erythematosus, recurrent infections and atherosclerosis. In this study, we have evaluated The Binding Site's Human Complement C2 SPAPLUS® assay. METHODS Linearity was tested using 13 sample dilutions covering the standard measuring range. Within- and between-assay variabilities were calculated using five samples with different C2 concentrations. The correlation between C2 concentrations in EDTA-plasma and serum was assessed, as was the correlation between C2 measurements by the automated assay and radial immunodiffusion. C2 concentrations were compared with CH50 activity, and quantified in individuals with homozygous or heterozygous C2 deficiency, acquired angioedema and patients with chronic inflammatory conditions. RESULTS The assay was linear across the measuring range (3.8-42.3 mg/L). Intra- and interassay variability were 2.3%-3.8% and 0%-3.3%, respectively. Comparison between C2 measurements in EDTA-plasma and serum provided a strong correlation (p<0.0001, R2=0.82, slope 0.92), as did the correlation between the automated and radial immunodiffusion methods (p<0.0001, R2=0.89, slope 1.07). A positive correlation between C2 concentration and CH50 activity was demonstrated (p<0.0001, R2=0.48). Significant differences were observed between the median C2 concentrations obtained in healthy controls and the patient clinical samples, with homozygous C2-deficient patients giving below detectable results. CONCLUSIONS This C2 SPAPLUS® assay allows the automated, rapid and precice quantification of complement C2 protein and could therefore be considered as a replacement for older, more time-consuming methods.
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Affiliation(s)
| | | | - Alex Cook
- The Binding Site Group Limited, Birmingham, UK
| | - Patrick Stordeur
- Immunobiology Clinic, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabian Brohet
- Immunobiology Clinic, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Rachel Steven
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mark Ponsford
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Andrew Roberts
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Tariq El-Shanawany
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
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Charest-Morin X, Betschel S, Borici-Mazi R, Kanani A, Lacuesta G, Rivard GÉ, Wagner E, Wasserman S, Yang B, Drouet C. The diagnosis of hereditary angioedema with C1 inhibitor deficiency: a survey of Canadian physicians and laboratories. Allergy Asthma Clin Immunol 2018; 14:83. [PMID: 30479631 PMCID: PMC6249925 DOI: 10.1186/s13223-018-0307-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 11/10/2018] [Indexed: 12/20/2022] Open
Abstract
Background Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is an autosomal dominant disease resulting in random and unpredictable attacks of swelling. The swelling in C1-INH-HAE is a result of impaired regulation of bradykinin production. The fact that the array of tests needed to diagnose HAE is not always available to the treating physicians is challenging for them and their patients. Methods The data for this article were extracted from two distinct surveys. The first survey was conducted among HAE treating physicians and aimed to determine the availability and utilization of the various assays performed to help the diagnosis of C1-INH-HAE. The second survey was conducted with the various laboratories across Canada that performs the assays used in the diagnosis of HAE. The aim of this survey was to determine the availability and profile of the various assays used in the diagnosis of C1-INH-HAE in Canada, thereby ultimately bringing a rational basis for the biological testing. Results C1-INH functional assay was widely available in Canada (93%), but was only offered by a small numbers of hospitals meaning that there could be longer delays in the analysis of these samples that may explain why the physicians expressed a lower level of confidence in this assay (59%). Antigenic C1-INH was available to the vast majority of the physicians treating C1-INH-HAE (93%) and was considered reliable by 96% of the respondents. Antigenic C4 was found available to all Canadian physicians and, although with limited specificity, was considered very reliable by all the participants. This study revealed that 81% of physicians were able to order the antigenic C1q and the confidence in this assay was moderate (70%). Concerning genetic testing, the survey revealed that most of the CHAEN members never had to or couldn't order this test. Conclusion This study highlights the need for improved education and knowledge exchange, about biological assays available to Canadian physicians and their performance in proper diagnosis of C1-INH-HAE to improve confidence and access to relevant tests.
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Affiliation(s)
- Xavier Charest-Morin
- 1Department of Microbiology-Infectious Disease and Immunology, Laval University, Quebec, QC Canada
| | - Stephen Betschel
- 2Division of Clinical Immunology and Allergy, St. Michael's Hospital, University of Toronto, Toronto, ON Canada
| | - Rozita Borici-Mazi
- 3Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Amin Kanani
- 4Division of Allergy and Immunology, Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Gina Lacuesta
- 5Department of Medicine, Dalhousie University, Halifax, NS Canada
| | - Georges-Étienne Rivard
- 6Hematology/Oncology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC Canada
| | - Eric Wagner
- 7Immunology and Histocompatibility Laboratory, CHU de Quebec, Laval University, Quebec, QC Canada
| | - Susan Wasserman
- 8Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Bill Yang
- 9University of Ottawa Medical School, Ottawa, ON Canada
| | - Christian Drouet
- 10GREPI EA7408, University Grenoble Alpes, Grenoble, France.,Filière de santé Maladies Rares Immuno-Hématologiques (MaRIH), CHU Grenoble Alpes, Grenoble, France.,12Present Address: INSERM U1016, Institut Cochin and Laboratoire d'Immunologie, Hôpital Cochin, AP-HP, Université Paris-Descartes, Paris, France
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Fukunaga A, Tsuchiyama S, Lee K, Washio K, Hashimura C, Horiuchi T, Nishigori C. The relationship between complement levels and disease activity in Japanese family cases of hereditary angioedema with C1-INH deficiency. Allergol Int 2018; 67:518-520. [PMID: 29661499 DOI: 10.1016/j.alit.2018.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/26/2018] [Accepted: 03/08/2018] [Indexed: 10/17/2022] Open
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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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Tange CE, Kaur A, Verma N, Hickey A, Grigoriadou S, Scott C, Kiani S, Steven R, Ponsford M, El-Shanawany T, Jolles S, Harding S, Parker AR. Quantification of human C1 esterase inhibitor protein using an automated turbidimetric immunoassay. J Clin Lab Anal 2018; 33:e22627. [PMID: 30058083 PMCID: PMC6430339 DOI: 10.1002/jcla.22627] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 12/02/2022] Open
Abstract
Background Impaired levels or function of C1 inhibitor (C1‐INH) results in angioedema due to increased bradykinin. It is important to distinguish between angioedema related to C1‐INH deficiency and that caused by other mechanisms, as treatment options are different. In hereditary (HAE) and acquired (AAE) angioedema, C1‐INH concentration is measured to aid patient diagnosis. Here, we describe an automated turbidimetric assay to measure C1‐INH concentration on the Optilite® analyzer. Methods Linearity, precision, and interference were established over a range of C1‐INH concentrations. The 95th percentile reference interval was generated from 120 healthy adult donors. To compare the Optilite C1‐INH assay with a predicate assay used in a clinical laboratory, samples sent for C1‐INH investigation were used. The predicate results were provided to allow comparison. Results The Optilite C1‐INH assay was linear across the measuring range at the standard sample dilution. Intra and interassay variability was <6%. The 95th percentile adult reference interval for the assay was 0.21‐0.38 g/L. There was a strong correlation between the Optilite concentrations and those generated with the predicate assay (R2 = 0.94, P < 0.0001, slope y = 0.83x). All patients with Type I HAE (n = 24) and AAE (n = 3) tested had concentrations below the measuring range in both assays, while all patients with unspecified angioedema (UAE), not diagnosed with HAE or AAE had values within the reference range. Conclusion The Optilite assay allows the automated and precise quantification of C1‐INH concentrations in patient samples. It could therefore be used as a tool to aid the investigation of patients with angioedema.
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Affiliation(s)
| | - Amrit Kaur
- The Binding Site Group Limited, Birmingham, UK
| | | | | | | | | | | | - Rachael Steven
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mark Ponsford
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Tariq El-Shanawany
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
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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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44
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Complement factor C4 activation in patients with hereditary angioedema. Clin Biochem 2017; 50:816-821. [DOI: 10.1016/j.clinbiochem.2017.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/07/2017] [Accepted: 04/11/2017] [Indexed: 01/08/2023]
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46
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Csuka D, Veszeli N, Varga L, Prohászka Z, Farkas H. The role of the complement system in hereditary angioedema. Mol Immunol 2017; 89:59-68. [PMID: 28595743 DOI: 10.1016/j.molimm.2017.05.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/22/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Abstract
Hereditary angioedema (HAE) is a rare, but potentially life-threatening disorder, characterized by acute, recurring, and self-limiting edematous episodes of the face, extremities, trunk, genitals, upper airways, or the gastrointestinal tract. HAE may be caused by the deficiency of C1-inhibitor (C1-INH-HAE) but another type of the disease, hereditary angioedema with normal C1-INH function (nC1-INH-HAE) was also described. The patient population is quite heterogeneous as regards the location, frequency, and severity of edematous attacks, presenting large intra- and inter-individual variation. Here, we review the role of the complement system in the pathomechanism of HAE and also present an overview on the complement parameters having an importance in the diagnosis or in predicting the severity of HAE.
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Affiliation(s)
- Dorottya Csuka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
| | - Nóra Veszeli
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Zoltán Prohászka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
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Aabom A, Andersen KE, Fagerberg C, Fisker N, Jakobsen MA, Bygum A. Clinical characteristics and real-life diagnostic approaches in all Danish children with hereditary angioedema. Orphanet J Rare Dis 2017; 12:55. [PMID: 28302171 PMCID: PMC5356294 DOI: 10.1186/s13023-017-0604-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 02/27/2017] [Indexed: 11/24/2022] Open
Abstract
Background With a potentially early onset, hereditary angioedema (HAE) requires special knowledge also in infancy and early childhood. In children from families with HAE, the diagnosis should be confirmed or refuted early, which can be difficult. Studies of childhood HAE and the diagnostic approaches are limited. Our aim was to investigate the entire Danish cohort of children with HAE and non-HAE children of HAE patients for diagnostic approaches and clinical characteristics. Results We included 41 children: 22 with HAE and 19 non-HAE. Of the HAE children, 14 were symptomatic—median age at onset was 4 [1–11] years. The first attack was peripheral in 8/14 children and abdominal in 6/14 children, i.e. no one had their first attacks in the upper airways. Most children had less than one attack per month. All of the symptomatic children had been treated with tranexamic acid and/or C1 inhibitor concentrate. Unlike in other countries, androgens were not used in our pediatric cohort. Home therapy with C1 inhibitor concentrate was established in 9 cases: 6 children were trained in self-administration and 3 children were treated by parents. Of the children, 10 had been diagnosed by symptoms, including 3 without family history—median age of diagnosis among these children was 5.35 [2–13.2] years. In 31 children, HAE was diagnosed or refuted before symptoms by blood samples. In 23 of these children, complement values were investigated, and in 9 cases genetic testing was added to the complement measurements. In 8 children recently investigated, genetic testing was first choice. Cord blood was used for complement measurements in 9 children and for genetic testing in 4 children. Results of complement measurements were equivocal in several cases, especially in the cord blood samples, and the sensitivity of low complement C4 for the diagnosis of HAE was 75%. Conclusions We investigated clinical characteristics in all Danish children with HAE. The rate of home therapy was high and androgens had been avoided. Complement values were often equivocal, especially in cord blood samples. Consequently, we have changed diagnostic practice to early genetic testing in children where the family mutation is known.
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Affiliation(s)
- Anne Aabom
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark. .,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark.
| | - Klaus E Andersen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark.,Center for Innovative Medical Technology, Institute for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christina Fagerberg
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Niels Fisker
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Marianne A Jakobsen
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark.,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
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Hereditary C1 inhibitor deficiency is associated with high spontaneous amidase activity. Mol Immunol 2017; 85:120-122. [PMID: 28222330 DOI: 10.1016/j.molimm.2017.01.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/26/2017] [Accepted: 01/31/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Angioedema diagnosis classically targets the complement system (via C1 inhibitor (C1Inh) function and antigenic C4 level) and contact phase activation (via amidase activity). Bradykinin is responsible for angioedema attacks and is produced from contact phase activation secondary to failed C1Inh control. OBJECTIVE We aimed to compare the diagnostic performances of spontaneous amidase activity and antigenic C4 level in C1Inh hereditary angioedema (C1Inh-HAE) patients. METHODS Samples from 185 C1Inh-HAE patients (81 men, 104 women; confirmed by SERPING1 gene mutations) and from 99 blood donors (50 men, 49 women) were tested for C1Inh function, antigenic C4 level and spontaneous amidase activity. RESULTS In the C1Inh-HAE group, antigenic C4 level was decreased (n=135) and amidase activity was increased (n=181). Receiver operating characteristic analyses showed higher diagnostic performance values for the spontaneous amidase assay compared to those of antigenic C4. CONCLUSION The spontaneous amidase activity assay should replace antigenic C4 level testing and should be tested alongside the C1Inh function for both AE screening and follow up of HAE patients.
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Abstract
Angioedema, as a distinct disease entity, often becomes a clinical challenge for physicians, because it may cause a life-threatening condition, whereas prompt and accurate laboratory diagnostics may not be available. Although the bedside diagnosis needs to be established based on clinical symptoms and signs, family history, and the therapeutic response, later, laboratory tests are available. Currently, only for five out of the nine different types of angioedema can be diagnosed by laboratory testing, and these occur only in a minority of the patient population. Hereditary angioedema with C1-inhibitor (C1-INH) deficiency type I can be diagnosed by the low C1-INH function and concentration, whereas in type II, C1-INH function is low, but its concentration is normal or even elevated. C1q concentration is normal in both forms. Acquired angioedema with C1-INH deficiency type I is characterized by the low C1-INH function and concentration; however, C1q concentration is also low, and autoantibodies against C1-INH cannot be detected. Complement profile of acquired angioedema with C1-INH deficiency type II is similar to that of type I, but in this form, autoantibodies against C1-INH are present. Hereditary angioedema due to a mutation of the coagulation factor XII can be diagnosed exclusively by mutation analysis of FXII gene. Diagnostic metrics are not available for idiopathic histaminergic acquired angioedema, idiopathic non-histaminergic acquired angioedema, acquired angioedema related to angiotensin-converting enzyme inhibitor, and hereditary angioedema of unknown origin; these angioedemas can be diagnosed by medical and family history, clinical symptoms, and therapeutic response and by excluding the forms previously described. Several potential biomarkers of angioedema are used to date only in research. In the future, they could be utilized into the clinical practice to improve the differential diagnosis, therapy, as well as the prognosis of angioedema.
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Henao MP, Kraschnewski JL, Kelbel T, Craig TJ. Diagnosis and screening of patients with hereditary angioedema in primary care. Ther Clin Risk Manag 2016; 12:701-11. [PMID: 27194914 PMCID: PMC4859422 DOI: 10.2147/tcrm.s86293] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant disease that commonly manifests with episodes of cutaneous or submucosal angioedema and intense abdominal pain. The condition usually presents due to a deficiency of C1 esterase inhibitor (C1-INH) that leads to the overproduction of bradykinin, causing an abrupt increase in vascular permeability. A less-understood and less-common form of the disease presents with normal C1-INH levels. Symptoms of angioedema may be confused initially with mast cell-mediated angioedema, such as allergic reactions, and may perplex physicians when epinephrine, antihistamine, or glucocorticoid therapies do not provide relief. Similarly, abdominal attacks may lead to unnecessary surgeries or opiate dependence. All affected individuals are at risk for a life-threatening episode of laryngeal angioedema, which continues to be a source of fatalities due to asphyxiation. Unfortunately, the diagnosis is delayed on average by almost a decade due to a misunderstanding of symptoms and general lack of awareness of the disease. Once physicians suspect HAE, however, diagnostic methods are reliable and available at most laboratories, and include testing for C4, C1-INH protein, and C1-INH functional levels. In patients with HAE, management consists of acute treatment of an attack as well as possible short- or long-term prophylaxis. Plasma-derived C1-INH, ecallantide, icatibant, and recombinant human C1-INH are new treatments that have been shown to be safe and effective in the treatment of HAE attacks. The current understanding of HAE has greatly improved in recent decades, leading to growing awareness, new treatments, improved management strategies, and better outcomes for patients.
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Affiliation(s)
- Maria Paula Henao
- Department of Medicine, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Jennifer L Kraschnewski
- Department of Medicine, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Theodore Kelbel
- Division of Allergy and Immunology, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Timothy J Craig
- Department of Medicine and Pediatrics, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
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