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Petersen RS, Fijen LM, Kelder JP, Cohn DM. Deucrictibant for angioedema due to acquired C1-inhibitor deficiency: A randomized-controlled trial. J Allergy Clin Immunol 2024; 154:179-183. [PMID: 38494092 DOI: 10.1016/j.jaci.2024.03.007] [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: 10/11/2023] [Revised: 02/14/2024] [Accepted: 03/01/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Angioedema due to acquired C1-inhibitor deficiency is a very rare but serious disease, with an estimated prevalence of 1 per 500,000 persons. There are no approved therapies to treat or prevent angioedema swelling in patients with this condition. Deucrictibant is a specific, orally bioavailable, competitive antagonist of the bradykinin B2 receptor currently under investigation for hereditary angioedema. OBJECTIVE Our aim was to assess the efficacy and safety of deucrictibant as acute and prophylactic treatment for angioedema due to acquired C1-inhibitor deficiency. METHODS A 2-part, randomized, double-blind, placebo-controlled crossover study was conducted. In Part 1, 4 consecutive angioedema attacks were treated with 3 doses of deucrictibant (10 mg, 20 mg, and 30 mg) or placebo. In Part 2, deucricibant, 20 mg, or placebo was administered twice daily for 2 treatment periods of 8 weeks. RESULTS Three patients were enrolled; of those 3 patients, 1 completed both study parts and 2 completed only Part 2. In Part 1, a reduction in attack severity was observed in the 3 attacks treated with deucrictibant as opposed to an increase in severity of the attack treated with placebo. In Part 2, the individual mean monthly attack rates were 2.0, 0.6, and 1.0 during the placebo period and 0.0 across all patients during treatment with deucrictibant. There were no severe adverse events and 1 self-limiting treatment-emergent adverse event (abdominal pain). CONCLUSIONS Deucrictibant has the potential to effectively and safely treat and prevent angioedema attacks due to acquired C1-inhibitor deficiency.
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Affiliation(s)
- Remy S Petersen
- Amsterdam University Medical Center, Department of Vascular Medicine, Amsterdam, and Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Lauré M Fijen
- Amsterdam University Medical Center, Department of Vascular Medicine, Amsterdam, and Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Johannes P Kelder
- Amsterdam University Medical Center, Department of Vascular Medicine, Amsterdam, and Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Danny M Cohn
- Amsterdam University Medical Center, Department of Vascular Medicine, Amsterdam, and Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands.
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Johnson F, Stenzl A, Hofauer B, Heppt H, Ebert EV, Wollenberg B, Lochbaum R, Hahn J, Greve J, Trainotti S. A Retrospective Analysis of Long-Term Prophylaxis with Berotralstat in Patients with Hereditary Angioedema and Acquired C1-Inhibitor Deficiency-Real-World Data. Clin Rev Allergy Immunol 2023; 65:354-364. [PMID: 37914894 PMCID: PMC10847220 DOI: 10.1007/s12016-023-08972-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2023] [Indexed: 11/03/2023]
Abstract
Hereditary angioedema (HAE) and acquired C1-inhibitor deficiency (AAE-C1-INH) are orphan diseases. Berotralstat is a recently licensed long-term prophylaxis (LTP) and the first oral therapy for HAE patients. No approved therapies exist for AAE-C1-INH patients. This study is the first to report real-world clinical data of patients with AAE-C1-INH and HAE who received Berotralstat. All patients treated with Berotralstat were included in this retrospective, bi-centric study. Data was collected from patients' attack calendars and the angioedema quality of life (AE-QoL) and angioedema control test (AECT) questionnaires before treatment, and at 3, 6, and 12 months after treatment and was then analyzed. Twelve patients were included, 3 patients with AAE-C1-INH, 7 patients with HAE type I, and 2 patients with HAE-nC1-INH. One patient (HAE I) quit treatment. Berotralstat was associated with fewer attacks in all groups. After 6 months of treatment, a median decrease of attacks per month was noted for HAE type I patients (3.3 to 1.5) and AAE-C1-INH patients (2.3 to 1.0). No aerodigestive attacks were noted for AAE-C1-INH patients. For HAE-nC1-INH patients, a mean decrease from 3.8 to 1.0 was noted (3 months). For HAE I patients, the total AE-QoL lowered a mean of 24.1 points after 6 months, for HAE-nC1-HAE patients 8.0 points, and for AAE-C1-INH patients 13.7 points. AECT scores increased for HAE I patients (mean: 7.1), HAE-nC1-INH patients (9.0), and AAE-C1-INH patients (4.2) after 6 months. Patients with HAE, HAE-nC1-INH, and AAE-C1-INH treated with Berotralstat showed reduced angioedema attacks and improved AE-QoL and AECT scores.
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Affiliation(s)
- Felix Johnson
- University Hospital for Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Anichstraße 35, A-6020, Innsbruck, Austria
| | - Anna Stenzl
- University Hospital for Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Anichstraße 35, A-6020, Innsbruck, Austria.
| | - Benedikt Hofauer
- University Hospital for Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Anichstraße 35, A-6020, Innsbruck, Austria
| | - Helen Heppt
- University Hospital for Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Anichstraße 35, A-6020, Innsbruck, Austria
| | - Eva-Vanessa Ebert
- Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum rechts der Isar, TUM School of Medicine and Health, Department Clinical Medicine, Munich, Germany
| | - Barbara Wollenberg
- Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum rechts der Isar, TUM School of Medicine and Health, Department Clinical Medicine, Munich, Germany
| | - Robin Lochbaum
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Janina Hahn
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Susanne Trainotti
- Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum rechts der Isar, TUM School of Medicine and Health, Department Clinical Medicine, Munich, Germany
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Shi Y, Wang C. Where we are with acquired angioedema due to C1 inhibitor deficiency: A systematic literature review. Clin Immunol 2021; 230:108819. [PMID: 34358691 DOI: 10.1016/j.clim.2021.108819] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022]
Abstract
Acquired angioedema due to C1 inhibitor deficiency (C1-INH-AAE) is a rare disease characterized by adult-onset recurrent non-urticarial angioedema with low levels of C1-INH. It is associated with lymphoproliferative disorders, and treatments are off-label with variable success. We conducted a systematic literature review to include patients with C1-INH-AAE identified in PubMed and Embase databases between January 2006 and February 2021. Clinical features of these patients were summarized, and factors associated with disease remission were explored. A total of 121 patients were included in the current study with a median age at diagnosis of 64 years and 45.5% being male. An associated disease was recorded in 94 patients (77.7%), and lymphoproliferative disorder was the most reported (59/94, 62.8%). Anti-C1-INH autoantibodies were present in 45 of 71 patients (63.4%). Factors impacting disease remissions included age (odds ratio [OR] 0.951, 95% confidence interval [CI] 0.909-0.994, p = 0.027), male (OR 0.327, 95% CI 0.124-0.866, p = 0.025), presence of monoclonal gammopathy (OR 0.133, 95% CI 0.041-0.429, p = 0.001), requirement of specific on-demand treatment (OR 0.216, 95% CI 0.066-0.709, p = 0.012) and rituximab use (OR 2.865, 95% CI 1.038-7.911, p = 0.042). A total of nine patients (7.4%) died at last follow up and most were unrelated to C1-INH-AAE. Our results imply that C1-INH-AAE is primarily associated with underlying B or plasma cell abnormalities, and clone-directed therapies could be promising options for its long-term management.
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Affiliation(s)
- Yiyun Shi
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Chen Wang
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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Mumneh N, Tick M, Borum M. Angioedema with severe acute abdominal pain: Think of hereditary angioedema. Clin Res Hepatol Gastroenterol 2021; 45:101702. [PMID: 33864899 DOI: 10.1016/j.clinre.2021.101702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/08/2021] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
Angioedema can be either mast cell-(histamine-)mediated or bradykinin-mediated. Treatment approaches for the two types are very different, making differential diagnosis critical. Severe acute abdominal pain caused by intestinal angioedema is commonly misdiagnosed, especially when associated with bradykinin-mediated angioedema. After describing a typical clinical scenario and diagnostic journey of a patient with recurrent, undiagnosed abdominal pain due to hereditary angioedema (HAE), a rare variant of bradykinin-mediated angioedema, we delve into the classification and differential diagnosis of the various types of angioedema and provide an overview of appropriate management with an emphasis on the bradykinin-mediated types. Bradykinin-induced angioedema may be inherited or acquired and is infrequent compared to mast cell-mediated angioedema. HAE is a rare disease characterized by recurrent attacks of non-urticarial, nonpruritic edema usually affecting the face, respiratory tract, extremities, gastrointestinal tract, and genitalia. Unlike mast cell-mediated angioedema, painful abdominal symptoms are prevalent in bradykinin-mediated angioedema and are sometimes the only manifestation of an attack, increasing the likelihood of initial misdiagnosis as appendicitis or other forms of acute abdomen. It is important for gastroenterologists to be vigilant for the possibility of angioedema pathology in patients presenting with undiagnosed, recurrent, abdominal symptoms to facilitate accurate diagnosis and effective treatment.
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Affiliation(s)
- Nayla Mumneh
- Medical Director Respiratory, Novartis Pharmaceuticals Corp, 1 Health Plaza, East Hanover, NJ, United States.
| | - Matthew Tick
- Gastroenterology Fellow, The George Washington University, 2121 I St NW, Washington, DC, United States
| | - Marie Borum
- Division of Gastroenterology and Liver Disease, The George Washington University, 3131 I St NW, Washington, DC, United States
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Angioedema. Interdisciplinary diagnostic and therapeutic recommendations of the Polish Dermatological Society (PTD) and Polish Society of Allergology (PTA). Postepy Dermatol Alergol 2020; 37:445-451. [PMID: 32994763 PMCID: PMC7507159 DOI: 10.5114/ada.2020.98226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 11/17/2022] Open
Abstract
Angioedema is a non-inflammatory oedema of the subcutaneous tissue and/or mucosal membranes. It most commonly coexists with urticaria wheals and is considered to be a deep form of urticaria. Less commonly, it occurs in isolation and can take two basic forms: acquired angioedema and hereditary angioedema. Currently, there are 4 defined types of acquired angioedema and 7 types of hereditary angioedema. Treatment of angioedema depends on its form and etiological factors. Especially the genetic form, i.e. hereditary angioedema, is a considerable challenge for medical specialists, particularly dermatologists and allergists.
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Abstract
A red swollen face can be a skin sign of a potentially life-threatening condition. We present in detail the main clinical presentations, diagnostic tests, and management of some of the most severe conditions that can frequently present as a red and swollen face: acute or recurrent angioedema, mast cell-driven or bradykinin-mediated angioedema, nonhereditary and hereditary angioedema, allergic or photoallergic facial contact dermatitis, contact urticaria, severe adverse drug reactions (particularly drug reaction with eosinophilia and systemic symptoms [DRESS]), skin infections (erysipelas, cellulitis, necrotizing fasciitis), and autoimmune diseases (dermatomyositis). There are many other conditions that also have to be considered in the differential diagnosis of a red swollen face.
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Affiliation(s)
- Mariana Batista
- Dermatology Department, Coimbra University Hospital, Coimbra, Portugal
| | - Margarida Gonçalo
- Dermatology Department, Coimbra University Hospital, Coimbra, Portugal; Clinic of Dermatology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
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Rasmussen ER, Aanæs K, Jakobsen MA, Bygum A. Acquired complement C1 esterase inhibitor deficiency in a patient with a rare SERPING1 variant with unknown significance. BMJ Case Rep 2019; 12:e231122. [PMID: 31488451 PMCID: PMC6731889 DOI: 10.1136/bcr-2019-231122] [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] [Accepted: 08/15/2019] [Indexed: 11/04/2022] Open
Abstract
Angioedema (AE) is caused by a wide range of diseases and pharmaceuticals; it can become life-threatening when located to the airways. Patients with deficiency or malfunction of complement C1 esterase inhibitor (hereditary or acquired) experience recurrent AE due to an accumulation of the vasoactive mediator bradykinin (BK). Complement C1 inhibitor normally decreases BK production, so a reduced function hereof causes increased levels. The diagnosis of hereditary or acquired AE can be difficult due to similarities to allergic reactions (swelling, abdominal pain, rash). We describe a 35-year-old man presenting with upper-airway AE progressing rapidly and promptly required cricothyroidotomy. Complement and autoantibody screening together with sequencing of SERPING1 were performed and gave the diagnosis of acquired complement C1 esterase inhibitor deficiency. The patient is unusual to have this disease before the age of 40 years. No associated comorbidities were found. It is important to know that antiallergic medication is not effective in BK-mediated AE.
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Affiliation(s)
- Eva Rye Rasmussen
- Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Kobenhavn, Denmark
- OPEN, Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Kasper Aanæs
- Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Kobenhavn, Denmark
| | | | - Anette Bygum
- OPEN, Clinical Institute, University of Southern Denmark, Odense, Denmark
- Dermatology and Allergy, Odense University Hospital, Odense, Denmark
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Raveendran S, Parameswaran B, Ummalyma SB, Abraham A, Mathew AK, Madhavan A, Rebello S, Pandey A. Applications of Microbial Enzymes in Food Industry. Food Technol Biotechnol 2018; 56:16-30. [PMID: 29795993 DOI: 10.17113/ftb.56.01.18.5491] [Citation(s) in RCA: 254] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The use of enzymes or microorganisms in food preparations is an age-old process. With the advancement of technology, novel enzymes with wide range of applications and specificity have been developed and new application areas are still being explored. Microorganisms such as bacteria, yeast and fungi and their enzymes are widely used in several food preparations for improving the taste and texture and they offer huge economic benefits to industries. Microbial enzymes are the preferred source to plants or animals due to several advantages such as easy, cost-effective and consistent production. The present review discusses the recent advancement in enzyme technology for food industries. A comprehensive list of enzymes used in food processing, the microbial source of these enzymes and the wide range of their application are discussed.
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Affiliation(s)
- Sindhu Raveendran
- Centre for Biofuels, National Institute for Interdisciplinary Science and Technology, CSIR, 695019 Trivandrum, India
| | - Binod Parameswaran
- Centre for Biofuels, National Institute for Interdisciplinary Science and Technology, CSIR, 695019 Trivandrum, India
| | - Sabeela Beevi Ummalyma
- Centre for Biofuels, National Institute for Interdisciplinary Science and Technology, CSIR, 695019 Trivandrum, India.,Institute of Bioresources and Sustainable Development, 795001 Imphal, India
| | - Amith Abraham
- Centre for Biofuels, National Institute for Interdisciplinary Science and Technology, CSIR, 695019 Trivandrum, India
| | - Anil Kuruvilla Mathew
- Centre for Biofuels, National Institute for Interdisciplinary Science and Technology, CSIR, 695019 Trivandrum, India
| | | | - Sharrel Rebello
- Communicable Disease Research Laboratory, St. Joseph's College, 680121 Irinjalakuda, India
| | - Ashok Pandey
- CSIR-Indian Institute of Toxicology Research (CSIR-IITR), 226001 Lucknow, India
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9
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Abstract
Acquired angioedema due to C1-INH deficiency (C1-INH-AAE) can occur when there are acquired (not inherited) deficiencies of C1-INH. A quantitative or functional C1-INH deficiency with negative family history and low C1q is diagnostic of C1-INH-AAE. The most common conditions associated with C1-INH-AAE are autoimmunity and B-cell lymphoproliferative disorders. A diagnosis of C1-INH-AAE can precede a diagnosis of lymphoproliferative disease and confers an increased risk for developing non-Hodgkin lymphoma. Treatment focuses on symptom control with therapies that regulate bradykinin activity (C1-INH concentrate, icatibant, ecallantide, tranexamic acid, androgens) and treatment of any underlying conditions.
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Affiliation(s)
- Iris M Otani
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, UCSF Medical Center, 400 Parnassus Avenue, Box 0359, San Francisco, CA 94143, USA.
| | - Aleena Banerji
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Cox 201 Allergy Associates, Boston, MA 02114, USA
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Zanichelli A, Azin GM, Wu MA, Suffritti C, Maggioni L, Caccia S, Perego F, Vacchini R, Cicardi M. Diagnosis, Course, and Management of Angioedema in Patients With Acquired C1-Inhibitor Deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1307-1313. [PMID: 28284781 DOI: 10.1016/j.jaip.2016.12.032] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/13/2016] [Accepted: 12/21/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND Acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) is a rare disease with no prevalence data or approved therapies. OBJECTIVE To report data on patients with C1-INH-AAE followed at Angioedema Center, Milan (from 1976 to 2015). METHODS Diagnostic criteria included history of recurrent angioedema without wheals; decreased C1-INH antigen levels and/or functional activity of C1-INH and C4 antigen less than 50% of normal; late symptom onset (>40 years); no family history of angioedema and C1-INH deficiency. RESULTS In total, 77 patients (58% females; median age, 70 years) were diagnosed with C1-INH-AAE and 675 patients with hereditary angioedema due to C1-INH deficiency (C1-INH-HAE) (1 patient with C1-INH-AAE/8.8 patients with C1-INH-HAE). Median age at diagnosis was 64 years. Median time between symptom onset and diagnosis was 2 years. Sixteen patients (21%) died since diagnosis, including 1 because of laryngeal edema. Angioedema of the face was most common (N = 63 [82%]), followed by abdomen (N = 51 [66%]), peripheries (N = 50 [65%]), and oral mucosa and/or glottis (N = 42 [55%]). Forty-eight of 71 patients (68%) had autoantibodies to C1-INH. In total, 56 patients (70%) used on-demand treatment for angioedema including intravenous pdC1-INH 2000 U (Berinert, CSL Behring, Marburg, Germany) (N = 49) and/or subcutaneous icatibant 30 mg (Firazyr, Shire; Milano, Italy) (N = 27). Eventually, 8 of 49 patients receiving pdC1-INH became nonresponsive; all had autoantibodies. Thirty-four patients received long-term prophylaxis with tranexamic acid (effective in 29) and 20 with androgens (effective in 8). CONCLUSIONS The incidence of C1-INH-AAE was 1 for every 8.8 patients with C1-INH-HAE. Thirty percent of the deaths were related to the disease. Treatments approved for C1-INH-HAE are effective in C1-INH-AAE, although with minimal differences.
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Affiliation(s)
- Andrea Zanichelli
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy.
| | - Giulia Maria Azin
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Chiara Suffritti
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Lorena Maggioni
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Sonia Caccia
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Francesca Perego
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Romualdo Vacchini
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy; ASST Fatebenefratelli Sacco, Milan, Italy
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Longhurst HJ, Zanichelli A, Caballero T, Bouillet L, Aberer W, Maurer M, Fain O, Fabien V, Andresen I. Comparing acquired angioedema with hereditary angioedema (types I/II): findings from the Icatibant Outcome Survey. Clin Exp Immunol 2017; 188:148-153. [PMID: 27936514 PMCID: PMC5343339 DOI: 10.1111/cei.12910] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2016] [Indexed: 11/26/2022] Open
Abstract
Icatibant is used to treat acute hereditary angioedema with C1 inhibitor deficiency types I/II (C1-INH-HAE types I/II) and has shown promise in angioedema due to acquired C1 inhibitor deficiency (C1-INH-AAE). Data from the Icatibant Outcome Survey (IOS) were analysed to evaluate the effectiveness of icatibant in the treatment of patients with C1-INH-AAE and compare disease characteristics with those with C1-INH-HAE types I/II. Key medical history (including prior occurrence of attacks) was recorded upon IOS enrolment. Thereafter, data were recorded retrospectively at approximately 6-month intervals during patient follow-up visits. In the icatibant-treated population, 16 patients with C1-INH-AAE had 287 attacks and 415 patients with C1-INH-HAE types I/II had 2245 attacks. Patients with C1-INH-AAE versus C1-INH-HAE types I/II were more often male (69 versus 42%; P = 0·035) and had a significantly later mean (95% confidence interval) age of symptom onset [57·9 (51·33-64·53) versus 14·0 (12·70-15·26) years]. Time from symptom onset to diagnosis was significantly shorter in patients with C1-INH-AAE versus C1-INH-HAE types I/II (mean 12·3 months versus 118·1 months; P = 0·006). Patients with C1-INH-AAE showed a trend for higher occurrence of attacks involving the face (35 versus 21% of attacks; P = 0·064). Overall, angioedema attacks were more severe in patients with C1-INH-HAE types I/II versus C1-INH-AAE (61 versus 40% of attacks were classified as severe to very severe; P < 0·001). Median total attack duration was 5·0 h and 9·0 h for patients with C1-INH-AAE versus C1-INH-HAE types I/II, respectively.
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Affiliation(s)
- H J Longhurst
- Department of Immunology, Barts Health NHS Trust, London, UK
| | - A Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Luigi Sacco Hospital Milan, Milan, Italy
| | - T Caballero
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPaz), Biomedical Research Network on Rare Diseases (CIBERER, U754), Madrid, Spain
| | - L Bouillet
- National Reference Centre for Angioedema, Internal Medicine Department, Grenoble University Hospital, Grenoble, France
| | - W Aberer
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - M Maurer
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - O Fain
- Department of Internal Medicine, DHU i2B, Saint Antoine Hospital, University Paris 6, Paris, France
| | - V Fabien
- Shire, Zug, Switzerland at the time of data analysis. Now with Vifor Pharma, Glattbrugg, Switzerland
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Bekos C, Perkmann T, Krauth M, Raderer M, Lechner K, Jaeger U. Acquired C1 esterase inhibitor deficiency in lymphomas: prevalence, symptoms, and response to treatment. Leuk Lymphoma 2016; 57:2033-6. [PMID: 26795750 DOI: 10.3109/10428194.2015.1131273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We retrospectively studied the prevalence of C1 esterase inhibitor (C1 INH) deficiency in 131 patients with various lymphomas. We determined C1 INH activity, C1 INH antigen, and C4 concentration at diagnosis and after chemotherapy. In follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL) and chronic lymphocytic leukemia (CLL) consecutive patients were studied. In these entities, the prevalence of C1 INH deficiency was 10.2% in DLBCL, 4.1% in CLL, and 0% in FL and Hodgkin lymphoma. In indolent lymphomas, we identified only single cases of C1 INH deficiency, predominantly in splenic marginal zone lymphomas (SMZL) (four cases). Only three patients were symptomatic while the majority (11 cases) was asymptomatic. In DLBCL patients who were successfully treated with chemotherapy, complete normalization of C1 INH activity and C4 was observed. In contrast, C1 INH deficiency remained in SMZL patients after splenectomy. We conclude that C1 INH deficiency in lymphomas is frequently asymptomatic and responsive to immunochemotherapy.
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Affiliation(s)
- Christine Bekos
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
| | - Thomas Perkmann
- b Clinical Institute of Laboratory Medicine and Clinical Chemistry, Medical University of Vienna , Vienna , Austria
| | - Maria Krauth
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
| | - Markus Raderer
- c Department of Medicine I, Division of Clinical Oncology , Comprehensive Cancer Center, Medical University of Vienna , Vienna , Austria
| | - Klaus Lechner
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
| | - Ulrich Jaeger
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
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Frazer-Abel A, Sepiashvili L, Mbughuni MM, Willrich MAV. Overview of Laboratory Testing and Clinical Presentations of Complement Deficiencies and Dysregulation. Adv Clin Chem 2016; 77:1-75. [PMID: 27717414 DOI: 10.1016/bs.acc.2016.06.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Historically, complement disorders have been attributed to immunodeficiency associated with severe or frequent infection. More recently, however, complement has been recognized for its role in inflammation, autoimmune disorders, and vision loss. This paradigm shift requires a fundamental change in how complement testing is performed and interpreted. Here, we provide an overview of the complement pathways and summarize recent literature related to hereditary and acquired angioedema, infectious diseases, autoimmunity, and age-related macular degeneration. The impact of complement dysregulation in atypical hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, and C3 glomerulopathies is also described. The advent of therapeutics such as eculizumab and other complement inhibitors has driven the need to more fully understand complement to facilitate diagnosis and monitoring. In this report, we review analytical methods and discuss challenges for the clinical laboratory in measuring this complex biochemical system.
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Abstract
Hereditary angioedema (HAE) is characterized as an episodic swelling disorder with autosomal dominant inheritance. Clinical features include nonpitting edema of external or mucosal body surfaces, and patients often present with swelling of the extremities, abdominal pain, and swelling of the mouth and throat, which can lead to asphyxiation. Patients with HAE classically have no associated urticaria, which is often referred to as nonhistaminergic angioedema. Treatment for HAE involves long-term prophylaxis, short-term prophylaxis, and management of acute attacks. Up until the past few years, acute HAE episodes were predominately treated with supportive measures. Three classes of medications have recently been approved by the US Food and Drug Administration (FDA) for the management of acute HAE attacks. Ecallantide, a recombinant protein that acts as a reversible inhibitor of kallikrein, is currently indicated for acute attacks of HAE in those aged ≥12 years. In two randomized, double-blind, placebo-controlled, multicenter trials, EDEMA3 and EDEMA4, patients treated with 30 mg of ecallantide demonstrated statistically significant improvement in symptoms compared to those on placebo. In addition to its use as treatment for HAE, ecallantide has been used off label in the management of nonhistaminergic angioedema, not due to HAE. Ecallantide has shown promise in the treatment of these other forms; however, data are limited to mainly case reports at this time. Ecallantide is generally a safe and well-tolerated medication; however, based on reports of anaphylaxis, ecallantide does contain a black box warning. Due to the risk of anaphylaxis, ecallantide cannot be self-administered and must be given by a health care professional. Overall, ecallantide is a safe and effective medication for the treatment of acute attacks of HAE.
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Affiliation(s)
- Hannah Duffey
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rafael Firszt
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA ; Division of Allergy, Immunology and Rheumatology, University of Utah, Salt Lake City, UT, USA
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An evidence based therapeutic approach to hereditary and acquired angioedema. Curr Opin Allergy Clin Immunol 2015; 14:354-62. [PMID: 24983294 DOI: 10.1097/aci.0000000000000082] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hereditary angioedema (HAE) due to C1 esterase inhibitor (C1-INH) deficiency (HAE-C1-INH), HAE with normal C1-INH, and acquired angioedema due to C1-INH deficiency are rare but important diseases that can be associated with significant morbidity and mortality. Research into the pathogenesis of angioedema has expanded greatly and has led to new clinical trials with novel therapeutic agents and strategies. RECENT FINDINGS Strategies for managing HAE-C1-INH are aimed at treating acute attacks or preventing attacks through the use of prophylactic treatment. Agents available in Europe for treating acute attacks include plasma-derived C1-INH concentrates, a bradykinin B2 receptor (B2R) antagonist, and a recombinant human C1-INH. In the USA, a plasma-derived C1-INH concentrate, a bradykinin B2R antagonist, and a plasma kallikrein inhibitor have been approved for the treatment of acute HAE-C1-INH attacks. C1-INH concentrates and attenuated androgens are used for short-term prophylactic treatment. Long-term prophylactic treatments include attenuated androgens, a plasma-derived C1-INH concentrate, and antifibrinolytics. Plasma-derived C1-INH and a bradykinin B2R antagonist are approved for self-administration at home. SUMMARY The number of management options for HAE-C1-INH and similar conditions has increased considerably within the last few years, thus helping to alleviate the burden of these rare diseases.
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Cicardi M, Aberer W, Banerji A, Bas M, Bernstein JA, Bork K, Caballero T, Farkas H, Grumach A, Kaplan AP, Riedl MA, Triggiani M, Zanichelli A, Zuraw B. Classification, diagnosis, and approach to treatment for angioedema: consensus report from the Hereditary Angioedema International Working Group. Allergy 2014; 69:602-16. [PMID: 24673465 DOI: 10.1111/all.12380] [Citation(s) in RCA: 428] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 01/13/2023]
Abstract
Angioedema is defined as localized and self-limiting edema of the subcutaneous and submucosal tissue, due to a temporary increase in vascular permeability caused by the release of vasoactive mediator(s). When angioedema recurs without significant wheals, the patient should be diagnosed to have angioedema as a distinct disease. In the absence of accepted classification, different types of angioedema are not uniquely identified. For this reason, the European Academy of Allergy and Clinical Immunology gave its patronage to a consensus conference aimed at classifying angioedema. Four types of acquired and three types of hereditary angioedema were identified as separate forms from the analysis of the literature and were presented in detail at the meeting. Here, we summarize the analysis of the data and the resulting classification of angioedema.
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Affiliation(s)
- M. Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - W. Aberer
- Department of Dermatology; Medical University of Graz; Graz Austria
| | - A. Banerji
- Division of Rheumatology, Allergy and Immunology; Massachusetts General Hospital; Boston MA USA
| | - M. Bas
- Department of Otorhinolaryngology; Klinikum rechts der Isar; Technische Universität München; Munich Germany
| | - J. A. Bernstein
- Division of Immunology/Allergy Section; Department of Internal Medicine; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - K. Bork
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
| | - T. Caballero
- Department of Allergy; Hospital La Paz Institute for Health Research (IdiPaz); Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - H. Farkas
- 3rd Department of Internal Medicine; National Angioedema Center; Semmelweis University; Budapest Hungary
| | - A. Grumach
- Department of Clinical Medicine; Faculty of Medicine ABC; Sao Paulo Brazil
| | - A. P. Kaplan
- Medical University of South Carolina; Charleston SC
| | - M. A. Riedl
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
| | - M. Triggiani
- Department of Medicine; University of Salerno; Salerno Italy
| | - A. Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - B. Zuraw
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
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Cicardi M, Bellis P, Bertazzoni G, Cancian M, Chiesa M, Cremonesi P, Marino P, Montano N, Morselli C, Ottaviani F, Perricone R, Triggiani M, Zanichelli A. Guidance for diagnosis and treatment of acute angioedema in the emergency department: consensus statement by a panel of Italian experts. Intern Emerg Med 2014; 9:85-92. [PMID: 24002787 DOI: 10.1007/s11739-013-0993-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 08/21/2013] [Indexed: 11/25/2022]
Abstract
Angioedema attacks, characterized by the transient swelling of the skin and mucosae, are a frequent cause of visits to the emergency department. Swellings of the oral cavity, tongue, or larynx can result in life-threatening airway obstruction, while abdominal attacks can cause severe pain and often lead to unnecessary surgery. The underlying pathophysiologic process resulting in increased vascular permeability and plasma extravasation is mediated by vasoactive molecules, most commonly histamine and bradykinin. Based on the mediator involved, distinct angioedema forms can be recognized, calling for distinct therapeutic approaches. Prompt recognition is challenging for the emergency physician. The low awareness among physicians of the existence of rare forms of angioedema with different aetiologies and pathogenesis, considerably adds to the problem. Also poorly appreciated by emergency personnel may be the recently introduced bradykinin-targeted treatments. The main objective of this consensus statement is to provide guidance for the management of acute angioedema in the emergency department, from presentation to discharge or hospital admission, with a focus on identifying patients in whom new treatments may prevent invasive intervention.
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Affiliation(s)
- Marco Cicardi
- Medicina Interna, Ospedale Luigi Sacco, Università degli Studi di Milano, Milan, Italy,
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