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Yeich A, Elhatw A, Ashoor Z, Park K, Craig T. Safety of medications for hereditary angioedema during pregnancy and lactation. Expert Opin Drug Saf 2023; 22:17-24. [PMID: 36744397 DOI: 10.1080/14740338.2023.2177269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hereditary Angioedema (HAE) attacks show an increased frequency and severity for pregnant and lactating females secondary to the hormonal changes. The diagnosis and management of HAE in pregnant and lactating females pose a challenge for physicians due to the rarity of the disease and the paucity of the data for specific management. AREAS COVERED In this manuscript, we discuss the diagnosis and special presentation of HAE types 1 and 2 in pregnant and lactating females, including acute management, short-term prophylaxis, long-term prophylaxis, and drugs that should be avoided. Relevant publications were found through key word search of papers indexed in both Google Scholar and PubMed on 1 July 2022. EXPERT OPINION Treatment of HAE in the past has been mainly provided by experts; however, with more medications and an increasing number of patients, knowledge of how to care for HAE patients during pregnancy and lactation is important to review. Despite approval of additional medications in many countries, plasma-derived C1-inhibitor remains the drug of first choice for treatment in this unique population. Additional research is needed to increase safe access to other therapy options. We hope that future clinical studies, registries, and databases will shed additional light on this subject.
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Affiliation(s)
- Andrew Yeich
- Department of Allergy, Asthma and Immunology, Medical Student, Penn State College of Medicine, Hershey, PA, USA
| | - Ahmed Elhatw
- Department of Allergy, Asthma and Immunology, Resident, Cairo University School of Medicine, Giza, Egypt
| | - Zaynab Ashoor
- Department of Allergy, Asthma and Immunology, Medical Student, Cairo University School of Medicine, Giza, Egypt
| | - Kristen Park
- Department of Allergy, Asthma and Immunology, Medical Student, Penn State College of Medicine, Hershey, PA, USA
| | - Timothy Craig
- Department of Allergy, Asthma, and Immunology, Professor of Medicine, Pediatrics, and Biomedical Sciences, Hershey, PA, USA
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Drouet C, López-Lera A, Ghannam A, López-Trascasa M, Cichon S, Ponard D, Parsopoulou F, Grombirikova H, Freiberger T, Rijavec M, Veronez CL, Pesquero JB, Germenis AE. SERPING1 Variants and C1-INH Biological Function: A Close Relationship With C1-INH-HAE. Front Allergy 2022; 3:835503. [PMID: 35958943 PMCID: PMC9361472 DOI: 10.3389/falgy.2022.835503] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/16/2022] [Indexed: 11/13/2022] Open
Abstract
Hereditary angioedema with C1 Inhibitor deficiency (C1-INH-HAE) is caused by a constellation of variants of the SERPING1 gene (n = 809; 1,494 pedigrees), accounting for 86.8% of HAE families, showing a pronounced mutagenic liability of SERPING1 and pertaining to 5.6% de novo variants. C1-INH is the major control serpin of the kallikrein–kinin system (KKS). In addition, C1-INH controls complement C1 and plasminogen activation, both systems contributing to inflammation. Recognizing the failed control of C1s protease or KKS provides the diagnosis of C1-INH-HAE. SERPING1 variants usually behave in an autosomal-dominant character with an incomplete penetrance and a low prevalence. A great majority of variants (809/893; 90.5%) that were introduced into online database have been considered as pathogenic/likely pathogenic. Haploinsufficiency is a common feature in C1-INH-HAE where a dominant-negative variant product impacts the wild-type allele and renders it inactive. Small (36.2%) and large (8.3%) deletions/duplications are common, with exon 4 as the most affected one. Point substitutions with missense variants (32.2%) are of interest for the serpin structure–function relationship. Canonical splice sites can be affected by variants within introns and exons also (14.3%). For noncanonical sequences, exon skipping has been confirmed by splicing analyses of patients' blood-derived RNAs (n = 25). Exonic variants (n = 6) can affect exon splicing. Rare deep-intron variants (n = 6), putatively acting as pseudo-exon activating mutations, have been characterized as pathogenic. Some variants have been characterized as benign/likely benign/of uncertain significance (n = 74). This category includes some homozygous (n = 10) or compound heterozygous variants (n = 11). They are presenting with minor allele frequency (MAF) below 0.00002 (i.e., lower than C1-INH-HAE frequency), and may be quantitatively unable to cause haploinsufficiency. Rare benign variants could contribute as disease modifiers. Gonadal mosaicism in C1-INH-HAE is rare and must be distinguished from a de novo variant. Situations with paternal or maternal disomy have been recorded (n = 3). Genotypes must be interpreted with biological investigation fitting with C1-INH expression and typing. Any SERPING1 variant reminiscent of the dysfunctional phenotype of serpin with multimerization or latency should be identified as serpinopathy.
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Affiliation(s)
- Christian Drouet
- Department of Infection, Immunity and Inflammation, Institut Cochin, INSERM UMR1016, Université de Paris, Paris, France
- Univ. Grenoble-Alpes & Centre Hospitalier Universitaire de Grenoble, Grenoble, France
- *Correspondence: Christian Drouet
| | - Alberto López-Lera
- Hospital La Paz Institute for Health Research (IdiPAZ), CIBERER U-754, Madrid, Spain
| | | | - Margarita López-Trascasa
- Hospital La Paz Institute for Health Research (IdiPAZ), Universidad Autónoma de Madrid, Madrid, Spain
| | - Sven Cichon
- Human Genomics Research Group, Department of Biomedicine, University of Basel, Basel, Switzerland
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Denise Ponard
- Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | | | - Hana Grombirikova
- Molecular Genetics Laboratory, Centre for Cardiovascular Surgery and Transplantation Brno and Medical Faculty, Masaryk University, Brno, Czechia
| | - Tomáš Freiberger
- Molecular Genetics Laboratory, Centre for Cardiovascular Surgery and Transplantation Brno and Medical Faculty, Masaryk University, Brno, Czechia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Camila L. Veronez
- Department of Biophysics, Centre for Research and Genetic Diagnosis of Genetic Diseases, Federal University of São Paolo, São Paolo, Brazil
| | - João Bosco Pesquero
- Department of Biophysics, Centre for Research and Genetic Diagnosis of Genetic Diseases, Federal University of São Paolo, São Paolo, Brazil
| | - Anastasios E. Germenis
- CeMIA SA, Larissa, Greece
- Department of Immunology & Histocompatibility, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
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Germenis AE, Rijavec M, Veronez CL. Leveraging Genetics for Hereditary Angioedema: A Road Map to Precision Medicine. Clin Rev Allergy Immunol 2021; 60:416-428. [PMID: 33507496 DOI: 10.1007/s12016-021-08836-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 12/25/2022]
Abstract
Biochemical studies performed during the last decades resulted in the development of various innovative medicinal products for hereditary angioedema (HAE). These therapeutic agents target the production or the function of bradykinin-the main mediator of HAE due to C1-inhibitor (C1-INH) deficiency. However, despite these remarkable achievements, current knowledge cannot provide convincing explanations for the clinical variability of the disease. As a consequence, treatment indications apply for drugs available for C1-INH deficiency. The advent of high-throughput next-generation sequencing technologies may assist in covering the missing part of our understanding of HAE pathogenesis. During the last 3 years alone, several new entities were added to the already described genotypes. The recent discovery of four novel target genes expands our understanding of other causes which may explain recurrent angioedema in individuals and families with normal C1-INH activity. Furthermore, new genetic technologies allowed the recognition of deep intronic variants associated with the disease, and elegant functional studies characterized new variants for the C1-INH gene. Thus, evidence has been provided regarding pathogenetic aspects remaining obscure for many years, such as the defective intracellular transport of mutant C1-INH, and environmental effect on the disease expression. Therefore, it seems that the stage for Precision Medicine era in HAE management is ready. Disease endotypes are expected to be uncovered and specified targets for therapeutic intervention will be detected, promising a more effective, individualized management of the disease.
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Affiliation(s)
- Anastasios E Germenis
- Department of Immunology and Histocompatibility, School of Medicine, University of Thessaly, 3 Panepistimiou Street, GR-41500, Biopolis Larissa, Greece.
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Camila Lopes Veronez
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, University of California San Diego, San Diego, CA, USA.,Research Service, San Diego Veterans Affairs Healthcare, San Diego, CA, USA
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Abstract
The availability of effective acute treatment for angioedema has been fundamental in reducing the burden of illness for patients with hereditary angioedema (HAE). In building on the foundation of scientific advances that elucidate the pathomechanism(s) of attacks related to vascular permeability, novel targeted on-demand treatments have been developed and approved. These therapies have provided the means to arrest episodes of swelling, which, in the past, had the potential to inexorably lead to morbidity, and even mortality, for patients with HAE. Access to these medications, along with an emphasis on early administration and guidance that all attacks are candidates for treatment, has shifted the management paradigm for HAE. Although unmet needs remain, these acute therapies, coupled with advances in prophylactic treatment, have furthered the goal for all patients with HAE to live a normal life.
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Affiliation(s)
| | - Bruce L. Zuraw
- From the University of California San Diego, La Jolla, California; and
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Bork K, Machnig T, Wulff K, Witzke G, Prusty S, Hardt J. Clinical features of genetically characterized types of hereditary angioedema with normal C1 inhibitor: a systematic review of qualitative evidence. Orphanet J Rare Dis 2020; 15:289. [PMID: 33059692 PMCID: PMC7559394 DOI: 10.1186/s13023-020-01570-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/05/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Hereditary angioedema (HAE) with normal C1 inhibitor (C1-INH) (HAEnCI) is associated with skin swellings, abdominal attacks, and the risk of asphyxia due to upper airway obstruction. Several different gene mutations linked to the HAE phenotype have been identified. Our aim was to qualitatively assess and describe the clinical differentiators of these genetically identified HAEnCI types. To achieve this, we performed a systematic literature review of patients with angioedema symptoms and a genetically confirmed diagnosis of an HAEnCI type. RESULTS A systematic literature search, conducted in March 2020, returned 132 records, 43 of which describe patients with symptoms of angioedema and a genetically confirmed diagnosis of an HAEnCI type. Overall, this included 602 patient cases from 220 families. HAEnCI with a mutation in the coagulation factor XII gene (F12) (HAE-FXII) was diagnosed in 446 patients from 185 families (male:female ratio = 1:10). Estrogens (oral contraceptives, hormonal replacement therapy, and pregnancy) negatively impacted the course of disease in most female patients (252 of 277). Asphyxia occurred in 2 of 446 patients. On-demand and/or long-term prophylaxis treatment included C1-INH concentrates, icatibant, progestins, and tranexamic acid. HAEnCI with a specific mutation in the plasminogen gene (HAE-PLG) was diagnosed in 146 patients from 33 families (male:female ratio = 1:3). Estrogens had a negative influence on the course of disease in the minority of female patients (14 of 62). Tongue swelling was an important clinical feature. Asphyxia occurred in 3 of 146 patients. On-demand treatment with icatibant and C1-INH concentrate and long-term prophylaxis with progestins and tranexamic acid were effective. HAEnCI with a specific mutation in the angiopoietin-1 gene (HAE-ANGPT1) was diagnosed in 4 patients from 1 family and HAEnCI with a specific mutation in the kininogen-1 gene (HAE-KNG1) in 6 patients from 1 family. CONCLUSIONS A number of clinical differentiators for the different types of HAEnCI have been identified which may support clinicians to narrow down the correct diagnosis of HAEnCI prior to genetic testing and thereby guide appropriate treatment and management decisions. However, confirmation of the causative gene mutation by genetic testing will always be required.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany.
| | | | - Karin Wulff
- University Medicine, Ernst Moritz Arndt University, Greifswald, Germany
| | - Guenther Witzke
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | | | - Jochen Hardt
- Department of Medical Psychology and Medical Sociology, Johannes Gutenberg University, Mainz, Germany
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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. J Allergy Clin Immunol Pract 2020; 9:132-150.e3. [PMID: 32898710 DOI: 10.1016/j.jaip.2020.08.046] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Brooks JP, Radojicic C, Riedl MA, Newcomer SD, Banerji A, Hsu FI. Experience with Intravenous Plasma-Derived C1-Inhibitor in Pregnant Women with Hereditary Angioedema: A Systematic Literature Review. J Allergy Clin Immunol Pract 2020; 8:1875-1880.e3. [PMID: 32251736 DOI: 10.1016/j.jaip.2020.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 11/19/2022]
Abstract
Consensus guidelines recommend plasma-derived C1 inhibitor (C1-INH) as first-line treatment in pregnant women with hereditary angioedema (HAE). We conducted a systematic review of the literature that describes experience with plasma-derived C1-INH during pregnancy. A literature search of PubMed was conducted in November 2018 using variants of "hereditary angioedema" and "pregnancy." English language articles that presented original data about the use of plasma-derived C1-INH during pregnancy were selected for data extraction. The search returned 253 unique records, of which 40 described the use of C1-INH during pregnancy (91 patients, 136 pregnancies). When the number of doses was reported, a total of 1562 doses were administered ranging from 500 to 3000 IU. Infusions were administered during all 3 trimesters and were most commonly administered during the third trimester. Overall, 1,490,500 IU of plasma-derived C1-INH were administered during pregnancy. Of the 128 fetuses for which outcomes were reported, 3 (2%) resulted in spontaneous abortion, 1 (1%) was stillborn, and 1 (1%) was a vanishing twin. Use of plasma-derived C1-INH in women with HAE during pregnancy has been widely reported in the scientific literature and has a favorable safety profile, supporting treatment guideline recommendations.
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Affiliation(s)
- Joel P Brooks
- Department of Internal Medicine, Section of Allergy and Clinical Immunology, Yale University School of Medicine, New Haven, Conn.
| | | | - Marc A Riedl
- Clinical Allergy and Immunology Section, University of California San Diego School of Medicine, La Jolla, Calif
| | | | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - F Ida Hsu
- Department of Internal Medicine, Section of Allergy and Clinical Immunology, Yale University School of Medicine, New Haven, Conn
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Dias MM, Moreno AS, Maia LSM, Nunes FL, Campos WN, Ferriani MPL, Silva WA, Arruda LK. A cost-effective algorithm for diagnosis of hereditary angioedema with normal C1 inhibitor: Applying molecular approach to clinical practice. J Allergy Clin Immunol Pract 2019; 8:419-421.e4. [PMID: 31319218 DOI: 10.1016/j.jaip.2019.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Marina M Dias
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Adriana S Moreno
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; Center for Genomic Medicine, Clinical Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Luana S M Maia
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fernanda Leonel Nunes
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Wagner N Campos
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Mariana P L Ferriani
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Wilson A Silva
- Center for Genomic Medicine, Clinical Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - L Karla Arruda
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; Center for Genomic Medicine, Clinical Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
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Veronez CL, Moreno AS, Constantino-Silva RN, Maia LS, Ferriani MP, Castro FF, Valle SR, Nakamura VK, Cagini N, Gonçalves RF, Mansour E, Serpa FS, Coelho Dias GA, Piccirillo MA, Toledo E, de Souza Bernardes M, Cichon S, Stieber C, Arruda LK, Pesquero JB, Grumach AS. Hereditary Angioedema with Normal C1 Inhibitor and F12 Mutations in 42 Brazilian Families. The Journal of Allergy and Clinical Immunology: In Practice 2018; 6:1209-1216.e8. [DOI: 10.1016/j.jaip.2017.09.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/29/2017] [Accepted: 09/22/2017] [Indexed: 01/14/2023]
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Deroux A, Boccon-Gibod I, Fain O, Pralong P, Ollivier Y, Pagnier A, Djenouhat K, Du-Thanh A, Gompel A, Faisant C, Launay D, Bouillet L. Hereditary angioedema with normal C1 inhibitor and factor XII mutation: a series of 57 patients from the French National Center of Reference for Angioedema. Clin Exp Immunol 2017; 185:332-7. [PMID: 27271546 DOI: 10.1111/cei.12820] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 11/29/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare disease associated with either a quantitative or qualitative deficiency in C1-inhibitor (C1-INH) or normal C1-INH. HAE with normal C1-INH is associated in 20% of cases with mutations in the gene for factor XII (FXII) or FXII-HAE. A recent review described 41 families, including 14 German and 15 Spanish families. We have constructed a register of French patients and their characteristics. A national survey was launched through the French National Center of Reference for Angioedema (CREAK) to study the clinical, biological and therapeutic characteristics of patients with HAE linked to a mutation of FXII gene. Fifty-seven patients were identified from 24 different families. In most cases they were young women (mean age at diagnosis: 31 years, mean age at first symptom: 21 years, female/male ratio: 76%). Twenty-one per cent of the patients experienced angioedema attacks only during pregnancy or when on oestrogen contraception. Sixty-three per cent had attacks at all times, but they were more severe during these same periods. Male carriers of the mutation were more frequently asymptomatic than females (P = 0·003). C1-INH concentrate and icatibant were both effective for treating attacks. The prophylactic use of tranexamic acid led to a 64% decrease in the number of attacks. This is one of the largest series reported of HAE patients with FXII mutation. The therapeutic management appeared to be identical to that of HAE with C1-INH deficiency.
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Affiliation(s)
- A Deroux
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
| | - I Boccon-Gibod
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
| | - O Fain
- Internal Medicine Department, Hôpital Saint Antoine, Université Paris, France
| | - P Pralong
- Dermatology Department, Allergology and Photobiology, CHU De Grenoble, Grenoble, France
| | - Y Ollivier
- Internal Medicine Department, Caen, France
| | - A Pagnier
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
| | - K Djenouhat
- Service De Biologie Médicale, EPH De Rouïba, Alger, Algéria
| | - A Du-Thanh
- Dermatology Department, Hôpital Saint-Eloi, Centre Hospitalier Universitaire De Montpellier, Montpellier, France
| | - A Gompel
- Gynecology Department, CHU Paris-Centre, Hopital, Cochin, Paris, France
| | - C Faisant
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
| | - D Launay
- Université Lille, Lille Inflammation Research International Center, Lille, France.,Département De Médecine Interne Et Immunologie Clinique, Lille, Lille, France
| | - L Bouillet
- Internal Medicine Department, Centre Hospitalier Des Alpes, Grenoble, France
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Abstract
Remarkable progress in understanding the pathophysiology and underlying mechanisms of hereditary angioedema has led to the development of effective treatment for this disorder. Progress in three separate areas has catalyzed our understanding of hereditary angioedema. The first is the recognition that HAE type I and type II result from a deficiency in the plasma level of functional C1 inhibitor. This observation has led to a detailed understanding of the SERPING1 mutations responsible for this deficiency as well as the molecular regulation of C1 inhibitor expression and function. The second is that the fundamental cause of swelling is enhanced contact system activation leading to increased generation of bradykinin. Substantial progress has been made in defining the parameters regulating bradykinin generation and catabolism as well as the receptors that transduce the biologic effects of kinins. The third is the understanding that tissue swelling in hereditary angioedema primarily involves the function of endothelial cell adherens junctions. This knowledge is driving increased attention to the role of endothelial biology in determining disease activity in hereditary angioedema. While there has been considerable progress made, large gaps still remain in our knowledge. Important areas that remain poorly understood include the factors that lead to very low plasma functional C1 inhibitor levels, the triggers of contact system activation in hereditary angioedema, and the role of the bradykinin B1 receptor. The phenotypic variability of hereditary angioedema has been extensively documented but never understood. The mechanisms discussed in this chapter likely contribute to this variability. Future progress in understanding these mechanisms should provide new means to improve the diagnosis and treatment of hereditary angioedema.
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Bork K, Wulff K, Witzke G, Hardt J. Treatment for hereditary angioedema with normal C1-INH and specific mutations in the F12 gene (HAE-FXII). Allergy 2017; 72:320-324. [PMID: 27905115 DOI: 10.1111/all.13076] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 11/28/2022]
Abstract
Hereditary angioedema with normal C1 esterase inhibitor and mutations in the F12 gene (HAE-FXII) is associated with skin swellings, abdominal pain attacks, and the risk of asphyxiation due to upper airway obstruction. It occurs nearly exclusively in women. We report our experience treating HAE-FXII with discontinuation of potential trigger factors and drug therapies. The study included 72 patients with HAE-FXII. Potential triggers included estrogen-containing oral contraceptives (eOC), hormonal replacement therapy, or angiotensin-converting enzyme inhibitors. Drug treatment comprised plasma-derived C1 inhibitor (pdC1-INH) for acute swelling attacks and progestins, tranexamic acid, and danazol for the prevention of attacks. Discontinuation of eOC was effective in 25 (89.3%) of 28 women and led to a reduction in the number of attacks (about 90%). After ending hormonal replacement therapy, three of eight women became symptom-free. Three women with exacerbation of HAE-FXII during intake of quinapril or enalapril had no further HAE-FXII attacks after discontinuation of those drugs. Eleven women were treated with pdC1-INH for 143 facial attacks. The duration of the treated facial attacks (mean: 26.6 h; SD: 10.1 h) was significantly shorter than that of the previous 88 untreated facial attacks in the same women (mean: 64.1 h; SD: 28.0 h; P < 0.01). The mean reduction in attack frequency was 99.8% under progestins after discontinuing eOC (16 women), 93.8% under tranexamic acid (four women), and 100% under danazol (three women). For patients with HAE-FXII, various treatment options are available which completely or at least partially reduce the number or duration of attacks.
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Affiliation(s)
- K. Bork
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
| | - K. Wulff
- University Medicine; Ernst Moritz Arndt University; Greifswald Germany
| | - G. Witzke
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
| | - J. Hardt
- Department of Medical Psychology and Medical Sociology; Johannes Gutenberg University; Mainz Germany
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Piñero-Saavedra M, González-Quevedo T, Saenz de San Pedro B, Alcaraz C, Bobadilla-González P, Fernández-Vieira L, Hinojosa B, García-Lozano R. Hereditary angioedema with F12 mutation: Clinical features and enzyme polymorphisms in 9 Southwestern Spanish families. Ann Allergy Asthma Immunol 2016; 117:520-526. [PMID: 27788882 DOI: 10.1016/j.anai.2016.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/20/2016] [Accepted: 09/02/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Information on F12 mutation hereditary angioedema (HAE) is still limited, but Spain is now recognized as having one of the highest concentrations of cases in Western Europe. OBJECTIVE To describe unique features of HAE in Spanish carriers of the F12 mutation and investigate a potential role for angiotensin-converting enzyme (ACE) and aminopeptidase-P polymorphisms in disease expression. METHODS This was a prospective observational cohort study of 35 individuals (80% females) from 9 unrelated families carrying the p.Thr309Lys mutation. We analyzed detailed medical records and complement activity (C4, C1q, C1 inhibitor) and screened for mutations in exon 9 of the F12 gene and 2 polymorphisms: XPNPEP2 c-2399A and the ACE insertion/deletion polymorphism. RESULTS The p.Thr309Lys mutation was found in all individuals. Three of the 9 index patients had a clinically negative family history, and 72% of males and 29% of females were asymptomatic. Sixteen females (44% estrogen dependent, 56% estrogen sensitive) were clearly symptomatic. The most common locations of attacks were the abdomen (63%), face (25%), and peripheral structures (6%). Triggers other than hyperestrogenic states included stress and minor trauma or pressure. Short-term treatment with C1-inhibitor concentrate and icatibant and long-term prophylaxis with tranexamic acid were useful. The combination of the I allele and A allele was detected in 17% of patients. CONCLUSION The polymorphisms analyzed were not a major determinant of disease expression in our population. We recommend searching for F12 mutations in women with edema attacks without associated wheals and with normal C1-inhibitor levels, particularly when they develop symptoms during hyperestrogenic states or are of Western European or African origin.
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Affiliation(s)
- Macarena Piñero-Saavedra
- Reference Unit for Angioedema in Andalusia, Allergy Department, Virgen del Rocío University Hospital, Seville, Spain
| | - Teresa González-Quevedo
- Reference Unit for Angioedema in Andalusia, Allergy Department, Virgen del Rocío University Hospital, Seville, Spain.
| | | | - Cristina Alcaraz
- Allergy Department, Virgen Macarena University Hospital, Seville, Spain
| | | | | | - Belén Hinojosa
- Allergy Department, Virgen de la Cinta Specialities Center, Huelva, Spain
| | - Raúl García-Lozano
- Immunology Department, Virgen del Rocío University Hospital, Seville, Spain
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Firinu D, Bafunno V, Vecchione G, Barca MP, Manconi PE, Santacroce R, Margaglione M, Del Giacco SR. Characterization of patients with angioedema without wheals: the importance of F12 gene screening. Clin Immunol 2015; 157:239-48. [PMID: 25744496 DOI: 10.1016/j.clim.2015.02.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/20/2015] [Indexed: 11/28/2022]
Abstract
Sporadic and familiar forms of non-histaminergic angioedema and normal C1 inhibitor encompass a group of disorders possibly caused by bradikinin. We aimed to study the subgroups of hereditary angioedema with FXII mutation (FXII-HAE), unknown genetic defect (U-HAE) and idiopathic non-histaminergic acquired angioedema (InH-AAE). We screened the F12 locus in our cohort and delineated the clinical, laboratory and genetic features. Four families carried the p.Thr309Lys mutation in F12 gene. Haplotyping confirmed the hypothesis of a common founder. Six families were affected by U-HAE and 13 patients by sporadic InH-AAE. C4 levels were significantly lower in FXII-HAE than in InH-AAE. In the FXII-HAE group, none had attacks exclusively in high estrogenic states; acute attacks were treated with icatibant. Prophylaxis with tranexamic acid reduced the attack frequency in most patients. Our study provides new data on the diagnosis, clinical features and treatment of non-histaminergic angioedema, underlying the role of the screening for F12 mutations.
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Affiliation(s)
- Davide Firinu
- Department of Medical Sciences "M. Aresu", University of Cagliari, Italy.
| | - Valeria Bafunno
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Gennaro Vecchione
- Atherosclerosis and Thrombosis Unit, I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
| | - Maria Pina Barca
- Department of Medical Sciences "M. Aresu", University of Cagliari, Italy
| | | | - Rosa Santacroce
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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Ponard D. [Hereditary angioedema biological diagnosis]. Presse Med 2014; 44:57-64. [PMID: 25511654 DOI: 10.1016/j.lpm.2014.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/16/2014] [Accepted: 06/02/2014] [Indexed: 11/24/2022] Open
Abstract
C1 inhibitor (C1 Inh) activity is an essential parameter for kinins angioedema (AE) diagnosis either hereditary or acquired or sporadic, it is analysed on plasma exclusively. Hereditary AE with C1 Inh functional deficiency is associated with alterations of the SERPING1 gene. Hereditary AE with normal C1 Inh (HAE nC1 Inh) is combined with F12 gene mutations, it is coding for Factor XII whose activity is controlled by C1 Inh, they are found in about 5% of HAE nC1 Inh cases. Every loss of C1 Inh activity must be taken as anormal by clinicians even for women with oral oestroprogestatives, it would be confirmed by the presence of cleaved C1 Inh. The kinins (primarily bradykinin) are the mediators responsible for local increase of vascular permeability. Bradykinin is released from high MW kininogen (HK) during the contact system activation. Plasma proteases mainly support this proteolytic activity controlled by C1 Inh. Family of a patient diagnosed with HAE must be studied, symptomatic as asymptomatic members indeed clinical symptoms regularly emerge very late in the life.
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Affiliation(s)
- Denise Ponard
- CHU de Grenoble, laboratoire d'immunologie, IBP, CS10217, boulevard de la Chantourne, 38043 Grenoble cedex 09, France.
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Charignon D, Ghannam A, Defendi F, Ponard D, Monnier N, López Trascasa M, Launay D, Caballero T, Djenouhat K, Fain O, Cichon S, Martin L, Drouet C. Hereditary angioedema with F12 mutation: factors modifying the clinical phenotype. Allergy 2014; 69:1659-65. [PMID: 25134986 DOI: 10.1111/all.12515] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) with normal C1 inhibitor (C1Inh) associated with the c.983C>A and c.983C>G mutations of the F12 gene (FXII-HAE) is a rare condition, and presents with highly variable clinical expression. On the basis of data gathered from a large carrier cohort, we assessed the modifiers affecting the clinical phenotype. METHODS We analyzed clinical and biological data recorded from 118 mutation carriers (80 symptomatic and 38 asymptomatic), 58 noncarrier relatives from 40 families, and 200 healthy donors. Disease severity was scored in relation to frequency and location of edema, as well as age at disease onset. To predict FXII-HAE disease severity, we analyzed the biological phenotype [C1Inh, C4, spontaneous amidase, angiotensin-I-converting enzyme (ACE), aminopeptidase P (APP), and carboxypeptidase N/M (CPN)] by means of logistic regression (Akaike information criterion) and odds ratio (OR). RESULTS Meaningful variables contributed to FXII-HAE, with the kinin catabolism enzymes ACE and CPN exhibiting a significant inverse relationship with disease severity (OR = 0.36, 95% CI 0.23-0.59, P < 0.001; OR = 0.58, 95% CI 0.36-0.91, P < 0.05, respectively). CPN activities were 37.5 (28.5-41.3) nmol/ml/min and 38.5 (32.8-45.6) for FXII-HAE asymptomatic and symptomatic carriers, respectively, and 37.9 (30.5-43.7) nmol/ml/min for noncarriers. Angiotensin-I-converting enzyme activities were 58 (44-76) and 49 (35-59) nmol/ml/min for FXII-HAE asymptomatic and symptomatic carriers, respectively, and 56 (49-66) nmol/ml/min for noncarriers. CONCLUSIONS The FXII-HAE is associated with modifiers, for example kinin catabolism enzymes, ACE and CPN, different from those recognized in HAE with C1Inh deficiency.
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Affiliation(s)
- D. Charignon
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
| | - A. Ghannam
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
| | - F. Defendi
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
| | - D. Ponard
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
| | - N. Monnier
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
| | - M. López Trascasa
- Institute for Health Research (IdiPaz); Hospital Universitario La Paz; Madrid Spain
- Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - D. Launay
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- Département de Médecine Interne; Université du Droit et de la Santé Lille 2; Lille France
| | - T. Caballero
- Institute for Health Research (IdiPaz); Hospital Universitario La Paz; Madrid Spain
- Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - K. Djenouhat
- Département d'Immunologie; Institut Pasteur; Alger Algeria
| | - O. Fain
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- Département de Médecine Interne; Université Paris XIII; Bondy France
| | - S. Cichon
- Institute für Humangenetics; Universität Bonn; Bonn Germany
- Departement Biomedizin; Universität Basel; Basel Switzerland
| | - L. Martin
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- Département de Dermatologie; L'UNAM Université; Hôpital d'Angers; Angers France
| | - C. Drouet
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
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Pedrosa M, Prieto-García A, Sala-Cunill A, Baeza ML, Cabañas R, Campos A, Cimbollek S, Gómez-Traseira C, González Quevedo T, Guilarte M, Jurado-Palomo J, Lobera T, López-Serrano MC, Marcos C, Piñero-Saavedra M, Prior N, Sáenz de San Pedro B, Ferrer M, Barceló JM, Daschner A, Echechipía M, Garcés M, Iriarte P, Jáuregui I, Lázaro M, Quiñones M, Veleiro B, Villareal O. Management of angioedema without urticaria in the emergency department. Ann Med 2014; 46:607-18. [PMID: 25580506 DOI: 10.3109/07853890.2014.949300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.
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Affiliation(s)
- Maria Pedrosa
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.
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Abstract
THREE TYPES OF HEREDITARY ANGIOEDEMA (HAE) HAVE BEEN DESCRIBED two are due to C1 inhibitor (C1-INH) deficiency (C1-INH-HAE types I and II) and one is characterized by normal C1-INH (nC1-INH-HAE). The management of pregnancy in patients with HAE is often a clinical challenge owing to potential worsening of the disease in relation to the physiological increase in estrogens and the limited treatment options. This review addresses the potential influence of pregnancy on the clinical severity of hereditary angioedema and the management of this disease during pregnancy with currently available treatments.
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Affiliation(s)
- Teresa Caballero
- Hospital La Paz Institute for Health Research, (IdiPaz), Madrid, Spain
- Biomedical Research Network on Rare Diseases-U754 (CIBERER), Madrid, Spain
| | - Julio Canabal
- Hospital La Paz Institute for Health Research, (IdiPaz), Madrid, Spain
| | | | - Rosario Cabañas
- Hospital La Paz Institute for Health Research, (IdiPaz), Madrid, Spain
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Abstract
BACKGROUND Angioedema is a serious medical condition characterized by recurrent non-pitting tissue edema. Hereditary (HAE) forms of this disorder are potentially fatal. METHODS PubMED, Up to Date and Cochrane Library databases were used to identify scholarly peer reviewed original research or review articles on angioedema. Search terms used were: angioedema, HAE, ACE inhibitor induced angioedema, acquired angioedema, type III HAE (now termed HAE with normal C1-INH), diagnosis of HAE, and treatment of HAE. Inclusive dates of the search were 1946 through 2013. Articles on urticaria were excluded. RESULTS The pathophysiology, clinical manifestations, differential diagnosis and treatments of angioedema are presented. Three variants of HAE are discussed and differentiated from acquired, ACE induced and allergic types of angioedema. Emphasis is placed on understanding that HAE is mediated by bradykinin, not histamine, and is therefore unresponsive to antihistamines, corticosteroids and epinephrine. In contrast, newer therapies that replace C1-INH or block bradykinin production or action are the appropriate treatments for prophylaxis and acute treatment of HAE. CONCLUSION Recognition of HAE by primary care providers and distinguishing it from allergic histamine mediated angioedema is essential in preventing recurrent attacks and avoiding inappropriate therapy, and may be life-saving.
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Abstract
When faced with a patient with recurrent swelling, a thorough laboratory evaluation to determine the underlying etiology ensues. When the laboratory work-up is unrevealing, health care practitioners are frequently left in a quandary. This review will attempt to provide up-to-date information on how to approach the diagnosis and management of angioedema in a patient with normal laboratory values. The subtypes that will be reviewed in detail include: hereditary angioedema with normal C1 inhibitor (HAE with normal C1INH), drug-induced angioedema, and idiopathic angioedema. We present literature to aid the physician in the diagnosis and treatment of these disorders.
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Affiliation(s)
- Janelle Sher
- Rheumatology, Allergy & Immunology, Winthrop University, 120 Mineola Blvd., Suite 410, Mineola, NY, 11501, USA,
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23
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Ghannam A, Defendi F, Charignon D, Csopaki F, Favier B, Habib M, Cichon S, Drouet C. Contact System Activation in Patients with HAE and Normal C1 Inhibitor Function. Immunol Allergy Clin North Am 2013; 33:513-33. [PMID: 24176216 DOI: 10.1016/j.iac.2013.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
Until recently it was assumed that hereditary angioedema was a disease that results exclusively from a genetic deficiency of the C1 inhibitor. In 2000, families with hereditary angioedema, normal C1 inhibitor activity, and protein in plasma were described. Since then, numerous patients and families with that condition have been reported. Most of the patients were women. In many of the affected women, oral contraceptives, hormone replacement therapy containing estrogens, and pregnancies triggered the clinical symptoms. In some families mutations in the coagulation factor XII (Hageman factor) gene were detected.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany.
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Riedl MA. Hereditary Angioedema with Normal C1-INH (HAE Type III). The Journal of Allergy and Clinical Immunology: In Practice 2013; 1:427-32. [DOI: 10.1016/j.jaip.2013.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 06/14/2013] [Indexed: 10/26/2022]
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Zuraw BL, Bernstein JA, Lang DM, Craig T, Dreyfus D, Hsieh F, Khan D, Sheikh J, Weldon D, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. A focused parameter update: Hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor–associated angioedema. J Allergy Clin Immunol 2013; 131:1491-3. [DOI: 10.1016/j.jaci.2013.03.034] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 03/11/2013] [Accepted: 03/14/2013] [Indexed: 11/26/2022]
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Marcos C, López Lera A, Varela S, Liñares T, Alvarez-Eire MG, López-Trascasa M. Clinical, biochemical, and genetic characterization of type III hereditary angioedema in 13 Northwest Spanish families. Ann Allergy Asthma Immunol 2012; 109:195-200.e2. [PMID: 22920075 DOI: 10.1016/j.anai.2012.05.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 05/09/2012] [Accepted: 05/16/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND A new variant of hereditary angioedema has been reported during the last decade. Three main characteristics distinguish it from classic hereditary angioedema: normal C1 inhibitor activity, predominance in women, and different genetic alterations. OBJECTIVE To assess the symptoms, laboratory findings, and treatment of a population with type III hereditary angioedema from Northwest Spain. METHODS We studied 29 patients (26 female and 3 male) from 13 different families. RESULTS The 26 female patients showed a similar clinical pattern to the classic forms of hereditary angioedema, and 22 of these patients had the estrogen-dependent phenotype. Three patients had a negative family history, and 1 of the parents was confirmed as an asymptomatic carrier in 2 of them. All had functional C1 inhibitor activity within the normal range in periods without high estrogen levels, but during attacks (in female patients) and pregnancy, activity decreased to below 50%. One male patient had normal C1 inhibitor activity during attacks, and he was initially diagnosed as having idiopathic angioedema. The C4 and antigenic C1 inhibitor levels were always normal. All studied patients had the c.1032C>A, Thr309Lys mutation in the factor XII gene. The mutation was also found in asymptomatic relatives: 5 of 6 men studied and 1 of 8 women studied. CONCLUSION Positive family history is a diagnosis criterion, but it could be lacking because there may be asymptomatic relatives, primarily males.
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Affiliation(s)
- Carmen Marcos
- Allergy Service of University Hospital Complex of Vigo, Pontevedra, Spain.
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30
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Bork K, Wulff K, Meinke P, Wagner N, Hardt J, Witzke G. A novel mutation in the coagulation factor 12 gene in subjects with hereditary angioedema and normal C1-inhibitor. Clin Immunol 2011; 141:31-5. [DOI: 10.1016/j.clim.2011.07.002] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 07/15/2011] [Accepted: 07/19/2011] [Indexed: 10/17/2022]
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Vitrat-Hincky V, Gompel A, Dumestre-Perard C, Boccon-Gibod I, Drouet C, Cesbron JY, Lunardi J, Massot C, Bouillet L. Type III hereditary angio-oedema: clinical and biological features in a French cohort. Allergy 2010; 65:1331-6. [PMID: 20384613 DOI: 10.1111/j.1398-9995.2010.02368.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hereditary angio-oedema (HAE) has been associated with C1inhibitor deficiency. The first cases of type III HAE were described in patients with normal C1Inh antigenic protein level and function and normal C4 levels in 2000. This finding has been reported mostly in women with a family history and may be influenced by exogenous oestrogen exposure. OBJECTIVES The purpose of this article is to describe the clinical, biological and genetic characteristics of a French population suffering from type III HAE. PATIENTS AND METHODS We conducted a retrospective analysis of angio-oedema (AE) cases seen in the National Reference Centre of AE between 2000 and 2009. RESULTS We found 26 patients (from 15 unrelated families) with type III HAE. All but four were women and presented with typical AE attacks, exacerbated by pregnancy or oral contraceptives containing oestrogens (OC). We also found that 54.5% of women were worsened with oestrogen and 23% were oestrogen dependent. All patients improved on long-term prophylactic tranexamic acid treatment; some acute attacks improved with C1Inh concentrate infusion. All of the patients had normal C1Inh and C4 levels. C1Inh function was also normal, except in women receiving OC or during a pregnancy: transient, moderately low levels (32-74% of the normal range) were found in 18 patients tested (67%). No SERPING1 gene mutation was found. Six patients from three unrelated families were heterozygous for an F12 gene variant. CONCLUSION Diagnosis of type III HAE should be based on clinical (typical attacks, often hormonally influenced), laboratory (normal C1Inh antigenic protein) and genetic (F12 gene mutation) evidence.
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Affiliation(s)
- V Vitrat-Hincky
- Internal Medicine Department, University Hospital of Grenoble, Grenoble, France
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Binkley KE. Factor XII mutations, estrogen-dependent inherited angioedema, and related conditions. Allergy Asthma Clin Immunol 2010; 6:16. [PMID: 20667119 PMCID: PMC2920236 DOI: 10.1186/1710-1492-6-16] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 07/28/2010] [Indexed: 11/10/2022]
Abstract
The clinical, biochemical and genetic features of the conditions known as estrogen-dependent inherited angioedema, estrogen-associated angioedema, hereditary angioedema with normal C-1 inhibitor, type III angioedema, or factor XII angioedema are reviewed. Discussion emphasizes pathogenesis, diagnosis, and management.
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Affiliation(s)
- Karen E Binkley
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Women with hereditary angioedema (HAE) are more likely to be symptomatic that men. Hormonal factors (puberty, contraception, pregnancy,....) play a significant role in the precipitation or worsening of the condition in women. So, combined contraceptive pills are not indicated and progestogen pill must be preferred. During pregnancy, attack rate can increase (38-48% of women). C1Inhibitor concentrate and tranexamic acid can be used during pregnancy. Attenuated androgens for long term prophylaxis are effective but side effects appear more often in female patients. These side effects are dose dependant and can be attenuated by titrating the dose down the lowest effective level.
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Affiliation(s)
- Laurence Bouillet
- National French Reference Centre of Angioedema, Internal Medicine Department, Grenoble University Hospital, France.
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Bork K. Diagnosis and treatment of hereditary angioedema with normal C1 inhibitor. Allergy Asthma Clin Immunol 2010; 6:15. [PMID: 20667118 PMCID: PMC2919521 DOI: 10.1186/1710-1492-6-15] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 07/28/2010] [Indexed: 11/23/2022] Open
Abstract
Until recently it was assumed that hereditary angioedema is a disease that results exclusively from a genetic deficiency of the C1 inhibitor. In 2000, families with hereditary angioedema, normal C1 inhibitor activity and protein in plasma were described. Since then numerous patients and families with that condition have been reported. Most of the patients by far were women. In many of the affected women, oral contraceptives, hormone replacement therapy containing estrogens, and pregnancies triggered the clinical symptoms. Recently, in some families mutations in the coagulation factor XII (Hageman factor) gene were detected in the affected persons.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Mainz, Germany.
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Abstract
Hereditary and acquired angioedema are of outstanding clinical importance, as edematous attacks associated with these conditions can thrust afflicted patients into mortal danger. Currently, C1 inhibitor concentrate - a human blood product - is available as a replacement therapy. In view of the limited number of donors, as well as the risk of transmission of blood-borne infections, it is a reasonable expectation to develop a therapeutic alternative based on recombinant technology, which would eliminate all these shortcomings. Pharming (Leiden, The Netherlands) has developed Rhucin, a recombinant human C1 inhibitor, as a proprietary product, which is currently being evaluated in Phase III clinical trials. Ongoing studies conducted within the framework of the development program are almost complete and their interim findings are reassuring. This should facilitate successful regulatory approval in the near future, which is indispensable in order to make Rhucin available for patients with hereditary angioedema or other disorders amenable to C1 inhibitor replacement.
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Affiliation(s)
- Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University Budapest, H-1125 Kútvölgyi Street 4, Budapest, Hungary.
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Abstract
Bradykinin angioedema (AE) are characterized by acute recurrent episodes of localized swelling. They are not associated with pruritus or erythema, and are short-lived (24 to 72 hours), disappearing without any sequelae. Corticosteroids are useless. Skin or mucous membranes (upper respiratory and intestinal) could be affected. Bradykinin AE can be secondary to: (1) AE associated with C1 inhibitor deficiency (hereditary or acquired); (2) drug-induced AE (converting enzyme inhibitors…); (3) type III AE type (oestrogen dependant) without C1 inhibitor deficiency. These type III AE can be associated with a gain of function mutation that markedly increases factor XII activity. Prognosis depends on the laryngeal attacks (resulting in 25 % of death in the absence of specific treatment). In case of severe attacks, icatibant (bradykinin receptor antagonist) or C1 inhibitor concentrate can be used. In case of frequent attacks, long-term therapy with danazol or tranexamic acid is effective.
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Abstract
Angioedema can result from allergic, hereditary, and acquired conditions. Hereditary angioedema (HAE) attacks are disabling at the time of occurrence and can be life threatening; they often result in hospitalization and intensive care unit admission. Although there are several variants of HAE, they share a final common pathway: unopposed activation of multiple kinins and mediators including kallikrein and bradykinin. This leads to increased vascular permeability, which in turn produces the edema after which the condition is named. Older treatment options licensed in the United States, anabolic steroids and antifibrinolytics, have troublesome side effect profiles and may not reverse a severe acute attack. In Europe, C1 esterase inhibitor (C1-INH) concentrates have been used since 1974 for both preventing and terminating attacks. Two of these have now been licensed in the United States for use in HAE patients, one for prophylaxis and the other for treating acute abdominal and facial HAE attacks. The first kinin pathway modulator, ecallantide, has also been licensed recently in the United States for treating HAE attacks. The objective of this article is to describe HAE and review the available options for managing patients, as well as different drugs currently under investigation. Specific attention is given to the perioperative management of patients with HAE.
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Affiliation(s)
- Jerrold H Levy
- FAHA, Department of Anesthesiology, Emory University Hospital, Atlanta, GA 30322, USA.
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Picone O, Donnadieu AC, Brivet FG, Boyer-Neumann C, Frémeaux-Bacchi V, Frydman R. Obstetrical Complications and Outcome in Two Families with Hereditary Angioedema due to Mutation in the F12 Gene. Obstet Gynecol Int 2010; 2010:957507. [PMID: 20490261 DOI: 10.1155/2010/957507] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 03/16/2010] [Accepted: 03/16/2010] [Indexed: 11/21/2022] Open
Abstract
Backgroud. Hereditary angioedema (HAE) is characterized by recurrent swelling of the skin, the abdomen (causing severe acute pain), and the airways. A recently discovered type caused by mutations in the factor XII gene (designated as HAE type III) occurs mainly in women. Estrogens may play an important role, but few obstetrical complications have been reported. Case. We report the symptoms and obstetrical complications of women in two families with HAE attributable to the p. Thr328Lys mutation in the F12 gene. Clinical manifestations included acute and severe maternal abdominal pain, with transient ascites, laryngeal edema, and fetal and neonatal deaths. Patients had normal C4 levels and a normal C1 inhibitor gene. Administration of C1-inhibitor concentration twice monthly decreased the attack rate in one mother, and its predelivery administration (1000 U) led to the delivery of healthy girls. Conclusions. Obstetricians and anesthesiologists should be aware of this rare cause of unexplained maternal ascites and in utero or fetal death associated with edema.
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Bouillet L, Boccon-Gibod I, Ponard D, Drouet C, Cesbron JY, Dumestre-Perard C, Monnier N, Lunardi J, Massot C, Gompel A. Bradykinin receptor 2 antagonist (icatibant) for hereditary angioedema type III attacks. Ann Allergy Asthma Immunol 2009; 103:448. [PMID: 19927548 DOI: 10.1016/s1081-1206(10)60369-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Abstract
Until recently, it was assumed that hereditary angioedema was a disease resulting exclusively from a genetic deficiency of the C1 inhibitor. In 2000, families with hereditary angioedema, normal C1 inhibitor activity, and protein in plasma were described. Since then, numerous patients and families with this condition have been reported. Most of the patients were women. In many of the affected women, oral contraceptives, hormone replacement therapy containing estrogens, and pregnancies triggered the clinical symptoms. In some families, mutations in the coagulation factor XII (Hageman factor) gene were detected in the affected persons.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Mainz, Germany.
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Bork K, Kleist R, Hardt J, Witzke G. Kallikrein–kinin system and fibrinolysis in hereditary angioedema due to factor XII gene mutation Thr309Lys. Blood Coagul Fibrinolysis 2009; 20:325-32. [DOI: 10.1097/mbc.0b013e32832811f8] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bork K, Wulff K, Hardt J, Witzke G, Staubach P. Hereditary angioedema caused by missense mutations in the factor XII gene: Clinical features, trigger factors, and therapy. J Allergy Clin Immunol 2009; 124:129-34. [DOI: 10.1016/j.jaci.2009.03.038] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 03/05/2009] [Accepted: 03/27/2009] [Indexed: 10/20/2022]
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Abstract
Angio-oedema is a common reason for attendance at the accident and emergency department and for referral to immunology/allergy clinics. Causative factors should always be sought, but a large proportion of patients have the idiopathic form of the disease. A minority of patients represent a diagnostic and treatment challenge. Failure to identify the more unusual causes of angio-oedema may result in life-threatening situations. Common and rare causes of angio-oedema will be discussed in this article, as well as the diagnostic and treatment pathways for the management of these patients. A comprehensive history and close monitoring of response to treatment are the most cost-effective diagnostic and treatment tools.
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Affiliation(s)
- S Grigoriadou
- Barts and The London NHS Trust, Royal London Hospital, London, UK
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