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Lochbaum R, Trainotti S, Hoffmann TK, Greve J, Hahn J. A clinical evaluation of patients with known mutations (plasminogen and factor XII) with a focus on prophylactic treatment. J DERMATOL TREAT 2024; 35:2290362. [PMID: 38086754 DOI: 10.1080/09546634.2023.2290362] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Hereditary angioedema with normal C1-inhibitor (HAE-nC1-INH) is a rare genetic disease. The symptoms can resemble other forms of hereditary angioedema (HAE), but the specific laboratory values are inconspicuous. The knowledge about treatment strategies in HAE-nC1-INH remains insufficient; most of the drugs are only licensed and approved for other types of HAE. METHODS An analysis of all patients with HAE-nC1-INH was carried out in a certified angioedema treatment center in southern Germany. Only patients with a confirmed HAE-nC1-INH mutation were included. The impact of disease was monitored with validated questionnaires. RESULTS Eighteen patients were included: two families with a factor XII mutation and seven families with a plasminogen mutation. All individuals received icatibant for on-demand therapy-efficient treatment response was reported. Three patients were severely affected, and prophylaxis was initiated with lanadelumab. According to the questionnaires, the clinical course and symptoms improved significantly under this prophylactic regime. CONCLUSION This is one of the first descriptions of the clinical outcomes as a response to prophylactic treatment with lanadelumab in HAE-nC1-INH patients with a known mutation. The therapeutic management of HAE-1 and HAE-2 should also be the basis of HAE-nC1-INH, including prophylaxis.
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Affiliation(s)
- Robin Lochbaum
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Susanne Trainotti
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas K Hoffmann
- 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
| | - Janina Hahn
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
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2
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Birmingham JM, Wisnivesky J, Busse PJ. The effect of estrogen-containing birth control pills on the constituents of bradykinin expression in plasma. J Allergy Clin Immunol Glob 2024; 3:100226. [PMID: 38495866 PMCID: PMC10940926 DOI: 10.1016/j.jacig.2024.100226] [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] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/12/2023] [Accepted: 12/20/2023] [Indexed: 03/19/2024]
Abstract
Background Hereditary angioedema with C1-inhibitor deficiency (HAE-C1INH) is a rare autosomal disorder presenting with recurrent angioedema. Estrogen-containing medications trigger angioedema in some patients, and conversely, progesterone may decrease attack frequency. The mechanism by which estrogen may exacerbate angioedema in HAE-C1INH is not well characterized. Objective Our aim was to investigate the link between estrogen and bradykinin constituents to better understand the specific underlying triggers that may exacerbate angioedema in patients with HAE-C1INH. Methods As estrogen is contraindicated for patients with HAE-C1INH, females without a history of angioedema were recruited to evaluate whether estrogen-containing oral contraceptive pills (OCPs) alter plasma protein levels of bradykinin, cleaved high-molecular-weight kininogen (cHK), and activated factor XII (FXIIa). Blood (plasma) was collected before initiation of OCP administration and 3 months thereafter. High-molecular-weight kininogen (HK) was measured by ELISA and FXIIa and cHK were analyzed by Western blot analysis. Results A total of 12 adult females without HAE-CINH (aged <40 years) had a median baseline plasma HK level of 33,976 ng/mL. After 3 months of OCP therapy, their median HK level increased to 38,202 ng/mL. With OCPs, there was also a significant increase in level of FXIIa protein (P <.01), as well as an increase in cHK protein level. Conclusion This preliminary study, performed in females without HAE-C1INH, suggests that estrogen may exacerbate angioedema by increasing the production of cHK and FXIIa.
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Affiliation(s)
- Janette M. Birmingham
- Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Juan Wisnivesky
- Division of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Paula J. Busse
- Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
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3
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Riedl MA, Bordone L, Revenko A, Newman KB, Cohn DM. Clinical Progress in Hepatic Targeting for Novel Prophylactic Therapies in Hereditary Angioedema. J Allergy Clin Immunol Pract 2024; 12:911-918. [PMID: 38142864 DOI: 10.1016/j.jaip.2023.12.025] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/09/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023]
Abstract
Hereditary angioedema (HAE) is typically caused by a deficiency of the protease inhibitor C1 inhibitor (C1INH). The absence of C1INH activity on plasma kallikrein and factor XIIa leads to overproduction of the vasoactive peptide bradykinin, with resulting angioedema. As the primary site of C1INH and prekallikrein production, the liver is recognized as an important therapeutic target in HAE, leading to the development of hepatic-focused treatment strategies such as GalNAc-conjugated antisense technology and gene modification. This report reviews currently available data on hepatic-focused interventions for HAE that have advanced into human trials. Donidalorsen is an investigational GalNAc3-conjugated antisense oligonucleotide that binds to prekallikrein mRNA in the liver and reduces the expression of prekallikrein. Phase 2 data with subcutaneous donidalorsen demonstrated a significant reduction in HAE attack rate compared with placebo. Phase 3 trials are underway. ADX-324 is a GalNAc3-conjugated short-interfering RNA being investigated in HAE. BMN 331 is an investigational AAV5-based gene therapy vector that expresses wild-type human C1INH and is targeted to hepatocytes. A single intravenous dose of BMN 331 is intended to replace the defective SERPING1 gene and enable patients to produce functional C1INH. A first-in-human phase 1/2 study is ongoing with BMN 331. NTLA-2002 is an investigational in vivo clustered regularly interspaced short palindromic repeats/Cas9-based therapy designed to knock out the prekallikrein-coding KLKB1 gene in hepatocytes; a phase 1/2 study is ongoing. Findings from these and other ongoing studies are highly anticipated with the expectation of expanding the array of treatment options in HAE.
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Affiliation(s)
- Marc A Riedl
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif.
| | | | | | | | - Danny M Cohn
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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4
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Özdemir Ö, Dikici Ü. COVID-19 and vaccination in hereditary angioedema: Single center experience. World Allergy Organ J 2024; 17:100892. [PMID: 38559494 PMCID: PMC10973662 DOI: 10.1016/j.waojou.2024.100892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/26/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Like many microbial agents, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its vaccination may increase the frequency and/or severity of attacks. We aimed to observe/evaluate patients with hereditary angioedema (HAE) followed by Sakarya University Research/Training Hospital pediatric allergy unit, Sakarya, Türkiye, for the effects of SARS-CoV-2 infection and COVID-19 vaccination. Ten HAE patients-3 males and 7 females-were evaluated retrospectively. Their mean age was 31.80 ± 19.15 (min. 12 - max. 66) years. Four of 10 patients were diagnosed with type 1 HAE and 6 with type 2 HAE. Two out of 6 patients (mother and daughter) diagnosed with type 2 HAE had angioedema attacks during COVID-19 disease. Six out of 10 HAE patients received different COVID-19 vaccines available in Türkiye up to third and fourth doses. There was no increase in COVID-19 vaccine-related attacks during, after 72 hours, and up to the year after vaccination. As a result, we consider it safe to administer inactivated and/or mRNA vaccines in our patients with HAE. In addition, catching SARS-CoV-2 infection was not always associated with disease exacerbation or activation.
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Affiliation(s)
- Öner Özdemir
- Division of Allergy and Immunology, Department of Pediatrics, Sakarya University Faculty of Medicine, Research and Training Hospital of Sakarya University, Sakarya, Türkiye
| | - Ümmügülsüm Dikici
- Division of Allergy and Immunology, Department of Pediatrics, Sakarya University Faculty of Medicine, Research and Training Hospital of Sakarya University, Sakarya, Türkiye
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5
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Zanichelli A, Senter R, Merlo A, Gidaro A, Popescu Janu V, Cogliati CB, Cancian M. Comorbidities in Angioedema Due to C1-Inhibitor Deficiency: An Italian Survey. J Allergy Clin Immunol Pract 2024; 12:1029-1036. [PMID: 38182098 DOI: 10.1016/j.jaip.2023.12.046] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 11/28/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Hereditary angioedema (HAE) due to C1-inhibitor (C1-INH) deficiency is characterized by unpredictable recurrent episodes of swelling affecting the skin and the mucosa tissues, including gastrointestinal tract and/or oropharyngeal-laryngeal mucosae. Long-term prophylaxis (LTP) is used to prevent attacks. OBJECTIVE Because C1-INH plays a pivotal role in several biological pathways, we investigated the possible association of comorbidities with C1-INH deficiency and the use of LTP with attenuated androgens (AA) or tranexamic acid (TXA). METHODS This retrospective cohort study involved adult patients with HAE referred to Milan and Padua angioedema centers in the period 1979-2021. A qualitative comparison was performed to analyze comorbidities versus general population. The incidence of comorbidities was evaluated during LTP with AA or TXA versus patients without LTP. RESULTS A total of 446 patients were studied. A greater prevalence among patients was found for heart diseases (9.6% vs 4.8%), acute myocardial infarction (5.6% vs 1.4%), hepatitis C virus infection (10.5% vs 2.5%), and appendectomy (15.9% vs 4.3%). In patients taking AA, a greater incidence was found for hypertension (22.8% vs 10.8%; odds ratio [OR]: 2.02), hypercholesterolemia (19.5% vs 5.3%; OR: 3.97), diabetes mellitus (5% vs 1.4%; OR: 3.21), hepatic angioma (4.4% vs 0.7%; OR: 8.35), and focal nodular hyperplasia (2.5% vs 0.4%; OR: 6.9). No association between TXA and comorbidities was found. CONCLUSION In this large patient population with a rare disease followed for up to a 43-year period, we found a greater prevalence of comorbidities hitherto unreported in the literature and an association between comorbidities and LTP with AA.
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Affiliation(s)
- Andrea Zanichelli
- Operative Unit of Medicine, Angioedema Center, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.
| | - Riccardo Senter
- Department of Systems Medicine, University Hospital of Padua, Padua, Italy
| | - Andrea Merlo
- Internal Medicine, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, Milan, Italy
| | - Antonio Gidaro
- Internal Medicine, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, Milan, Italy
| | - Valentina Popescu Janu
- Internal Medicine, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, Milan, Italy
| | - Chiara Beatrice Cogliati
- Internal Medicine, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, Milan, Italy
| | - Mauro Cancian
- Department of Systems Medicine, University Hospital of Padua, Padua, Italy
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Yong PFK, Annals R, Diwakar L, Elkhalifa S, Gompels M, Jain R, Karim MY, Khan S, Metcalfe A, Noorani S, Steele C, Kiani-Alikhan S, Garcez T. Prophylaxis in hereditary angioedema: a United Kingdom Delphi consensus. Clin Exp Immunol 2024:uxae020. [PMID: 38456386 DOI: 10.1093/cei/uxae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Indexed: 03/09/2024] Open
Abstract
Hereditary angioedema (HAE) is a rare inherited disorder causing recurrent of episodes of swelling that can be potentially life threatening. Treatment of HAE can be divided into on-demand treatment for swelling, and prophylaxis. The last UK consensus on HAE was in 2014 and since then, new medications for prophylaxis have been developed, with more drugs in the pipeline. International guidelines currently recommend the use of long-term prophylaxis (LTP) as the only way of achieving disease control and normalising patient lives. Modern prophylactic medications are available in the UK, although access is restricted primarily by HAE attack frequency. To establish an updated view of UK clinicians and patients, a Delphi process was used to develop statements regarding long-term prophylaxis as well as other aspects of HAE management. There was consensus that UK access criteria for modern LTP agents based on numerical frequency of attacks alone is too simplistic and potentially disadvantage a cohort of patients who may benefit from LTP. Additionally, there was agreement that patients should be seen in expert centres, remote monitoring of patients is popular post-pandemic, and that the use of patient reported outcome measures have the potential to improve patient care. Psychological health is an area in which patients may benefit, and recognition of this is important for future research and development.
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Affiliation(s)
- Patrick F K Yong
- Department of Immunology, Frimley Health NHS Foundation Trust, Frimley, UK
| | | | - Lavanya Diwakar
- Department of Immunology, University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Shuayb Elkhalifa
- Department of Allergy & Immunology, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Mark Gompels
- Department of Immunology, North Bristol NHS Trust, Bristol, UK
| | - Rashmi Jain
- Department of Clinical Immunology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Sujoy Khan
- Department of Immunology and Allergy, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | - Sadia Noorani
- Department of Immunology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Cathal Steele
- Regional Immunology Service, Royal Hospitals Belfast, Belfast, UK
| | | | - Tomaz Garcez
- Department of Immunology, Manchester University NHS Foundation Trust, Manchester, UK
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7
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Ding L, Zhang MJ, Rao GW. Summary and future of medicine for hereditary angioedema. Drug Discov Today 2024; 29:103890. [PMID: 38246415 DOI: 10.1016/j.drudis.2024.103890] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/24/2023] [Accepted: 01/16/2024] [Indexed: 01/23/2024]
Abstract
Hereditary angioedema (HAE) is a rare autosomal genetic disease for which there are currently nine FDA-approved drugs. This review summarizes drug treatments for HAE based on four therapeutic pathways: inhibiting the contact system, inhibiting bradykinin binding to B2 receptors, supplying missing C1 inhibitors, and inhibiting plasminogen conversion. The review generalizes the clinical use, pharmacological effects and mechanisms of HAE drugs, and it also discusses possible development directions and targets to enhance understanding of HAE and help researchers.
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Affiliation(s)
- Lei Ding
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou 310014, PR China; Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, PR China
| | - Meng-Jiao Zhang
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou 310014, PR China; Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, PR China
| | - Guo-Wu Rao
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou 310014, PR China; Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, PR China.
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8
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de Castro ED, Pinhal AL, Bragança M, Freixo JP, Martinho A. Hereditary angioedema with normal C1-Inhibitor: Clinical and genetic characterization of 15 Portuguese unrelated families. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00073-5. [PMID: 38342132 DOI: 10.1016/j.anai.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 01/09/2024] [Accepted: 01/26/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Hereditary angioedema with normal C1-INH (HAE-nC1-INH) is a rare genetic disease with similar phenotype to HAE-C1-INH, but different genetic background. Currently six subtypes are recognized, based on the underlying mutations. Several aspects need further clarification. OBJECTIVE To assess clinical features of patients with genetically characterized HAE-nC1-INH, from the North of Portugal. METHODS Retrospective assessment of clinical data from all patients with HAE-nC1-INH followed at a HAE Reference Center. RESULTS Forty-one patients were identified, four with no family history. The FXII-mutation Thr328Lys (38 carriers) was the most prevalent. Three new potentially disease causing variants linked to HAE-nC1-INH were identified (c.529+4A>G:FXII; Cys248*:Kininogen-1; Arg261His:Plasminogen). The HAE-FXII cohort included 82% females and 71.8% symptomatic patients. Penetrance rate was significantly higher in females (81.3% vs 28.6; p=0.012). A hormonal influence was observed in 96.2% of the symptomatic females, although 62.5% remained symptomatic after oral estrogens withdrawal. Trauma and dental procedures were frequent triggers (82.6% and 45.5%, respectively). Main locations were facial (described by 96%), lips (82.1%) and eyelids (64.3%). One patient reported erythema marginatum as prodrome. Plasma derived C1-INH was effective as short-term prophylaxis in all treated patients, but only in 80% as on demand treatment. Icatibant was effectively used on demand in 9 patients, but with relapses in five (57%). CONCLUSION We described the first Portuguese series of patients with HAE-nC1-INH genetically characterized. Differences with others may contribute to improve current unmet needs and raise awareness of this rare disease. We highlight the identification of 3 new variants(additional molecular studies are ongoing) and the first report of erythema marginatum in HAE-n-C1INH.
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Affiliation(s)
- Eunice Dias de Castro
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João EPE, Porto, Portugal;; Public Health and Forensic Sciences and Medical Education Department, Faculty of Medicine, University of Porto, Porto, Portugal;.
| | - Ana Luísa Pinhal
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João EPE, Porto, Portugal
| | - Mariana Bragança
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João EPE, Porto, Portugal
| | - João Parente Freixo
- Center for Predictive and Preventive Genetics, Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal;; Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - António Martinho
- Centro do Sangue e Transplantação de Coimbra, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
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Honda D, Li PH, Jindal AK, Katelaris CH, Zhi YX, Thong BYH, Longhurst HJ. Uncovering the true burden of hereditary angioedema due to C1-inhibitor deficiency: A focus on the Asia-Pacific region. J Allergy Clin Immunol 2024; 153:42-54. [PMID: 37898409 DOI: 10.1016/j.jaci.2023.09.039] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/01/2023] [Accepted: 09/28/2023] [Indexed: 10/30/2023]
Abstract
Hereditary angioedema (HAE) due to C1-inhibitor deficiency or dysfunction is a rare genetic disorder that causes recurrent episodes of swelling in various parts of the body. Treatment goals of HAE aim to "normalize" life for all patients; however, lack of diagnostic facilities and limited access to effective treatment options in developing nations cause delays in diagnosis and place a significant burden on patients. In this review, we aim to highlight the burden of disease caused by C1-inhibitor HAE across the Asia-Pacific region, considering its epidemiology, morbidity and mortality, and socioeconomic and psychological impact. We also review the availability of guideline-recommended diagnostic facilities and treatments, and how patients are currently managed. Data were collected from published literature and HAE experts in the region, who provided information regarding diagnosis and management in their countries. Current practice was reviewed against international guidelines, as well as local guidelines/consensus used in Australia, Japan, and China. Suggestions are provided for improving the time to diagnosis in the region, increasing access to guideline-recommended treatments, and providing support to reduce the burden on patients and caregivers. There is an urgent need to improve HAE services and provide access to life-saving treatment in developing countries, and efforts should be made to increase awareness of guideline recommendations in high-income economies that do not currently provide long-term prophylactic treatments.
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Affiliation(s)
- Daisuke Honda
- Department of Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Ankur Kumar Jindal
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Constance H Katelaris
- Immunology and Allergy Unit, Department of Medicine, Campbelltown Hospital and Western Sydney University, Campbelltown, Sydney, Australia
| | - Yu-Xiang Zhi
- Department of Allergy and Clinical Immunology, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing, China
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Hilary J Longhurst
- Department of Immunology, Auckland City Hospital, Grafton, Auckland, New Zealand; Department of Medicine, University of Auckland, Auckland, New Zealand.
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Maurer M, Lumry WR, Li HH, Aygören-Pürsün E, Busse PJ, Jacobs J, Nurse C, Ahmed MA, Watt M, Yu M. Lanadelumab in Patients 2 to Less Than 12 Years Old With Hereditary Angioedema: Results From the Phase 3 SPRING Study. J Allergy Clin Immunol Pract 2024; 12:201-211.e6. [PMID: 37730089 DOI: 10.1016/j.jaip.2023.09.009] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/16/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Symptoms of hereditary angioedema (HAE) often first occur during childhood, and HAE attacks in children can be severe and substantially affect health-related quality of life (HRQoL). However, there are no approved long-term prophylaxis treatments for children aged less than 6 years. OBJECTIVE The SPRING Study (NCT04070326) evaluated the safety, pharmacokinetics, and efficacy of lanadelumab and HRQoL in patients aged 2 to less than 12 years. METHODS Over 52 weeks of treatment, patients aged 2 to less than 6 years received lanadelumab 150 mg every 4 weeks (Q4W) and patients aged 6 to less than 12 years received 150 mg every 2 weeks (Q2W) but could switch to Q4W if they were attack-free for 26 weeks. RESULTS We enrolled 21 patients (aged 2 to less than 6 years: n = 4; aged 6 to less than 12 years: n = 17), 20 of whom completed the study. There were no reported serious treatment-emergent adverse events or discontinuations resulting from such events. Treatment-emergent adverse events were reported for 17 patients (81.0%). The most common TEAE was injection site pain. Overall systemic exposure was comparable for both age groups. The mean (SD) attack rate during treatment decreased by 94.8% from baseline (1.84 [1.53] to 0.08 [0.17] attacks/mo), and 16 (76.2%) patients were attack-free. The attack rate reduction in both age groups was similar during the first 26-week fixed-dosing treatment. Seven patients switched from Q2W to Q4W and remained attack-free. A large, clinically meaningful increase in the Pediatric Quality of Life Inventory Generic Core Scale Total Score and a large increase in the Pediatric Quality of Life Inventory Generic Core Scale-Family Impact Module Total Score from baseline to end of study (better HRQoL) were observed. CONCLUSIONS Findings support safety, efficacy, and improved HRQoL with lanadelumab 150 mg Q2W and Q4W regimens for the prevention of HAE attacks in patients aged 2 to less than 12 years.
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Affiliation(s)
- Marcus Maurer
- Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany.
| | | | - H Henry Li
- Institute for Asthma and Allergy, Chevy Chase, Md
| | - Emel Aygören-Pürsün
- Department for Children and Adolescents, Angioedema Centre, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Paula J Busse
- Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua Jacobs
- Allergy and Asthma Clinical Research, Walnut Creek, Calif
| | | | - Mariam A Ahmed
- Takeda Development Center Americas, Inc, Lexington, Mass
| | - Maureen Watt
- Takeda Development Center Americas, Inc, Lexington, Mass
| | - Ming Yu
- Takeda Development Center Americas, Inc, Lexington, Mass
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11
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Ebo DG, Van der Poorten MM, Van Gasse AL, Schrijvers R, Hermans C, Bartiaux M, Haerynck F, Willekens J, Lapeere H, Moutschen M, Michel O, Sabato V. Clinical practice of hereditary angioedema in Belgium: opportunities for optimized care. Acta Clin Belg 2023; 78:431-437. [PMID: 37243680 DOI: 10.1080/17843286.2023.2213491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/09/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Hereditary angioedema (HAE) is a rare disorder characterized by unpredictable painful and potentially life-threatening swelling episodes. The international WAO/EAACI guideline on the diagnosis and management of HAE was recently updated and provides up-to-date guidance for the management of. In this paper, we assessed to what extent the Belgian clinical practice was aligned with the revised guideline, and whether there were opportunities to optimise Belgian clinical practice in HAE. METHODS We compared the updated international guideline for HAE with information we acquired on Belgian clinical practice, a Belgian patient registry and expert opinion analysis. The Belgian patient registry was developed with the involvement of eight Belgian reference centers for HAE patients. Eight Belgian experts, physicians in the participating centers, included patients in the patient registry and participated in the expert opinion analysis. RESULTS The main action points to further optimise the Belgian clinical practice of HAE are Work towards total disease control and normalize patients' life by considering the use of new and innovative long-term prophylactic treatment options; (2) inform C1-INH-HAE patients about new long-term prophylactic therapies; (3) assure the availability of on-demand therapy for all C1-INH-HAE patients; (4) implement a more universally used assessment including multiple aspects of the disease (e.g. quality of life assessment) in daily clinical practice; and (5) continue and expand an existing patient registry to assure continued data availability on C1-INH-HAE in Belgium. CONCLUSIONS In light of the updated WAO/EAACI guideline, five action points were identified and several other suggestions were made to optimise the Belgian clinical practice in C1-INH-HAE.
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Affiliation(s)
- D G Ebo
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium
| | - M M Van der Poorten
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine and Health Science, Department of Paediatrics, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - A L Van Gasse
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine and Health Science, Department of Paediatrics, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - R Schrijvers
- Faculty of Medicine, Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, Leuven, KU, Belgium
| | - C Hermans
- Faculty of Medicine and Health Science, Department of Hematology, Cliniques universitaires Saint-Lu, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - M Bartiaux
- Faculty of Medicine and Health Science, Department of Urgent Medicine, Hospital Saint-Pierre, Brussels, Belgium
| | - F Haerynck
- Faculty of Medicine and Health Science, Department of Internal medicine and Paediatrics, Ghent University Hospital, Ghent, Belgium
| | - J Willekens
- Faculty of Medicine and Health Science, Department of Internal medicine and Paediatrics, Ghent University Hospital, Ghent, Belgium
| | - H Lapeere
- Faculty of Medicine and Health Science, Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - M Moutschen
- Faculty of Medicine and Health Science, Department of Internal Medicine and Infectious diseases, C.H.U. de Liège - Site du Sart Tilman, Liège, Belgium
| | - O Michel
- Faculty of Medicine, Department of Immunology and Allergology, C.H.U. Brugmann, Brussels, Belgium
| | - V Sabato
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Ryø LB, Haslund D, Rovsing AB, Pihl R, Sanrattana W, de Maat S, Palarasah Y, Maas C, Thiel S, Mikkelsen JG. Restriction of C1-inhibitor activity in hereditary angioedema by dominant-negative effects of disease-associated SERPING1 gene variants. J Allergy Clin Immunol 2023; 152:1218-1236.e9. [PMID: 37301409 DOI: 10.1016/j.jaci.2023.04.023] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/17/2023] [Accepted: 04/25/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Patients with hereditary angioedema experience recurrent, sometimes life-threatening, attacks of edema. It is a rare genetic disorder characterized by genetic and clinical heterogenicity. Most cases are caused by genetic variants in the SERPING1 gene leading to plasma deficiency of the encoded protein C1 inhibitor (C1INH). More than 500 different hereditary angioedema-causing variants have been identified in the SERPING1 gene, but the disease mechanisms by which they result in pathologically low C1INH plasma levels remain largely unknown. OBJECTIVES The aim was to describe trans-inhibitory effects of full-length or near full-length C1INH encoded by 28 disease-associated SERPING1 variants. METHODS HeLa cells were transfected with expression constructs encoding the studied SERPING1 variants. Extensive and comparative studies of C1INH expression, secretion, functionality, and intracellular localization were carried out. RESULTS Our findings characterized functional properties of a subset of SERPING1 variants allowing the examined variants to be subdivided into 5 different clusters, each containing variants sharing specific molecular characteristics. For all variants except 2, we found that coexpression of mutant and normal C1INH negatively affected the overall capacity to target proteases. Strikingly, for a subset of variants, intracellular formation of C1INH foci was detectable only in heterozygous configurations enabling simultaneous expression of normal and mutant C1INH. CONCLUSIONS We provide a functional classification of SERPING1 gene variants suggesting that different SERPING1 variants drive the pathogenicity through different and in some cases overlapping molecular disease mechanisms. For a subset of gene variants, our data define some types of hereditary angioedema with C1INH deficiency as serpinopathies driven by dominant-negative disease mechanisms.
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Affiliation(s)
| | - Didde Haslund
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Rasmus Pihl
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Wariya Sanrattana
- CDL Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Steven de Maat
- CDL Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Yaseelan Palarasah
- Department of Cancer and Inflammation Research, University of Southern Denmark, Odense, Denmark; Department of Clinical Biochemistry, Hospital of South West Jutland, Esbjerg, Denmark
| | - Coen Maas
- CDL Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Steffen Thiel
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
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Baynova K, Cimbollek S, Quiralte J, García R, Lucena JM, Lasa Luaces E, Lara Jiménez MA, Alvarez Nieto J, Moreto J, González-Quevedo T. Subcutaneous C1 inhibitor for the long-term prophylaxis of hereditary angioedema -a real life experience. J Investig Allergol Clin Immunol 2023; 34:0. [PMID: 37796634 DOI: 10.18176/jiaci.0948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Affiliation(s)
- K Baynova
- National Angioedema Reference Unit, Allergology Department, Virgen del Rocío University Hospital. Avenida Manuel Siurot, s/n, 41013 Seville, Spain
| | - S Cimbollek
- National Angioedema Reference Unit, Allergology Department, Virgen del Rocío University Hospital. Avenida Manuel Siurot, s/n, 41013 Seville, Spain
| | - J Quiralte
- National Angioedema Reference Unit, Allergology Department, Virgen del Rocío University Hospital. Avenida Manuel Siurot, s/n, 41013 Seville, Spain
| | - R García
- National Angioedema Reference Unit, Allergology Department, Virgen del Rocío University Hospital. Avenida Manuel Siurot, s/n, 41013 Seville, Spain
| | - J M Lucena
- Immunology Department, Virgen del Rocío University Hospital. Avenida Manuel Siurot, s/n, 41013 Seville, Spain
| | - E Lasa Luaces
- Pediatric Allergology Unit, Allergology Department, Donostia University Hospital. Begiristain Doktorea Pasealekua, s/n, 20014 Donostia, Spain
| | - M A Lara Jiménez
- Allergology Unit, San Cecilio University Hospital, Av. del Conocimiento, s/n, 18016 Granada, Spain
| | - J Alvarez Nieto
- CSL Behring España S.A. Calle Tarragona, 157, 18th floor, 08014 Barcelona, Spain
| | - J Moreto
- Ampersand Consulting. Calle Muntaner, 140, Pral, 2a, 08036 Barcelona, Spain
| | - T González-Quevedo
- National Angioedema Reference Unit, Allergology Department, Virgen del Rocío University Hospital. Avenida Manuel Siurot, s/n, 41013 Seville, Spain
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15
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Eyice Karabacak D, Can A, Demir S, Yegit OO, Colakoglu B, Buyukozturk S, Gelincik AA. How Does Pregnancy and Type of Delivery Affect the Clinical Course of Hereditary Angioedema? Int Arch Allergy Immunol 2023; 184:1216-1224. [PMID: 37673053 DOI: 10.1159/000531074] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/28/2023] [Indexed: 09/08/2023] Open
Abstract
INTRODUCTION Knowledge on the clinical course of hereditary angioedema (HAE) during pregnancy, delivery, and breastfeeding is very limited. In this study, we aimed to evaluate the course of HAE during these periods. METHODS The HAE attacks C1-INH prophylaxis before and during pregnancy and during breastfeeding, and the delivery types were retrospectively determined. The severity of attacks was assessed by a 10-point Visual Analogue Scale (VAS). RESULTS We evaluated 88 pregnancies in 48 HAE patients among whom 20 were primiparous. Among those who had a HAE diagnosis during pregnancy (n = 34), the median attack numbers before pregnancy, during pregnancy, breastfeeding, and after breastfeeding were 17, 39, 24, and 14 (before pregnancy vs. pregnancy, p < 0.001; during pregnancy vs. breastfeeding, p = 0.001). The mean VASs (SD) were 6.59 (1.82), 8.33 (1.58), 7.32 (1.66), and 6.95 (1.90) (before pregnancy vs. pregnancy, p < 0.001; during pregnancy vs. breastfeeding, p = 0.016), respectively. Among those who received a HAE diagnosis after pregnancy (n = 54), the number (59.3%) and the severity (60%) of HAE attacks were high in pregnancy. 47 of the deliveries were normal vaginal delivery (NVD). Regional anesthesia was applied in 8 NVDs. 20 of caesarean deliveries were performed under general anesthesia, and 21 were under spinal anesthesia. Lowest numbers of attacks were found in patients who did not receive anesthesia during NVD (p = 0.001). CONCLUSION The course of HAE can be worse during pregnancy and breastfeeding. NVD is related to fewer HAE attacks and prophylaxis with C1-INH during NVD is not necessary to prevent a HAE attack.
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Affiliation(s)
- Deniz Eyice Karabacak
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ali Can
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Semra Demir
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Osman Ozan Yegit
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bahauddin Colakoglu
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Suna Buyukozturk
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aslı Akkor Gelincik
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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16
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Vargas Camaño ME, Buendía López YO, Garcés Flores H, Guzmán Vázquez S. Hereditary angioedema: Patient journey approach in Mexico. Rev Alerg Mex 2023; 70:121-128. [PMID: 37933922 DOI: 10.29262/ram.v70i3.1250] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/22/2023] [Indexed: 11/08/2023] Open
Abstract
Objective To understand the patient's journey with HAE from symptom initiation to diagnosis, treatment allocation, follow-up, and the impact of the disease on their quality of life in Mexico. Methods A survey was administered to the patients with HAE. Participants completed a questionnaire covering five domains: patient journey; effects on productivity, school performance and daily activities; quality of life; anxiety and depression. Responses were analyzed using descriptive statistics. Results A total of 17 surveys were analyzed (15 women and 2 men, age range: 23-67 years). Type I HAE was most common (71%), normal C1 inhibitor HAE was 12% and 18% did not know their HAE type. The average disease evolution was 13.7 years and the time from symptom initiation to diagnosis was 20 years. 59% of patients knew of one or two treatments available, 12% knew 3 treatments and 18% were aware of 4 or more, 12% were not aware of any treatments. 53% had a job, 18% referred a severely anxious state, 41% were depressed and all patients referred some social impact due to HAE. Conclusions There is a need to reinforce the knowledge of general practitioners on HAE to promote an earlier diagnosis and awareness of rare diseases and their impact on quality of life among the general population and promote the removal of barriers to treatment.
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Nieto S, Madrigal I, Contreras F, Vargas ME. Real-world experience of hereditary angioedema (HAE) in Mexico: A mixed-methods approach to describe epidemiology, diagnosis, and treatment patterns. World Allergy Organ J 2023; 16:100812. [PMID: 37727628 PMCID: PMC10506135 DOI: 10.1016/j.waojou.2023.100812] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/03/2023] [Accepted: 08/17/2023] [Indexed: 09/21/2023] Open
Abstract
Introduction and objectives Due to the lack of structured and systematic information available, the aim of this study was to describe the epidemiology, diagnosis, healthcare processes, and treatment patterns of hereditary angioedema (HAE) in Mexico. To achieve this, different data sources were consulted regarding medical literature, structured health system databases, and angioedema-specialized physicians (AEP) opinion regarding HAE. Material and methods A mixed methods approach was conducted in 4 phases: I) systematic literature review (SLR) and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; II) review of national health system (NHS) databases and systematic reports; III) physician survey; and IV) an epidemiologic model. ICD 10 D84.1 encoded records from the NHS were used to estimate the number of patients with HAE attended and treated during 2019. A survey was implemented to increase understanding of the clinical profile and treatments used. Results A prevalence rate of 0.9/50 000 inhabitants was estimated for 2019. In the same year, an estimated 317 HAE type 1 patients were recorded in the NHS, aged ≥11 years old. The most frequent clinical symptoms were cutaneous edema (67.5%) and abdominal pain (47.9%). A severe episode with laryngeal edema appeared in 27.5% of cases. Acute episodes were mainly moderate to severe (77.0%), with an annual per capita frequency of emergency visits of 7.6 patient-year (range 1-12/patient-year). The main reasons for hospitalization corresponded to laryngeal facial, tongue, and abdominal edemas, representing 73.3% of annual ICD 10 D84.1 reported hospitalizations. The main treatments that patients with HAE received were fresh frozen plasma for acute attacks and danazol for short-term prophylaxis (STP). Conclusions Despite efforts to make HAE visible, according to this study, cases recognized and treated in the NHS represent only 16.6% of the estimated prevalence.
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Affiliation(s)
- Sandra Nieto
- Specialty in Pediatrics and Pediatric Hematology. Genetics of Nutrition Unit, Instituto Nacional de Pediatría, CDMX, Mexico
| | - Ileana Madrigal
- Specialty in Allergy and Immunology. High Specialty Medical Unit (UMAE), Centro Médico Nacional de Occidente, IMSS, Guadalajara, Mexico
| | - Francisco Contreras
- Specialty in Pediatrics and Allergy and Clinical Immunology. Allergy and Immunology Department, Instituto Nacional de Pediatría, CDMX, Mexico
| | - María Eugenia Vargas
- Specialty in Internal Medicine, Allergy and Clinical Immunology Master's Degree in History. Allergy and Immunology Department, Centro Médico Nacional 20 de Noviembre, ISSSTE, CDMX, Mexico
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18
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Arora NS, Nelson B, Carpenter L, Wettenstein RP, Hashmi M, Selva CN, Castaldo AJ, Baptist AP. Consequences of Insurance Coverage Delays and Denials for Patients With Hereditary Angioedema. J Allergy Clin Immunol Pract 2023; 11:2432-2438.e1. [PMID: 37558360 DOI: 10.1016/j.jaip.2023.03.006] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/27/2023] [Accepted: 03/06/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare and potentially fatal genetic disease associated with recurrent and unpredictable episodes of angioedema. Although modern therapies have dramatically increased quality of life, insurance changes, delays, and denials are becoming more common. OBJECTIVE To examine the impact of insurance delays and denials on patient health and well-being. METHODS A total of 20 patients with HAE (type 1 and 2) who recently experienced insurance delays or denials completed an online survey, and 19 participated in a follow-up focus group. The survey and focus group addressed the impact of insurance challenges on the use of health care services, work/school attendance, and anxiety. Three independent reviewers coded each focus group transcript using a thematic saturation approach. RESULTS A total of 70% of participants reported an increased frequency of angioedema attacks resulting from insurance delays or denials. More than 50% missed work/school days because of increased attacks, and 90% reported greater anxiety. Twenty-five percent of respondents reported more urgent care or emergency department visits. In focus groups, participants identified specific ways that losing access to medication had a negative impact on their health, family, and work/school life. Insufficient notification of health insurance policy changes and the time and effort required to regain access to medications compounded patients' frustration and anxiety. CONCLUSION Insurance delays and denials have significant impacts on individuals with HAE including (1) increased urgent care and emergency department visits, (2) missed work/school days, (3) higher levels of anxiety, and (4) a negative impact on family life.
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Affiliation(s)
- Nonie S Arora
- Department of Internal Medicine, University of Michigan, Ann Arbor, Mich.
| | - Belinda Nelson
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | - Laurie Carpenter
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | - Rachel P Wettenstein
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | - Muzhda Hashmi
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | | | | | - Alan P Baptist
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
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Yong PFK, Coulter T, El-Shanawany T, Garcez T, Hackett S, Jain R, Kiani-Alikhan S, Manson A, Noorani S, Stroud C, Symons C, Sargur R, Steele C, Alachkar H, Anantharachagan A, Arkwright PD, Bernatoniene J, Bhole M, Brown L, Buckland M, Burns S, Chopra C, Darroch J, Drewe E, Edmonds J, Ekbote A, Elkhalifa S, Goddard S, Grosse-Kreul D, Gurugama P, Hague R, Herriot R, Herwadkar A, Hughes SM, Jones L, Lear S, McDermott E, Kham Murng SH, Price A, Redenbaugh V, Richter A, Riordan A, Shackley F, Stichbury J, Springett D, Tarzi MD, Thomas M, Vijayadurai P, Worth A. A National Survey of Hereditary Angioedema and Acquired C1 Inhibitor Deficiency in the United Kingdom. J Allergy Clin Immunol Pract 2023; 11:2476-2483. [PMID: 37146882 DOI: 10.1016/j.jaip.2023.04.035] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 03/30/2023] [Accepted: 04/14/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Detailed demographic data on people with hereditary angioedema (HAE) and acquired C1 inhibitor deficiency in the United Kingdom are relatively limited. Better demographic data would be beneficial in planning service provision, identifying areas of improvement, and improving care. OBJECTIVE To obtain more accurate data on the demographics of HAE and acquired C1 inhibitor deficiency in the United Kingdom, including treatment modalities and services available to patients. METHODS A survey was distributed to all centers in the United Kingdom that look after patients with HAE and acquired C1 inhibitor deficiency to collect these data. RESULTS The survey identified 1152 patients with HAE-1/2 (58% female and 92% type 1), 22 patients with HAE with normal C1 inhibitor, and 91 patients with acquired C1 inhibitor deficiency. Data were provided by 37 centers across the United Kingdom. This gives a minimum prevalence of 1:59,000 for HAE-1/2 and 1:734,000 for acquired C1 inhibitor deficiency in the United Kingdom. A total of 45% of patients with HAE were on long-term prophylaxis (LTP) with the most used medication being danazol (55% of all patients on LTP). Eighty-two percent of patients with HAE had a home supply of acute treatment with C1 inhibitor or icatibant. A total of 45% of patients had a supply of icatibant and 56% had a supply of C1 inhibitor at home. CONCLUSIONS Data obtained from the survey provide useful information about the demographics and treatment modalities used in HAE and acquired C1 inhibitor deficiency in the United Kingdom. These data are useful for planning service provision and improving services for these patients.
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Affiliation(s)
- Patrick F K Yong
- Department of Allergy and Clinical Immunology, Frimley Health NHS Foundation Trust, Frimley, United Kingdom.
| | - Tanya Coulter
- Regional Immunology Service, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Tariq El-Shanawany
- Department of Immunology, University Hospital of Wales, Cardiff, Wales, United Kingdom
| | - Tomaz Garcez
- Department of Immunology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Scott Hackett
- Department of Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Rashmi Jain
- Department of Clinical Immunology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Ania Manson
- Department of Clinical Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Sadia Noorani
- Department of Immunology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
| | - Catherine Stroud
- Regional Department of Immunology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | - Christine Symons
- Department of Clinical Immunology and Allergy, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Ravishankar Sargur
- Department of Clinical Immunology and Allergy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Cathal Steele
- Department of Clinical Immunology, Ninewells Hospital, NHS Tayside, Dundee, United Kingdom
| | - Hana Alachkar
- Department of Immunology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Ariharan Anantharachagan
- Department of Immunology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Peter D Arkwright
- Department of Paediatric Allergy and Immunology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Jolanta Bernatoniene
- Department of Paediatric Immunology, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Malini Bhole
- Department of Immunology, The Dudley Group NHS Foundation Trust, Dudley, United Kingdom
| | - Lindsay Brown
- Department of Immunology and infectious Diseases, Royal Hospital for Children and Young People, NHS Lothian, Edinburgh, United Kingdom
| | - Matthew Buckland
- Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Siobhan Burns
- Department of Immunology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Charu Chopra
- Department of Clinical Immunology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - James Darroch
- Department of Immunology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Elizabeth Drewe
- Department of Clinical Immunology and Allergy, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Jillian Edmonds
- Department of Clinical Immunology, Ninewells Hospital, NHS Tayside, Dundee, United Kingdom
| | - Anjali Ekbote
- Department of Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Shuayb Elkhalifa
- Department of Clinical Immunology, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Sarah Goddard
- Department of Clinical Immunology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Dorothea Grosse-Kreul
- Department of Clinical Immunology and Allergy, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Padmalal Gurugama
- Department of Clinical Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rosie Hague
- Department of Paediatric Immunology and Infectious Diseases, Royal Hospital for Sick Children, Glasgow, United Kingdom
| | - Richard Herriot
- Department of Immunology, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Archana Herwadkar
- Department of Clinical Immunology, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Stephen M Hughes
- Department of Paediatric Allergy and Immunology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Laura Jones
- Department of Immunology and infectious Diseases, Royal Hospital for Children and Young People, NHS Lothian, Edinburgh, United Kingdom
| | - Sara Lear
- Department of Clinical Immunology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Elizabeth McDermott
- Department of Clinical Immunology and Allergy, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Sai Hurng Kham Murng
- Department of Clinical Immunology, Epsom and St Helier University Hospitals NHS Trust, Epsom, United Kingdom
| | - Arthur Price
- Department of Clinical Immunology and Allergy, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Vyanka Redenbaugh
- Regional Immunology Service, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Alex Richter
- Department of Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrew Riordan
- Department of Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Fiona Shackley
- Department of Immunology and Infectious Diseases, Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Julia Stichbury
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Debbie Springett
- Department of Clinical Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Michael D Tarzi
- Department of Immunology, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Moira Thomas
- Department of Clinical Immunology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Pavaladurai Vijayadurai
- Department of Immunology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Austen Worth
- Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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20
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Katelaris CH, Grumach AS, Bork K. Angioedema With Normal Complement Studies: What Do We Know? J Allergy Clin Immunol Pract 2023; 11:2309-2314. [PMID: 37343921 DOI: 10.1016/j.jaip.2023.06.022] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
Angioedema is generally readily recognizable clinically and is characterized by localized nonpitting edema involving subcutaneous, submucosal, or deep dermal tissue caused by increased vascular permeability and extravasation of intravascular fluid. It can occur via a variety of mechanisms. A number of clinical conditions (masqueraders) are occasionally mistaken for angioedema. Clinical classification of the various angioedema forms begins with noting the presence or absence of concurrent urticaria or wheals. Pathogenesis can be considered through two broad categories: mast cell-mediated with release of vasoactive mediators causing angioedema usually associated with urticaria or in the context of an anaphylactic reaction; and bradykinin (BK)-driven, in which increased vascular permeability is mediated by BK. BK-mediated angioedema does not occur with urticaria, nor does it respond to antiallergic medications. The various forms of hereditary angioedema are included in this category, requiring specific tests of C4 and C1 inhibitor level and function to confirm the diagnosis. Angiotensin converting enzyme inhibitors, which impair the degradation of BK, account for up to a third of all patients with angioedema presenting to the emergency department. Finally, angioedema may occur by yet unknown mechanisms; under this circumstance, it is difficult to manage.
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Affiliation(s)
- Constance H Katelaris
- Immunology/Allergy Unit, Department of Medicine, Campbelltown Hospital and Faculty of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia.
| | - Anete S Grumach
- Clinical Immunology, Department of Clinical Medicine, Faculty of Medicine, Centro Universitario FMABC, Santo Andre, São Paulo, Brazil.
| | - Konrad Bork
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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21
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Katelaris CH, Boicos K, Button PH, McCloud PI, Burton PK, Perram FA, Youssef S, Tognarini D. Living With Hereditary Angioedema in Australia: Findings From a National Observational Study Using Short Message Service to Monitor the Burden of Disease. J Allergy Clin Immunol Pract 2023; 11:2457-2467.e1. [PMID: 36918098 DOI: 10.1016/j.jaip.2023.02.037] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 12/18/2022] [Accepted: 02/23/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND To understand the impact and burden of disease experienced by patients with hereditary angioedema (HAE). OBJECTIVE To determine whether the use of short message service (SMS) to communicate with patients with HAE facilitates the collection of attack rate, medication use, and quality of life measurements. METHODS Patients aged 12 years and older with doctor-confirmed HAE C1-inhibitor deficiency types I and II were invited to participate. We devised a novel method for monitoring attacks by using questions weekly via SMS to gain a more accurate picture of the burden of HAE in Australian patients in real time. RESULTS A total of 2,648 weekly SMS messages were sent to 47 participants; 1,892 responses were received (71%). Participants reported 463 attacks across all treatment groups. Sixty percent of attacks were treated. Icatibant and C1-inhibitor concentrate were administered IV for 210 and 67 attacks, respectively. Of the 463 recorded attacks, 23 necessitated presentation to the hospital (5%), predominantly for facial and/or throat swelling. Several participants reported attacks (n = 186), which they chose not to treat. Most of those attacks were rated mildly severe. Twenty-one participants reported lost days owing to HAE attacks (44.7%). Fifty-eight attacks (17%) resulted in time away from work or school, equating to a total of 85.5 days lost. CONCLUSIONS This study was a first of its kind, real-world, prospective, observational study of Australian patients living with HAE. Despite the availability of effective on-demand therapies, HAE remains burdensome. Wider access to safe and effective prophylactic therapies is needed for patients living with HAE.
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Affiliation(s)
- Constance H Katelaris
- Immunology and Allergy Unit, Campbelltown Hospital, Campbelltown, New South Wales, Australia; Faculty of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia.
| | | | - Peter H Button
- McCloud Consulting Group, Sydney, New South Wales, Australia
| | | | - Pamela K Burton
- Immunology and Allergy Unit, Campbelltown Hospital, Campbelltown, New South Wales, Australia
| | - Fiona A Perram
- Immunology and Allergy Unit, Campbelltown Hospital, Campbelltown, New South Wales, Australia
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22
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Riedl MA, Danese M, Danese S, Ulloa J, Maetzel A, Audhya PK. Hereditary Angioedema With Normal C1 Inhibitor: US Survey of Prevalence and Provider Practice Patterns. J Allergy Clin Immunol Pract 2023; 11:2450-2456.e6. [PMID: 36720386 DOI: 10.1016/j.jaip.2023.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 10/24/2022] [Revised: 12/20/2022] [Accepted: 01/01/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) with normal C1-INH (HAE-nl-C1INH) is phenotypically similar to HAE resulting from C1-INH deficiency (HAE-C1INH). Confirmatory diagnostic tests for HAE-nl-C1INH are limited and few clinical study data exist regarding management of the condition. Therefore, survey studies may provide initial estimates of prevalence, diagnosis, and management patterns of this condition. OBJECTIVE To estimate the prevalence and describe current management patterns for HAE-nl-C1INH in the United States (US). METHODS We conducted an Internet-based survey of US physicians to estimate the prevalence of the HAE-nl-C1INH population in the United States. Potential participating physicians were identified from the US Hereditary Angioedema Association database and IQVIA Xponent prescription database. Eligible physicians were invited to complete an online survey between June and September 2021. RESULTS A total of 113 physicians provided data for the estimation of HAE-nl-C1INH prevalence and 81 physicians treating HAE-nl-C1INH patients provided data about treatment patterns. In bias-corrected analysis, we estimated 1,230 to 1,331 HAE-nl-C1INH patients within the United States between May 2019 and April 2020. Mean time to diagnosis for HAE-nl-C1INH was approximately 6 years (range, 2.4-13.5 years). Response to medication was commonly used to inform diagnosis (antihistamine response or nonresponse used by 73% of physician respondents, corticosteroids by 57%, or HAE-specific medications by 74%), and Factor XII genetic testing was used by 43%. CONCLUSIONS These survey data provide estimates of HAE-nl-C1INH prevalence in the United States as well as current diagnosis and management strategies. Results may be useful for developing studies to assess treatment efficacy and safety, and potentially improve the diagnosis for and management of this patient population.
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Affiliation(s)
- Marc A Riedl
- Division of Rheumatology, Allergy, and Immunology, University of California, San Diego, Calif.
| | | | | | | | - Andreas Maetzel
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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23
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Fijen LM, Klein PCG, Cohn DM, Kanters TA. The Disease Burden and Societal Costs of Hereditary Angioedema. J Allergy Clin Immunol Pract 2023; 11:2468-2475.e2. [PMID: 36990433 DOI: 10.1016/j.jaip.2023.03.032] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/12/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND According to the current treatment guidelines, the goals of treatment of patients with hereditary angioedema (HAE) are to achieve total control of the disease and to normalize patients' lives. OBJECTIVE This study aims to establish the entire burden of HAE comprising disease control, treatment satisfaction, reductions in quality of life, and societal costs. METHODS Adult patients with HAE under treatment at the Dutch national center of reference completed a cross-sectional survey in 2021. The survey consisted of different questionnaires: angioedema-specific questionnaires (4-week Angioedema Activity Score and Angioedema Control Test), quality of life questionnaires (Angioedema Quality of Life [AE-QoL] questionnaire and EQ-5D-5L), the Treatment Satisfaction Questionnaire for Medication (TSQM), and societal costs questionnaires (iMTA Medical Consumption Questionnaire and iMTA Productivity Cost Questionnaire). RESULTS The response rate was 78% (69 of 88). The entire sample had a mean Angioedema Activity Score of 16.61, and 36% of participants had poorly controlled disease as expressed by the Angioedema Control Test. The mean quality of life in the entire sample was 30.99 as expressed by the AE-QoL and 0.873 as expressed by the EQ-5D-5L utility value. Utilities dropped by 0.320 points during an angioedema attack. TSQM scores ranged from 66.67 to 75.00 across its 4 domains. On average, total costs per year incurred €22,764, predominantly existing of HAE-medication costs. Total costs showed substantial variation between patients. CONCLUSIONS This study describes the entire burden of HAE among Dutch patients comprising disease control, quality of life, treatment satisfaction, and societal costs. These results can inform cost-effectiveness analyses that can aid reimbursement decisions for HAE treatments.
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Affiliation(s)
- Lauré M Fijen
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Philip C G Klein
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Danny M Cohn
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Tim A Kanters
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands.
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24
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Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45267-0769, USA. https://twitter.com/edmojo
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25
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Betschel SD, Banerji A, Busse PJ, Cohn DM, Magerl M. Hereditary Angioedema: A Review of the Current and Evolving Treatment Landscape. J Allergy Clin Immunol Pract 2023; 11:2315-2325. [PMID: 37116793 DOI: 10.1016/j.jaip.2023.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/30/2023]
Abstract
Hereditary angioedema (HAE) is a rare disease characterized by sudden and often unprovoked episodes of swelling that can be potentially life-threatening when it involves the upper airway. The treatment options for both acute episodes of HAE and LTP, used to minimize the frequency and severity of angioedema attacks, were limited historically to very few options, had considerable side effects, and/or had considerable burden of treatment. Fortunately, through the elucidation of the pathophysiology of HAE, the development of newer targeted therapies has been possible both for acute therapy and long-term prophylaxis and even more are on the horizon. Because of the rapid development of these therapies, it can be challenging for clinicians to keep abreast of newer and developing treatments for HAE. This review article will outline the current and potential future treatments for HAE. It will also highlight important considerations when treating special HAE patient populations including women and pediatric patients.
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Affiliation(s)
- Stephen D Betschel
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Aleena Banerji
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Mass.
| | - Paula J Busse
- Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Danny M Cohn
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Markus Magerl
- Institute of Allergology, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin), Berlin, Germany; Department of Immunology and Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany
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26
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Wongsa C, Phinyo P, Dharakul T, Sompornrattanaphan M, Srisuwatchari W, Thongngarm T. Patient-rated angioedema severity using a novel photo-aid for predicting non-mast cell mediator-induced angioedema diagnosis. World Allergy Organ J 2023; 16:100784. [PMID: 37435178 PMCID: PMC10331577 DOI: 10.1016/j.waojou.2023.100784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/25/2023] [Accepted: 05/09/2023] [Indexed: 07/13/2023] Open
Abstract
Background Patients with non-mast cell mediator-induced angioedema (NM-AE) usually experience a diagnostic delay. Therefore, a clinical tool for predicting NM-AE diagnosis is essential. Objective To identify clinical predictors related to a confirmed diagnosis of NM-AE. Methods Participants with a history of recurrent AE with unknown causes were enrolled. They were classified into mast cell mediator-induced AE (M-AE) and NM-AE according to the response to anti-mast cell mediator therapy. All participants were asked to rate their worst AE ever experienced (% Photomax) from 0 to 100% using a novel photo aid. Clinical characteristics were recorded and analyzed by univariable and multivariable analysis. Results Thirty-five participants were included, 25 with NM-AE and 10 with M-AE. AE located at extremities, face, and genitalia and positive family history were significantly associated with NM-AE. The AE severity in the NM-AE group was significantly higher than in the M-AE group, with the mean % Photomax of 82.4 ± 20.3 vs 47.5 ± 25.6 (p < 0.001), respectively. Univariable analysis showed that the % Photomax (every 10% increase), feet AE and hands AE were predictive of being NM-AE with the area under the receiver operating characteristic curve (AuROC) of 0.87 (95% CI 0.75, 0.99), 0.85 (95% CI 0.72, 0.98), and 0.84 (0.69, 0.99), respectively. Multivariable analysis showed that the combination of hands AE and % Photomax enhanced diagnostic accuracy (AuROC 0.94, 95% CI 0.86, 1.0) and constituted the prototype formula for calculating the diagnostic probability. Conclusion Patient-rated angioedema severity using a novel photo aid combined with hands AE had a high probability of diagnosing NM-AE.
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Affiliation(s)
- Chamard Wongsa
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Musculoskeletal Science and Translational Research (MSTR) Center, Chiang Mai University, Chiang Mai, Thailand
| | - Tararaj Dharakul
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mongkhon Sompornrattanaphan
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Witchaya Srisuwatchari
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Torpong Thongngarm
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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27
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Raasch J, Glaum MC, O’Connor M. The multifactorial impact of receiving a hereditary angioedema diagnosis. World Allergy Organ J 2023; 16:100792. [PMID: 37448849 PMCID: PMC10336685 DOI: 10.1016/j.waojou.2023.100792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/08/2023] [Accepted: 05/24/2023] [Indexed: 07/15/2023] Open
Abstract
Hereditary angioedema (HAE) is a rare, chronic, debilitating genetic disorder characterized by recurrent, unpredictable, and potentially life-threatening episodes of swelling that typically affect the extremities, face, abdomen, genitals, and larynx. The most frequent cause of HAE is a mutation in the serpin family G member 1 (SERPING1) gene, which either leads to deficient plasma levels of the C1-esterase inhibitor (C1-INH) protein (type I HAE-C1-INH) or normal plasma levels of dysfunctional C1-INH protein (type II HAE-C1-INH). Mutations in SERPING1 are known to be associated with dysregulation of the kallikrein-bradykinin cascade leading to enhancement of bradykinin production and increased vascular permeability. However, some patients present with a third type of HAE (HAE-nl-C1-INH) that is characterized by normal plasma levels and functionality of the C1-INH protein. While mutations in the factor XII, angiopoietin-1, plasminogen, kininogen-1, myoferlin, and heparan sulfate-glucosamine 3-O-sulfotransferase-6 genes have been identified in some patients with HAE-nI-C1-INH, genetic cause remains unknown in many cases with further research required to fully elucidate the pathology of disease in these patients. Here we review the challenges that arise on the pathway to a confirmed diagnosis of HAE and explore the multifactorial impact of receiving a HAE diagnosis. We conclude that it is important to continue to raise awareness of HAE because delays to diagnosis have a direct impact upon patient suffering and quality of life. Since many patients will seek help from hospitals during their first swelling attack it is vital that emergency department staff are aware of the different pathological pathways that distinguish HAE from other forms of angioedema to ensure that the most appropriate treatment is administered. As disease awareness increases, it is hoped that patients will be diagnosed earlier and that pre-authorization and insurance coverage of HAE treatments will become easier to obtain, ultimately reducing the burden of treatment for these patients and their caregivers.
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Affiliation(s)
| | - Mark C Glaum
- Department of Internal Medicine, Division of Allergy and Immunology, University of South Florida, FL, USA
| | - Maeve O’Connor
- Allergy, Asthma & Immunology Relief of Charlotte, Charlotte, NC, USA
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28
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Mendivil J, DerSarkissian M, Banerji A, Diwakar L, Katelaris CH, Keith PK, Kim H, Lacuesta G, Magerl M, Slade C, Smith WB, Choudhry Z, Simon A, Sarda SP, Busse PJ. A multicenter chart review of patient characteristics, treatment, and outcomes in hereditary angioedema: unmet need for more effective long-term prophylaxis. Allergy Asthma Clin Immunol 2023; 19:48. [PMID: 37248521 DOI: 10.1186/s13223-023-00795-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/16/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare disease characterized by unpredictable, recurring subcutaneous or submucosal swelling. Without effective therapy, HAE can negatively impact patients' quality of life. Management of HAE includes on-demand treatment of attacks and short- and long-term prophylaxis (LTP) to prevent attacks. Newer therapies may be more tolerable and effective in managing HAE; however, therapies such as androgens are still widely used in some countries owing to their relative ease of access and adequate disease control for some patients. This study evaluated the characteristics, treatment patterns, clinical outcomes, and healthcare resource utilization of a multinational cohort of patients with HAE, with a focus on understanding reasons for recommending or discontinuing available therapies. METHODS A retrospective chart review was conducted at 12 centers in six countries and included data from patients with HAE type 1 or 2 who were ≥ 12 years of age at their first clinical visit. The relationship between LTP use and attack rates was evaluated using a multivariable Poisson regression model. Data were collected between March 2018 and July 2019. RESULTS Data from 225 patients were collected (62.7% female, 86.2% White, 90.2% type 1); 64.4% of patients had their first HAE-related visit to the center prior to or during 2014. Treatment patterns varied between countries. Overall, 85.8% of patients were prescribed on-demand treatment and 53.8% were prescribed LTP, most commonly the androgen danazol (53.7% of patients who used LTP). Plasma-derived C1 inhibitor (Cinryze®) was used by 29.8% of patients for LTP. Patients who received LTP had a significantly lower rate of HAE attacks than patients who did not receive any LTP (incidence rate ratio (95% confidence interval) 0.90 (0.84-0.96)). Androgens were the most commonly discontinued therapy (51.3%), with low tolerability cited as the most frequent reason for discontinuation (50.0%). CONCLUSIONS Overall, findings from this study support the use of LTP in the prevention of HAE attacks; a lower rate of attacks was observed with LTP compared with no LTP. However, the type of LTP used varied between countries, with tolerability and accessibility to specific treatments playing important roles in management decision-making.
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Affiliation(s)
- Joan Mendivil
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | | | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lavanya Diwakar
- Department of Immunology, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | | | | | - Harold Kim
- McMaster University, Hamilton, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
| | - Gina Lacuesta
- Halifax Allergy and Asthma Associates, Halifax, NS, Canada
| | - Markus Magerl
- Institute of Allergology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Charlotte Slade
- Department of Clinical Immunology and Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - William B Smith
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Zia Choudhry
- Takeda Development Center Americas, Lexington, MA, USA
| | - Angela Simon
- Takeda Development Center Americas, Lexington, MA, USA.
| | | | - Paula J Busse
- Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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29
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Honda D, Ohsawa I, Aizawa M, Tomino Y, Asanuma K. Hereditary angioedema with an acute attack resolved after bone marrow transplantation for acute myeloid leukemia: a case report. Allergy Asthma Clin Immunol 2023; 19:42. [PMID: 37194078 DOI: 10.1186/s13223-023-00803-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE), which is caused by C1-inhibitor (C1-INH) deficiency or dysfunction, is a rare and potentially life-threatening disease. In patients with HAE, excess production of bradykinin causes acute unpredictable recurrent attacks of angioedema in localized regions, including the larynx and intestines. Given the fact that HAE is an autosomal dominant disease, C1-INH produced in patients with HAE is 50% of that produced in healthy individuals. However, most patients with HAE present plasma C1-INH function of < 25% owing to the chronic consumption of C1-INH by kallikrein-kinin, contact, complement, coagulation, and fibrinolysis cascades. Recently, several therapeutic options have been developed for acute attacks and prophylaxis in the treatment of HAE; however, currently, there is no curative therapy for HAE. CASE PRESENTATION Here we report the case of a 48-year-old male patient who presented with a long-standing history of HAE and underwent bone marrow transplantation (BMT) for acute myeloid leukemia (AML) at the age of 39 years and has been in complete remission of AML and HAE thereafter. Notably, after BMT, his C1-INH function gradually increased as follows: < 25%, 29%, 37%, and 45.6%. Since his 20 s, he intermittently presented with an acute attack of HAE once every 3 months from the initial attack. Further, after undergoing BMT, the number of acute attacks decreased to twice within 4 years until the age of 45 years, and subsequently, the patient has been free of acute attacks. C1-INH is mainly synthesized by hepatocytes, but it is known to be partially produced and secreted from peripheral blood monocytes, macrophages, endothelial cells, and fibroblasts. We speculate that the C1-INH function may be increased by extrahepatic production of C1-INH, possibly synthesized by differentiated cells derived from hematopoietic and mesenchymal stem cells after BMT. CONCLUSIONS This case report supports efforts to focus on extrahepatic production of C1-INH in the next strategy of new treatment development for HAE.
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Affiliation(s)
- Daisuke Honda
- Department of Nephrology, Chiba University Hospital, Chiba, Japan
| | - Isao Ohsawa
- Nephrology Unit, Internal Medicine, Saiyu Soka Hospital, Saitama, Japan
| | - Masashi Aizawa
- Department of Nephrology, Chiba University Hospital, Chiba, Japan
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Miyata T, Horiuchi T. Biochemistry, molecular genetics, and clinical aspects of hereditary angioedema with and without C1 inhibitor deficiency. Allergol Int 2023:S1323-8930(23)00042-4. [PMID: 37169642 DOI: 10.1016/j.alit.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/26/2023] [Indexed: 05/13/2023] Open
Abstract
Hereditary angioedema (HAE) is a rare disorder characterized by cutaneous and submucosal swelling caused mostly by excessive local bradykinin production. Bradykinin is a vasoactive peptide generated by the limited proteolysis of high molecular weight kininogen (HMWK) by plasma kallikrein via the contact activation system. The contact activation system occurs not only in solution but also on the cell surface. Factor XII (FXII), prekallikrein, and HMWK are assembled on the endothelial cell surface via several proteins, including a trimer of a receptor for globular C1q domain in a Zn2+-dependent manner, and the reciprocal activation on the cell surface is believed to be physiologically important in vivo. Thus, the contact activation system leads to the activation of coagulation, complement, inflammation, and fibrinolysis. C1-inhibitor (C1-INH) is a plasma protease inhibitor that is a member of the serpin family. It mainly inhibits activated FXII (FXIIa), plasma kallikrein, and C1s. C1-INH hereditary deficiency induces HAE (HAE-C1-INH) due to excessive bradykinin production via the incomplete inhibition of plasma kallikrein and FXIIa through the low C1-INH level. HAE is also observed in patients with normal C1-INH (HAEnCI) who carry pathogenic variants in genes of factor XII, plasminogen, angiopoietin 1, kininogen, myoferlin, and heparan sulfate 3-O-sulfotransferase 6, which are associated with bradykinin production and/or vascular permeability. HAE-causing pathways triggered by pathogenic variants in patients with HAE-C1-INH and HAEnCI are reviewed and discussed.
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Affiliation(s)
- Toshiyuki Miyata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Biomedical Engineering, Osaka Institute of Technology, Osaka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan; Center for Research, Education, and Treatment of AngioEdema, A Specified Non-profit Corporation, Fukuoka, Japan.
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Adatia A, Ritchie B. Successful use of lanadelumab in a patient with hereditary angioedema with normal C1 inhibitor and negative genetic testing. J Allergy Clin Immunol Glob 2023; 2:100087. [PMID: 37780787 PMCID: PMC10509950 DOI: 10.1016/j.jacig.2023.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/11/2023] [Accepted: 02/17/2023] [Indexed: 10/03/2023]
Abstract
We report an approximately 80% reduction in angioedema attacks with lanadelumab, a mAb targeting plasma kallikrein, in a case of hereditary angioedema with normal C1 inhibitor levels. This finding supports a central pathophysiologic role for kallikrein in hereditary angioedema with normal C1 levels and supports the need for prospective studies of lanadelumab use with this condition.
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Affiliation(s)
- Adil Adatia
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Bruce Ritchie
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Canada
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Kanepa A, Nartisa I, Rots D, Gailite L, Farkas H, Kurjane N. National survey on clinical and genetic characteristics of patients with hereditary angioedema in Latvia. Allergy Asthma Clin Immunol 2023; 19:28. [PMID: 37031173 PMCID: PMC10082512 DOI: 10.1186/s13223-023-00783-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/12/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare and life-threatening inborn error of immunity. HAE is mostly caused by pathogenic variations in the serine protease inhibitor gene 1 (SERPING1), leading to deficient or dysfunctional C1-inhibitor (C1-INH), overproduction of bradykinin, and development of recurrent subcutaneous and/or submucosal oedema. The prevalence of HAE is 1 in 50,000 - 100000 people worldwide. We aimed to describe the clinical features and genetic spectrum of hereditary angioedema with C1-INH deficiency (C1-INH-HAE) in Latvia. METHODS All patients from Latvia diagnosed with HAE (types I/II) from 2006 to March 2022 were included in the study. Laboratory tests and clinical data were analysed, and genetic tests with Sanger sequencing and whole genome sequencing were performed. RESULTS The study identified 10 C1-INH-HAE patients (nine females, one male) from eight families. The point prevalence of HAE in Latvia is 0.53 per 100 000 inhabitants. Of all patients, seven (70%) had HAE type I and three (30%) had HAE type II. The median age of patients was 54 years and the median age at onset of symptoms was 15 years. A significant delay (median 20.5 years) until diagnosis was observed, and 60% of patients had a positive family history of angioedema. All HAE patients have been hospitalised a median two times during their lifetime. Skin (100%), abdominal (80%), and airway (80%) oedema were the most frequent symptoms. Triggering factors (60%) and prodromal symptoms (90%) were referred. Attacks were severe in 50% of patients, moderate in 10%, and mild in 40%. Pathogenic variations of SERPING1 were identified in eight patients (six families), confirming the diagnosis molecularly. In two patients (two families), no pathogenic variations in the genes were found even after whole genome sequencing. CONCLUSIONS Current data shows a significant delay and clear underdiagnosis of HAE in Latvia. Higher awareness and better information and communication between doctors would improve the diagnosis and management of HAE; as would screening of family members, patients with recurrent angioedema unresponsive to antihistamines and glucocorticoids, and patients with recurrent episodes of severe, unexplained abdominal pain.
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Affiliation(s)
- Adine Kanepa
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia.
| | - Inga Nartisa
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia
- Children's Clinical University Hospital, Riga, Latvia
| | - Dmitrijs Rots
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia
- Children's Clinical University Hospital, Riga, Latvia
| | - Linda Gailite
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Natalja Kurjane
- Riga Stradiņš University, Dzirciema Street 16, Riga, LV-1007, Latvia
- Pauls Stradiņš Clinical University Hospital, Riga, Latvia
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Vanya M, Watt M, Shahraz S, Kosmas CE, Rhoten S, Costa-Cabral S, Menauthoril J, Devercelli G, Weller K. Content validation and psychometric evaluation of the Angioedema Quality of Life Questionnaire for hereditary angioedema. J Patient Rep Outcomes 2023; 7:33. [PMID: 37012445 PMCID: PMC10070575 DOI: 10.1186/s41687-023-00576-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/14/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND There is considerable burden of illness in hereditary angioedema (HAE). However, instruments to assess health-related quality of life (HRQoL) in HAE are limited. The Angioedema Quality of Life Questionnaire (AE-QoL) was developed to measure HRQoL in patients with recurrent angioedema; the validity of the AE-QoL in patients with HAE is described. METHODS To identify disease-related experiences with a focus on the impact of HAE on HRQoL, interviews were conducted with a group of clinician experts and patients with HAE from Canada, France, Germany, Spain, the United Kingdom, and the United States, along with a targeted literature review. Concepts were mapped to the AE-QoL to assess item relevance, interpretation, and conceptual coverage. Cognitive interviews assessed item clarity and relevance. A psychometric validation was performed using data from a phase 3 trial. RESULTS Interviews were conducted with seven clinicians and 40 adult patients. Patients reported 35 unique impacts of HAE on their lives, the most frequent being on work/school, social relationships, physical activities, and emotions, particularly fear/worrying and anxiety. Saturation for these impacts was reached, and all concepts covered in the AE-QoL were reported during the interviews. Patients agreed that the questionnaire items and response options were clear and relevant, and the 4-week recall period was appropriate. The psychometric validation included data from 64 patients. For AE-QoL total scores, excellent internal consistency (Cronbach's alpha > 0.90), test-retest reliability (intraclass coefficient > 0.80), convergent validity with the Sheehan Disability Scale (r = 0.663), divergent validity with the EQ-5D-5L index (r = 0.292) and EQ-VAS (r = 0.337), and known-groups validity (p < 0.0001; ɳ2 = 0.56) were demonstrated. CONCLUSIONS Qualitative and psychometric analyses showed that the AE-QoL is a reliable and valid instrument for measuring HRQoL in adult patients with HAE from six countries.
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Affiliation(s)
- Magdalena Vanya
- ICON plc, South San Francisco, CA, USA.
- Takeda Development Center Americas, Inc, Lexington, MA, USA.
| | - Maureen Watt
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - Saeid Shahraz
- ICON plc, South San Francisco, CA, USA
- Tufts Medical Center Institute for Clinical Research and Health Policy, Boston, MA, USA
| | | | - Stephanie Rhoten
- ICON plc, South San Francisco, CA, USA
- IQVIA, San Francisco, CA, USA
| | | | | | | | - Karsten Weller
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie, Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
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Li PH, Pawankar R, Thong BYH, Fok JS, Chantaphakul H, Hide M, Jindal AK, Kang HR, Abdul Latiff AH, Lobo RCM, Munkhbayarlakh S, Nguyen DV, Shyur SD, Zhi Y, Maurer M. Epidemiology, Management, and Treatment Access of Hereditary Angioedema in the Asia Pacific Region: Outcomes From an International Survey. J Allergy Clin Immunol Pract 2023; 11:1253-1260. [PMID: 36584968 DOI: 10.1016/j.jaip.2022.12.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/25/2022] [Accepted: 12/18/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare genetic disease with significant morbidity and mortality for which early diagnosis and effective therapy are critical. Many Asia Pacific (AP) countries still lack access to diagnostic tests and evidence-based therapies. Epidemiologic data from the AP is needed to formulate regional guidelines to improve standards of care for HAE. OBJECTIVE To investigate the estimated minimal prevalence, needs, and potential interventions for the diagnosis and management of HAE in the AP. METHODS A structured questionnaire was distributed to representative experts from member societies of the Asia Pacific Association of Allergy, Asthma and Clinical Immunology. Patient profiles and the presence of diagnostic facilities or tests, regional and national HAE guidelines, and patient support groups were reported and compared. RESULTS Completed questionnaires were received from 14 representatives of 12 member countries and territories, representing 46% of the world population. Overall minimal prevalence of HAE in the AP region was 0.02/100,000 population, with significant heterogeneity across different centers. Only one-half and one-third had registered on-demand and prophylactic medications, respectively. Few had patient support groups (58%) or regional guidelines (33%), and their existence was associated with the availability of HAE-specific medications. Availability of C1-inhibitor level testing was associated with a lower age at HAE diagnosis (P = .017). CONCLUSIONS Hereditary angioedema in the AP differs from that in Western countries. Hereditary angioedema-specific medications were registered in only a minority of countries and territories, but those with patient support groups or regional guidelines were more likely to have better access. Asia Pacific-specific consensus and guidelines are lacking and urgently needed.
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Affiliation(s)
- Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong.
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan.
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy, and Immunology, Tan Tock Seng Hospital, Singapore
| | - Jie Shen Fok
- Department of Respiratory Medicine, Box Hill Hospital, Eastern Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Hiroshi Chantaphakul
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Michihiro Hide
- Department of Dermatology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ankur Kumar Jindal
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post-Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | | | - Rommel Crisenio M Lobo
- Philippine Children's Medical Center Hospital of Infant Jesus Medical Center, Fe del Mundo Medical Center, Quezon City, Philippines
| | - Sonomjamts Munkhbayarlakh
- Department of Pulmonology and Allergology, School of Medicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Dinh Van Nguyen
- Respiratory, Allergy, and Clinical Immunology Unit, Internal Medicine Department, Vinmec Times City International Hospital, Vinmec Healthcare System, Hanoi, Vietnam; College of Health Sciences, Vin University, Hanoi, Vietnam
| | | | - Yuxiang Zhi
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Marcus Maurer
- Angioedema Center of Reference and Excellence, Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
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Ren Z, Zhao S, Li T, Wedner HJ, Atkinson JP. Insights into the pathogenesis of hereditary angioedema using genetic sequencing and recombinant protein expression analyses. J Allergy Clin Immunol 2023; 151:1040-1049.e5. [PMID: 36587848 PMCID: PMC10449387 DOI: 10.1016/j.jaci.2022.11.027] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/09/2022] [Accepted: 11/29/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The pathogenesis of hereditary angioedema (HAE) type I and type II is linked to defective C1 esterase inhibitor (C1-INH) encoded by the SERPING1 gene. There are substantial variabilities in the clinical presentations of patients with HAE that are not directly correlated to the serum levels of C1-INH. The impact of SERPING1 variants on C1-INH expression, structure, and function is incompletely understood. OBJECTIVE To investigate the influence of SERPING1 variants on the C1-INH expression, structure, and function of 20 patients with HAE from 14 families with no prior genetic diagnosis. METHODS Patients underwent whole-exome sequencing (WES). If no variants were identified, whole-genome sequencing (WGS) was performed. Except for the frameshift and large deletions, each C1-INH variant was recombinantly produced and, if synthesized and secreted, was subjected to structural, oligosaccharide, and functional analyses. RESULTS We identified 11 heterozygous variants in the SERPING1 gene, of which 5 were classified as pathogenic (E85Dfs∗63, N166Qfs∗91, K201Qfs∗56, P399A, and R466H) and 6 as variants of uncertain significance (C130W, I224S, N272del, K273del, L349F, and F471C). Three large heterozygous deletions were discovered through WGS. Our data indicate that C130W, N272del, P399A, and F471C are poorly synthesized, I224S prevents proper C1-INH folding, and K273del impairs C1-INH function by adding an additional oligosaccharide. Further evaluation suggests that compound variant P399A/L349F contributes to a more severe clinical phenotype. CONCLUSIONS Our combined approach of WES and WGS uncovered SERPING1 gene alternations in each patient. The recombinant protein production followed by systematic antigenic, structural, and functional assessment facilitates the identification of underlying pathogenic mechanisms in HAE.
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Affiliation(s)
- Zhen Ren
- Division of Allergy and Immunology, Department of Medicine, Washington University School of Medicine, St Louis, Mo.
| | - Shuangxia Zhao
- Department of Molecular Diagnostics and Endocrinology, The Core Laboratory in Medical Center of Clinical Research, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tiandao Li
- Department of Developmental Biology, Washington University School of Medicine, St Louis, Mo
| | - H James Wedner
- Division of Allergy and Immunology, Department of Medicine, Washington University School of Medicine, St Louis, Mo
| | - John P Atkinson
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St Louis, Mo
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Nakayama T, Tamimoto Y, Shimomura Y, Tsukamoto H. Hereditary angioedema with normal C1-INH, developing recurrent acute abdomen after taking low-dose estrogen-progestin: A case report. Mod Rheumatol Case Rep 2023:7078904. [PMID: 36928504 DOI: 10.1093/mrcr/rxad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 03/18/2023]
Abstract
Hereditary angioedema is a rare genetic disease characterized by repeated episodes of temporary organ swelling. Three types of HAE are known, of which HAE with normal C1 inactivator is difficult to be diagnosed due to its lack of laboratory abnormalities. Here, we describe a case of HAE with normal C1 inactivator and recurrent acute abdomen following low-dose estrogen-progestin therapy. Notably, genetic analysis by Sanger sequencing led to the identification of a recurrent heterozygous missense mutation c.988A>G (p.K330E) in the plasminogen (PLG) gene of the patient. Prophylactic tranexamic acid and on-demand selective bradykinin B2 receptor blockers are used to treat her symptoms.
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Affiliation(s)
- Tsuyoshi Nakayama
- Department of Rheumatology, Japanese Red Cross Yamaguchi Hospital, Yamaguchi
| | - Yasuhiro Tamimoto
- Department of Rheumatology, Japanese Red Cross Yamaguchi Hospital, Yamaguchi
| | - Yutaka Shimomura
- Department of Dermatology, Yamaguchi University Graduate School of Medicine, Ube
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Launay D, Bouillet L, Boccon-Gibod I, Trumbic B, Gobert D, Fain O. [ Hereditary angioedema and its new treatments: An update]. Rev Med Interne 2023:S0248-8663(23)00061-9. [PMID: 36872215 DOI: 10.1016/j.revmed.2023.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/20/2023] [Accepted: 01/30/2023] [Indexed: 03/06/2023]
Abstract
Hereditary angioedema, with or without deficient C1 inhibitor level or function, is a rare disease characterized by recurrent attacks of noninflammatory subcutaneous and/or submucosal edema. It may be life-threatening and substantially affects quality of life. Attacks may be spontaneous or induced, in a setting of emotional stress, by infections or physical trauma, in particular. As the key mediator is bradykinin, this angioedema does not respond to the usual treatments of mast cell-mediated angioedema (antihistamines, corticosteroids, adrenaline), which is much more frequent. Therapeutic management of hereditary angioedema first consists in treating severe attacks with a selective B2 bradykinin receptor antagonist or a C1 inhibitor concentrate. The latter or an attenuated androgen (danazol) can be used for short-term prophylaxis. Therapeutic solutions conventionally proposed for long-term prophylaxis (danazol, antifibrinolytics [tranexamic acid], C1 inhibitor concentrate) vary in efficacy and/or pose problems of safety or ease of use. Kallikrein inhibitors (subcutaneous lanadelumab, oral berotralstat) recently made available as disease-modifying treatment constitute an important advance in long-term prophylaxis of hereditary angioedema attacks. The advent of these new drugs is accompanied by a new ambition for patients: optimize control of the disease and thereby minimize its impact on quality of life.
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Affiliation(s)
- D Launay
- University Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, service de médecine interne et immunologie clinique, centre de référence angioedèmes à kinine (CREAK), 59000 Lille, France.
| | - L Bouillet
- CHU Grenoble Alpes, service de médecine interne, centre de référence des angioedèmes (CREAK), 38000 Grenoble, France; University Grenoble Alpes, UMR 5525 TIMC-IMAG, laboratoire T-Raig, 38000 Grenoble, France
| | - I Boccon-Gibod
- Service de médecine interne et immunologie clinique, centre hospitalo-universitaire de Grenoble, CHUGA, centre de référence des angioedèmes national (CREAK) et international (ACARE), Grenoble, France
| | | | - D Gobert
- Sorbonne université, AP-HP, service de médecine interne, hôpital Saint-Antoine, 75012 Paris, France
| | - O Fain
- Sorbonne université, AP-HP, service de médecine interne, hôpital Saint-Antoine, 75012 Paris, France
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Evcen R, Çölkesen F, Saygın DA, Aykan FS, Kılınç M, Ergün ÜY, Akkuş FA, Önalan T, Yıldız E, Arslan Ş. High digit ratio (2D:4D) is associated with attack frequency and severity in hereditary angioedema patients. Early Hum Dev 2023; 177-178:105724. [PMID: 36827749 DOI: 10.1016/j.earlhumdev.2023.105724] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) caused by a deficiency or dysfunction of the plasma protease C1-inhibitor is a rare autosomal-dominant disorder. We explored a possible correlation between the ratio of the second and fourth finger lengths (2D:4D) and the frequency of HEA attacks, and whether the ratio might predict laryngeal attack. METHOD We evaluated 35 HEA patients aged 19 to 66 years; 3 were subsequently excluded. The 2D:4D ratio was calculated by dividing the length of the second finger by that of the fourth finger of both hands. A structured clinical questionnaire exploring HAE course and treatment over the prior year was administered. RESULTS Of the 32 participants, 56.25 % (n = 18) were female. Of them, those with high 2D:4D ratios suffered significantly more laryngeal attacks than others; 93.3% of patients with high 2D:4D ratios experienced ≥5 attacks annually, significantly more than those with low ratios. Among type 2 HEA patients, 75 % of those experiencing ≥5 attacks annually had high 2D:4D ratios; all patients with low 2D:4D ratios reported <5 attacks annually. These significant effects were found for right-hand 2D:4D ratios and not left-hand 2D:4D ratios. CONCLUSION The data suggest that intrauterine sex hormone exposure, which affects the 2D:4D ratio, is significantly associated with HEA attack frequency and severity, and laryngeal edema.
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Affiliation(s)
- Recep Evcen
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey.
| | - Fatih Çölkesen
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Duygu Akın Saygın
- Department of Anatomy, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Filiz Sadi Aykan
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Mehmet Kılınç
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Ümmügülsüm Yılmaz Ergün
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Fatma Arzu Akkuş
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Tuğba Önalan
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Eray Yıldız
- Necip Fazıl City Hospital, Division of Clinical Immunology and Allergy, Kahramanmaraş, Turkey
| | - Şevket Arslan
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
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Caballero T, Lleonart-Bellfill R, Pedrosa M, Ferrer L, Guilarte M. Expert review and consensus on the t2t management of hereditary angioedema: from the scientific evidence to clinical practice. J Investig Allergol Clin Immunol 2023:0. [PMID: 36811842 DOI: 10.18176/jiaci.0875] [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: 02/18/2023] Open
Abstract
BACKGROUND Hereditary angioedema with C1 inhibitor deficiency (HAE-C1INH) is a rare disease characterized by swelling episodes. It affects quality of life (QoL) and can be lethal, when involving upper airways. Treatment is individualized, with therapeutic options including on-demand treatment (ODT), and short- and long-term prophylaxis (STP, LTP). However, available guidelines are not always clear about treatment selection, its goals or assessment of goal achievement. OBJECTIVE To review the available evidence for the management of HAE-C1INH and build a Spanish expert consensus to steer HAE-C1INH management towards a treat-to-target (T2T) approach, while addressing some of the unclear aspects of the Spanish guidelines. METHODS We reviewed the literature on the management of HAE-C1INH with a T2T approach, focusing on: 1) treatment selection and goals; and 2) available tools to assess goal achievement. We discussed the literature based on clinical experience and drew up 45 statements on undefined management aspects. A panel of 53 HAE experts validated the statements through a two-round Delphi process. RESULTS The goals for ODT and STP are minimizing the morbidity and mortality of attacks, and preventing attacks caused by known triggers, respectively, while the main goal of LTP is to decrease the rate, severity and duration of attacks. Furthermore, when prescribing, clinicians should consider the reduction in adverse events, while increasing patient QoL and satisfaction. Appropriate instruments for assessing goal achievement have also been indicated. CONCLUSIONS We provide recommendations on previously unclear aspects of HAE-C1INH management with ODT, STP and LTP, focusing particularly on clinical and patient-oriented goals.
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Affiliation(s)
- T Caballero
- Allergy Department, Hospital Universitario La Paz, IdiPAZ Group 44, CIBERER U754, Madrid, Spain
| | - R Lleonart-Bellfill
- Allergology Service, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain.,Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - M Pedrosa
- Allergy Department, Hospital Universitario La Paz, IdiPAZ Group 44, CIBERER U754, Madrid, Spain
| | - L Ferrer
- Hospital Clínico Universitario "Lozano Blesa", Zaragoza, Spain
| | - M Guilarte
- Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain.,RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL)
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40
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Riedl MA. Hereditary Angioedema During Pregnancy: Considerations in Management. Immunol Allergy Clin North Am 2023; 43:145-57. [PMID: 36411000 DOI: 10.1016/j.iac.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In recent years, hereditary angioedema (HAE) management has substantially advanced but also become more complex with additional therapeutic options. Pregnancy significantly influences the clinical symptoms of HAE in many women because of estrogen effects or other physiologic factors, and also introduces important safety concerns related to HAE medications. Management of HAE during pregnancy requires clinicians to be familiar with the potential clinical course, triggers, and recommended treatment strategies to provide guidance and optimal medical management to women and families affected by the condition. This review provides an overview of data, considerations, and recommendations related to HAE and pregnancy.
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Shams M, Laney DA, Jacob DA, Yang J, Dronen J, Logue A, Rosen A, Riedl M. Validation of a suspicion index to identify patients at risk for hereditary angioedema. J Allergy Clin Immunol Glob 2023; 2:76-78. [PMID: 37780104 PMCID: PMC10509908 DOI: 10.1016/j.jacig.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 08/28/2022] [Accepted: 08/31/2022] [Indexed: 10/03/2023]
Abstract
Background Hereditary angioedema (HAE) is a genetic condition characterized by dysregulation of the contact (kallikrein-bradykinin) pathway, leading to recurrent episodes of angioedema. Objective This project sought to determine whether a suspicion index screening tool using electronic health record (EHR) data can identify patients with an increased likelihood of a diagnosis of HAE. Methods A suspicion index screening tool for HAE was created and validated by using known patients with HAE from the medical literature as well as positive and negative controls from HAE-focused centers. Through the use of key features of medical and family history, a series of logistic regression models for 5 known genetic causes of HAE were created. Top variables populated the digital suspicion scoring system and were run against deidentified EHR data. Patients at 2 diverse sites were categorized as being at increased, possible, or no increased risk of HAE. Results Prediction scoring using the strongest 13 variables on the "real-world" EHR-positive control data identified all but 1 patient with C1 inhibitor deficiency and patient with non-C1 inhibitor deficiency without false-positive results. The 2 missed patients had no documented family history of HAE in their EHR. When the prediction scoring variables were expanded to 25, the screening algorithm approached 100% sensitivity and specificity. The 25-variable algorithm run on general population EHR data identified 26 patients at the medical centers as being at increased risk for HAE. Conclusions These results suggest that development, validation, and implementation of suspicion index screening tools can be useful to aid providers in identifying patients with rare genetic conditions.
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Affiliation(s)
| | | | | | | | | | | | - Ami Rosen
- Emory School of Medicine, Atlanta, Ga
| | - Marc Riedl
- University of California, San Diego, Calif
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42
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Sheikh F, Alajlan H, Albanyan M, Alruwaili H, Alawami F, Sumayli S, Al Gazlan S, Abu Awwad S, Al-Dhekri H, Al-Saud B, Arnaout R, Alrayes H, Sayes N, Al-Hamed MH, Al-Mousa H, AlShareef S, Alazami AM. Phenotypic and Genotypic Characterization of Hereditary Angioedema in Saudi Arabia. J Clin Immunol 2023; 43:479-484. [PMID: 36348183 DOI: 10.1007/s10875-022-01399-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
Abstract
Hereditary angioedema (HAE) is a potentially life-threatening autosomal dominant disorder affecting roughly 1:50,000 individuals. It is commonly characterized by swelling of the larynx, gastrointestinal tract, extremities, and skin. There is growing genetic heterogeneity associated with this disease but more than 95% of mutations are found in SERPING1, the gene which encodes complement 1 inhibitor (C1-INH). HAE cohorts from several populations have been published but no large scale study has been reported from the Arab world to date. Here we document the clinical and genetic findings of HAE patients from a single Saudi institution, which is a major referral center at the national level. A total of 51 patients across 17 unrelated families were recruited including two large multi-generational families, of which one contained an in-frame exonic deletion that was resolved through MLPA. Two cases were negative for all the genes we tested (including F12, PLG, ANGPT1, MYOF, KNG1, and HS3ST6). The predominant HAE subtype in our cohort was type I, at 76%. We were able to uncover a mutation in 49 patients (96%). No type III (normal C1-INH) patients were encountered in the clinic, suggesting that this subtype does not play a major role in HAE pathogenesis in Saudi Arabia. Additionally, the existence of four patients with consistently normal complement 4 (C4) levels alongside abnormal C1-INH profiles highlights the utility of dual screening for both proteins in suspected patients.
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Affiliation(s)
- Farrukh Sheikh
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Huda Alajlan
- Translational Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital & Research Centre, MBC 3, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Maram Albanyan
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hibah Alruwaili
- Translational Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital & Research Centre, MBC 3, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Fatimah Alawami
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Safia Sumayli
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sulaiman Al Gazlan
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sawsan Abu Awwad
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
| | - Hasan Al-Dhekri
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
| | - Bandar Al-Saud
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Rand Arnaout
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hassan Alrayes
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Najla Sayes
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Mohamed H Al-Hamed
- Clinical Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hamoud Al-Mousa
- Department of Pediatrics, Allergy and Immunology Section, Faisal Specialist Hospital and Research Centre, Riyadh, King, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
| | - Saad AlShareef
- Department of Medicine, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Anas M Alazami
- Translational Genomics Department, Centre for Genomic Medicine, King Faisal Specialist Hospital & Research Centre, MBC 3, P.O. Box 3354, Riyadh, 11211, Saudi Arabia.
- Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia.
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Taha OS, Abi Melhem R, Taha Y, Meyer D, Assaad M. A patient with hereditary angioedema (HAE) with normal C1-INH and SLE with pregnancy. J Allergy Clin Immunol Glob 2023; 2:120-121. [PMID: 37780110 PMCID: PMC10510006 DOI: 10.1016/j.jacig.2022.09.005] [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] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 09/03/2022] [Accepted: 09/08/2022] [Indexed: 10/03/2023]
Abstract
The case of a 24-year-old female patient with hereditary angioedema, a normal C1 esterase inhibitor level, SLE, and pregnancy is reported.
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Affiliation(s)
| | | | | | | | - Marc Assaad
- Staten Island University Hospital, Staten Island, NY
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44
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Zuraw BL, Maurer M, Sexton DJ, Cicardi M. Therapeutic monoclonal antibodies with a focus on hereditary angioedema. Allergol Int 2023; 72:54-62. [PMID: 35787344 DOI: 10.1016/j.alit.2022.06.001] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/03/2022] [Accepted: 05/18/2022] [Indexed: 01/25/2023] Open
Abstract
Monoclonal antibodies (mAbs) have been shown to be effective and generally safe across a continually expanding list of therapeutic areas. We describe the advantages and limitations of mAbs as a therapeutic option compared with small molecules. Specifically, we discuss a novel mAb in the treatment of hereditary angioedema (HAE), a rare and potentially life-threatening condition characterized by recurrent unpredictable swelling attacks. HAE is mediated by dysregulation of plasma kallikrein activity leading to overproduction of bradykinin. Current prophylactic treatment for HAE includes androgens or replacement of the endogenous plasma kallikrein inhibitor, C1 inhibitor. However, there remains an unmet need for an effective, less burdensome treatment option. Lanadelumab is a fully human mAb targeting plasma kallikrein. Results from clinical trials, including a pivotal Phase 3 study and its ensuing open-label extension study, demonstrated that lanadelumab is associated with few treatment-related adverse events and reduced the rate of HAE attacks. This novel treatment option has the potential to significantly improve the lives of patients with HAE.
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Affiliation(s)
- Bruce L Zuraw
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, CA, USA.
| | - Marcus Maurer
- Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | | | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, Luigi Sacco, University of Milan, IRCCS ICS Maugeri, Milano, Italy
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Tanaka A, Huh JY, Yamamoto T, Washio K, Ariyoshi K. Bowel obstruction secondary to internal hernia in a hereditary angioedema patient: a case report. Int J Emerg Med 2022; 15:69. [PMID: 36585645 PMCID: PMC9805238 DOI: 10.1186/s12245-022-00475-9] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/22/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Gastrointestinal attacks are frequent symptoms in patients diagnosed with hereditary angioedema (HAE). Cases of self-limited bowel intussusception and unneeded exploratory laparotomy due to lack of knowledge about HAE have been reported. Furthermore, after the introduction of C1-esterase inhibitor (C1-INH) concentrate, the recommended medication for HAE attacks, treatment has become typically medical in nature. We share a rare case where operative exploration was indicated to resolve a mechanical small bowel obstruction secondary to an HAE attack. CASE REPORT An 80-year-old woman with HAE presented with lower left abdominal pain, vomiting, and nausea. Computed tomography (CT) showed edema of the small bowel and stomach as well as possible signs of mechanical small bowel obstruction. The patient was treated with C1-INH concentrate but showed only mild signs of relief, warranting diagnostic laparoscopy. Intraoperative findings showed internal herniation and strangulation of the small bowel caused by adhesions forming a band. After surgical intervention, no bowel resection was needed. CONCLUSION Although C1-INH concentrate remains the principal treatment for HAE, gastrointestinal attacks may potentially cause surgical emergencies.
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Affiliation(s)
- Atsuhito Tanaka
- grid.410843.a0000 0004 0466 8016Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo Prefecture 650-0047 Japan
| | - Ji Young Huh
- grid.410843.a0000 0004 0466 8016Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo Prefecture 650-0047 Japan
| | - Takamasa Yamamoto
- grid.416289.00000 0004 1772 3264Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, Hyogo Prefecture 651-2273 Japan
| | - Ken Washio
- grid.416289.00000 0004 1772 3264Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, Hyogo Prefecture 651-2273 Japan
| | - Koichi Ariyoshi
- grid.410843.a0000 0004 0466 8016Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo Prefecture 650-0047 Japan
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Maurer M, Abuzakouk M, Al-Ahmad M, Al-Herz W, Alrayes H, Al-Tamemi S, Arnaout R, Binghadeer H, Gutta R, Irani C, Mobayed H, Nasr I, Shendi H, Zaitoun F. Consensus on diagnosis and management of Hereditary Angioedema in the Middle East: A Delphi initiative. World Allergy Organ J 2022; 16:100729. [PMID: 36601261 PMCID: PMC9803817 DOI: 10.1016/j.waojou.2022.100729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/10/2022] [Accepted: 11/23/2022] [Indexed: 12/25/2022] Open
Abstract
Background Hereditary angioedema (HAE), a potentially life-threatening genetic disorder due to C1 inhibitor deficiency in most cases, is characterized by sudden and/or recurrent attacks of angioedema (subcutaneous/submucosal swellings). The global World Allergy Organization (WAO)/European Academy of Allergy and Clinical Immunology (EAACI) International guideline for HAE management is comprehensive, but the implementation of this guideline may require regional adaptation considering the diversity in disease awareness, type of medical care systems, and access to diagnostics and treatment. The aim of this Delphi initiative was to build on the global guideline and provide regional adaptation to address the concerns and specific needs in the Middle East. Methods The Consensus panel comprised 13 experts from the Middle East (3 from the United Arab Emirates, 3 from Saudi Arabia, 2 from Lebanon, 2 from Kuwait, 2 from Oman and 1 from Qatar) who have more than 2 decades of experience in allergy and immunology and are actively involved in managing HAE patients. The process that was carried out to reach the consensus recommendation included: 1.) A systematic literature review for articles related to HAE management using Ovid MEDLINE. 2.) The development of a questionnaire by an internationally acclaimed expert, with 10 questions specific to HAE management in the Middle East. 3.) Experts received the questionnaire via email individually and their answers were recorded (email/interview). 4.) A virtual consensus meeting was organized to discuss the questionnaire, make amends if needed, vote, and achieve consensus. Results The questionnaire comprised 10 questions, each with 2 or more statements/recommendations on which the regional experts voted. A consensus was reached based on a 70% agreement between the participants. The key highlights include: 1) HAE experts in the Middle East emphasized the importance of a positive family history for arriving at a diagnosis of HAE. 2) The number of episodes per month or per 6-month period and severity should be used, together with other markers, to determine the need for prophylaxis. 3) Disease status should be monitored by periodic visits and the use of patient-reported outcome measures such as the angioedema activity score and the angioedema control test. 4) Attenuated androgens and tranexamic acid may be considered for long-term prophylaxis, if lanadelumab, C1-Inhibitor or berotralstat are not available. Conclusion This consensus recommendation may help to educate healthcare practitioners in the Middle East and unify their approach to the diagnosis and management of HAE.
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Affiliation(s)
- Marcus Maurer
- Institute of Allergology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany,Corresponding author. Prof. Marcus Maurer Charité – Universitätsmedizin Berlin
- Institute of Allergology
| | | | - Mona Al-Ahmad
- Al-Rashed Allergy Center, Ministry of Health, Kuwait,Microbiology department, College of Medicine, Kuwait University, Kuwait
| | - Waleed Al-Herz
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Kuwait
| | - Hassan Alrayes
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Rand Arnaout
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hend Binghadeer
- King Abdulaziz Medical City-Riyadh, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Ravi Gutta
- Adult and Pediatric Allergy and Immunology Department, Mediclinic City Hospital, DHCC, Dubai
| | - Carla Irani
- Hotel Dieu de France Hospital, St Joseph University, Beirut, Lebanon
| | - Hassan Mobayed
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Hiba Shendi
- Tawam Hospital, Abu Dhabi, United Arab Emirates
| | - Fares Zaitoun
- Clemenceau Medical Center, Dubai, United Arab Emirates
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Lasa EM, Herrero L, Martínez S, Arruti N, Oliver P, Joral A. Use of concentrated plasma-derived subcutaneous C1 inhibitor as long-term prophylaxis in an 8-year-old child with hereditary angioedema. J Investig Allergol Clin Immunol 2022:0. [PMID: 36000819 DOI: 10.18176/jiaci.0855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- E M Lasa
- Hospital Universitario de Donostia. San Sebastián, España
| | - L Herrero
- Hospital de Mendaro. Mendaro, España
| | - S Martínez
- Hospital Universitario de Donostia. San Sebastián, España
| | - N Arruti
- Hospital Universitario de Donostia. San Sebastián, España
| | - P Oliver
- Hospital de Mendaro. Mendaro, España
| | - A Joral
- Hospital Universitario de Donostia. San Sebastián, España
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Wang X, Lei S, Xu Y, Liu S, Zhi Y. Mutation update of SERPING1 related to hereditary angioedema in the Chinese population. Hereditas 2022; 159:28. [PMID: 35821062 PMCID: PMC9277798 DOI: 10.1186/s41065-022-00242-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/21/2022] [Indexed: 12/12/2022] Open
Abstract
Background Hereditary angioedema (HAE) is a rare disease characterized by recurrent attacks of severe swellings of the skin and submucosa. More than 900 variants of the SERPING1 gene associated with HAE have been identified. However, only approximately 50 variants have been identified in the Chinese population. This study aimed to update the mutational spectrum in Chinese HAE patients and provide evidence for the accurate diagnosis of HAE. Methods A total of 97 unrelated HAE patients were enrolled in the study. Sanger sequencing and multiple ligation-dependent probe amplification analysis were used to identify the variants in the SERPING1 gene. The variants were reviewed in a number of databases, including the Human Gene Mutation Database (HGMD) (http://www.hgmd.cf.ac.uk/) and the Leiden Open Variation Database (LOVD, https://databases.lovd.nl/shared/variants/SERPING1). The American College of Medical Genetics and Genomics-Association for Molecular Pathology (ACMG-AMP) criteria was used to determine the pathogenicity of the variants. Results Of the 97 patients, 76 different variants were identified in 90 of them and no disease-causing variants were identified in the remaining 7 patients. Among the 76 variants, 35 variants were novel and submitted to ClinVar. Missense and in-frame variants were the most common variants (36.8%), followed by frameshift (28.9%), nonsense (14.5%), splice site (13.2%) variants, and gross deletions/duplications (6.6%). Conclusions Our findings broaden the mutational spectrum of SERPING1 and provide evidence for accurate diagnosis and predictive genetic counseling. Supplementary Information The online version contains supplementary material available at 10.1186/s41065-022-00242-z.
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Affiliation(s)
- Xue Wang
- Department of Allergy & Clinical Immunology, National Clinical Research Center for Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #1 Shuaifuyuan, Wangfujing, Beijing, 100730, P.R. China
| | - Shubin Lei
- Eighth-year Program of Clinical Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yingyang Xu
- Department of Allergy & Clinical Immunology, National Clinical Research Center for Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #1 Shuaifuyuan, Wangfujing, Beijing, 100730, P.R. China
| | - Shuang Liu
- Department of Allergy & Clinical Immunology, National Clinical Research Center for Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #1 Shuaifuyuan, Wangfujing, Beijing, 100730, P.R. China
| | - Yuxiang Zhi
- Department of Allergy & Clinical Immunology, National Clinical Research Center for Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #1 Shuaifuyuan, Wangfujing, Beijing, 100730, P.R. China.
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Farkas H, Máj C, Kenessey I, Sebestyén A, Krencz I, Pápay J, Cervenak L. A novel pathogenetic factor of laryngeal attack in hereditary angioedema? Involvement of protease activated receptor 1. Allergy Asthma Clin Immunol 2022; 18:60. [PMID: 35787812 PMCID: PMC9254515 DOI: 10.1186/s13223-022-00699-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare, life-threatening disease. The knowledge about the molecular pathogenesis of HAE has derived mainly from investigating blood samples. However, limited data are available on the role of the molecular mechanisms in the affected tissues during HAE attack. OBJECTIVE The aim of our study was to explore the histological changes occurring in HAE attacks. METHODS Post mortem macro-, microscopic and immunohistological assessment of upper airway tissues of a patient with HAE due to C1 inhibitor deficiency (C1-INH-HAE) type 2 who died from laryngeal HAE attack was compared with a non-HAE patient who died from other condition without any signs of angioedema. RESULTS Compared to the control patient, we demonstrated stronger T cell/monocyte infiltration and a more intense C1-INH staining in the C1-INH-HAE patient. The expression of both bradykinin receptors (B1/B2) was observed with a slightly lower level in the C1-INH-HAE patient than in the control patient. PAR1 expression was strongly reduced in the C1-INH-HAE patient suggesting overactivation of this hyperpermeability inducing receptor. CONCLUSION Our unique case and novel results correspond to the knowledge about C1-INH and BDKRs observed in plasma; however, it revealed new information about the pathomechanism of HAE attack focusing on the potential involvement of PAR1 in edema formation. This observation, if it is verified by subcutaneous biopsy studies, may designate a new therapeutic target in HAE.
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Affiliation(s)
- Henriette Farkas
- Hungarian Angioedema Reference Center, Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary.,Department of Internal Medicine and Hematology, Semmelweis University, Szentkirályi u. 46, Budapest, 1088, Hungary
| | - Csilla Máj
- Department of Pathology, Szent György University Hospital, Székesfehérvár, Hungary
| | - István Kenessey
- 2nd Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Anna Sebestyén
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Ildikó Krencz
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Judit Pápay
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - László Cervenak
- Department of Internal Medicine and Hematology, Semmelweis University, Szentkirályi u. 46, Budapest, 1088, Hungary.
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Minafra FG, Cunha LAO, Mariano RGDS, Goebel GA, de Lima LS, Pinto JA. Investigation of Mortality of Hereditary Angioedema in a Reference Center in Brazil. J Allergy Clin Immunol Pract 2022; 10:1805-1812. [PMID: 35526778 DOI: 10.1016/j.jaip.2022.04.030] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/05/2022] [Accepted: 04/24/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) is known for mortality when it is not treated properly. Many advances have occurred over the past decades that affected patients' lives. However, not all patient populations have access to the same diagnosis and treatment resources. OBJECTIVE To evaluate mortality from HAE in a large cohort in a reference center in Brazil. Furthermore, the research intended to describe patients' life span, the asphyxia evolution, and factors related to the fatal outcome. METHODS A cohort of 433 patients from 46 families was evaluated in this prospective and retrospective study. Families were organized in clusters and were given a verbal autopsy to arrange data collection for the deaths and analyze symptoms during life. Causes of death were classified as deaths from laryngeal edema (LE) or other causes. RESULTS Of 433 patients evaluated, 254 were not given the diagnosis of HAE. A total of 75 fatal events were evaluated. Only 10 of 75 patients were given the diagnosis of HAE before death, and the HAE diagnosis was made after death in 65 of 75 patients using verbal autopsy. The final cause of death after the investigation was asphyxiation owing to LE in 39 of 75 (52%) and deaths owing to other causes in 36 of 75 (48%). Ten deaths had occurred in the past decade. Time from onset of symptoms to seeking medical assistance was a median of 4 hours, and the time to death was a median of 8 hours. Three patients received fresh-frozen plasma and none received medications specific to HAE attacks. Throat pain or discomfort was the most common symptom, experienced by 71.8% of patients. The most common mistaken diagnosis at the original death certificate was allergy or anaphylaxis. The life span of patients who died of LE was reduced by 20 years compared with those who died of other causes. CONCLUSIONS Hereditary angioedema remains a threat to life in the studied population. The large number of patients who do not receive a diagnosis makes the situation even more severe and is responsible for most deaths. Death analyses add knowledge to an understanding of the diseases and their impact on patients' lives, improving the targeting of public health efforts.
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Affiliation(s)
- Fernanda Gontijo Minafra
- Department of Pediatrics, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Luciana Araújo Oliveira Cunha
- Allergy and Immunology Outpatient Clinic, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Rhaianny Gomes de Souza Mariano
- Allergy and Immunology Outpatient Clinic, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Gabriela Assunção Goebel
- Allergy and Immunology Outpatient Clinic, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Laís Sezini de Lima
- Allergy and Immunology Outpatient Clinic, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Jorge Andrade Pinto
- Department of Pediatrics, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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