1
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Theodorou A, Dimitriadou EM, Tzanetakos D, Bakola E, Chondrogianni M, Palaiodimou L, Keramida A, Vassilopoulou S, Makris M, Paraskevas GP, Tsivgoulis G. Icatibant averting mechanical ventilation in acute ischemic stroke patient with alteplase-induced orolingual angioedema. Eur J Neurol 2024; 31:e16173. [PMID: 38155474 DOI: 10.1111/ene.16173] [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: 10/29/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND AND PURPOSE Orolingual angioedema (OA) represents a rare but life-threatening complication among patients with acute ischemic stroke treated with intravenous thrombolysis with alteplase. Novel agents, including icatibant, are recommended in resistant patients with alteplase-induced OA who have failed to respond to first-line therapies including corticosteroids, antihistamines, and/or adrenaline. METHODS We present a patient with alteplase-induced OA who showed substantial clinical improvement following the administration of icatibant. RESULTS We describe a 71-year-old woman with known arterial hypertension under treatment with angiotensin-converting enzyme inhibitor, who presented with acute ischemic stroke in the territory of the right middle cerebral artery and received intravenous alteplase. During intravenous thrombolysis, the case was complicated with OA without any response to standard anaphylactic treatment including corticosteroids, dimetindene, and adrenaline. Thirty minutes after symptom onset, icatibant, a synthetic selective bradykinin B2-receptor antagonist, was administered subcutaneously. Substantial symptomatic resolution was observed only following the icatibant administration. CONCLUSIONS This case highlights the effectiveness of icatibant in the acute management of alteplase-induced OA. In particular, icatibant administration, following first-line therapies including corticosteroids, antihistamines, and/or adrenaline, may avert tracheostomy and intubation in resistant and refractory cases with OA following intravenous thrombolysis for acute ischemic stroke.
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Affiliation(s)
- Aikaterini Theodorou
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelia-Makrina Dimitriadou
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tzanetakos
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Bakola
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Chondrogianni
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Keramida
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sofia Vassilopoulou
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Makris
- Allergy Unit "D. Kalogeromitros", Second Department of Dermatology and Venereology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios P Paraskevas
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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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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3
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Hide M, Wang Y, Dote N, Miyakawa K, Sugiura K, Ishida K. Safety, efficacy, and pharmacokinetics of icatibant treatment in Japanese pediatric patients with hereditary angioedema: A phase 3, open-label study. J Dermatol 2023; 50:1473-1477. [PMID: 37381768 DOI: 10.1111/1346-8138.16883] [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: 12/13/2022] [Revised: 05/29/2023] [Accepted: 06/18/2023] [Indexed: 06/30/2023]
Abstract
We evaluated the safety, efficacy, and pharmacokinetics of subcutaneous weight-adjusted icatibant for the treatment of acute hereditary angioedema attacks in Japanese pediatric patients. Two patients (aged 10-13 and 6-9 years) received icatibant for a total of four attacks. Each attack was abdominal and/or cutaneous and was treated with a single icatibant injection. Mild or moderate injection-site reactions were the only adverse events reported. Time to onset of symptom relief was 0.9-1.0 h. Icatibant was rapidly absorbed, with a pharmacokinetic profile consistent with previous studies. Simulated exposure levels were consistent with non-Japanese pediatric patients. These results support the safety and efficacy of icatibant in Japanese pediatric patients.
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Affiliation(s)
- Michihiro Hide
- Department of Dermatology, Hiroshima Citizens Hospital, Hiroshima, Japan
- Department of Dermatology, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yi Wang
- Quantitative Clinical Pharmacology, Takeda Development Center Americas Inc., Cambridge, Massachusetts, USA
| | | | - Kou Miyakawa
- Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Kenkichi Sugiura
- Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Kazuyuki Ishida
- Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan
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4
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Nunes LR, Anselmo MP, Brito TS. A challenging case of bradykinin-mediated angioedema with airway obstruction: management and therapeutic strategies. Arch Clin Cases 2023; 10:138-141. [PMID: 37795171 PMCID: PMC10546096 DOI: 10.22551/2023.40.1003.10260] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Angioedema is a potentially life-threatening condition that can have an allergic origin, usually mediated by histamine or a non-allergic origin, mediated by bradykinin. The distinction between these origins may present a clinical challenge at first approach, especially in cases that appear as an emergency and the outcome is time dependent. The authors describe a rare case of bradykinin angioedema associated with airway obstruction and discuss the right approach and therapeutic options. A 46-year-old patient under ACE inhibitor, renin-angiotensin-aldosterone blocker and beta blocker presented with difficulty swallowing, shortness of breath and angioedema, associated with inspiratory stridor, incapacity of talking, plantar pruritus and vomits minutes after ingestion of shrimp. The symptoms did not respond to epinephrine, anti-histamines or steroids. The airway quickly became an emergency and the authors discuss the importance of airway obstruction management and having a multidisciplinary well-defined plan of approach with backup plans. Exuberant angioedema persisted leading to the suspicion of drug induced angioedema. Treatment with tranexamic acid 1g 6/6h and icatibant 30 mg 6/6h (3 doses) was started with resolution. In these cases, the rapid institution of the right pharmacological line will relate significantly to a better outcome. It is particularly important because, as their underlying physiopathologic mechanism differ, bradykinin mediated angioedema does not respond to drugs that histamine mediated angioedema does, like corticosteroids and antihistaminic. In severe and life-threatening cases icatibant and tranexamic acid have proven to be an effective therapy.
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5
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Kochvar AP, Cobb G, Bernabe CC, Levine T. Acquired Non-histaminergic Angioedema With C1q Autoantibody and Urticaria: A Case Report. Cureus 2023; 15:e43841. [PMID: 37736455 PMCID: PMC10510307 DOI: 10.7759/cureus.43841] [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] [Accepted: 08/20/2023] [Indexed: 09/23/2023] Open
Abstract
Acquired angioedema (AAE) is a rare disease with life-threatening complications. This pathology has classically been associated with medication use and B cell lymphoproliferative disorders. In this report, we describe a 61-year-old man with a six-year history of angioedema, unrelated to any known triggers or malignancy. Extensive workup has led to a diagnosis of idiopathic nonhistaminergic AAE with normal C1 inhibitor. The patient is currently being treated with lanadelumab, which has resolved the patient's symptoms. This case provides insight into the onset, exploration, treatment, and outcomes of an extremely rare disease process.
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Affiliation(s)
- Andrew P Kochvar
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Gavin Cobb
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Celina C Bernabe
- Allergy and Immunology, Allergy & Asthma Care, P.A., Overland Park, USA
| | - Terry Levine
- Allergy and Immunology, Allergy & Asthma Care, P.A., Overland Park, USA
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Wang K, Chen K. Direct Assessment of Oligomerization of Chemically Modified Peptides and Proteins in Formulations using DLS and DOSY-NMR. Pharm Res 2023; 40:1329-1339. [PMID: 36627448 DOI: 10.1007/s11095-022-03468-8] [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: 10/26/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Protein higher order structure (HOS) including the oligomer distribution can be critical for efficacy, safety and stability of drug products (DP). Oligomerization is particularly relevant to chemically modified protein therapeutics that have an extended pharmacokinetics profile. Therefore, the direct assessment of protein oligomerization in drug formulation is desired for quality assurance and control. METHODS Here, two non-invasive methods, dynamic light scattering (DLS) and diffusion ordered spectroscopy (DOSY) NMR, were applied to measure translational diffusion coefficients (Ddls and Dnmr) of proteins in formulated drug products. The hydrodynamic molecular weights (MWhd), similar to hydrodynamic size, of protein therapeutics were derived based on a log(Ddls) vs log(MWhd) correlation model established using protein standards. RESULTS An exponent value of -0.40 ± 0.01 was established for DLS measured log(D) vs. log(MWhd) using protein standards and a theoretical exponent value of -0.6 was used for unstructured polyethylene glycol (PEG) chains. The analysis of DLS derived MWhd of the primary species showed the fatty acid linked glucagon-like peptide 1 (GLP-1) was in different oligomer states, but the fatty acid linked insulin and PEG linked proteins were in monomer states. Nevertheless, equilibrium and exchange between oligomers in formulations were universal and clearly evidenced from DOSY-NMR for all drugs except peginterferon alfa-2a. CONCLUSION The correlation models of log(D) vs. log(MWhd) could be a quick and efficient way to predict MWhd of protein, which directly informs on the state of protein folding and oligomerization in formulation.
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Affiliation(s)
- Kai Wang
- Division of Complex Drug Analysis, Office of Testing and Research, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, 20993, USA
| | - Kang Chen
- Division of Complex Drug Analysis, Office of Testing and Research, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, 20993, USA.
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7
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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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Rocour S, Cochard B, Daniel V, Martin L, Corvaisier M. Large Predominance of Off-Label Prescriptions of C1-Inhibitor Concentrates and Icatibant in a Real-Life Setting: A Retrospective Clinical Study. J Clin Pharmacol 2023; 63:29-39. [PMID: 35871284 DOI: 10.1002/jcph.2125] [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: 03/15/2022] [Accepted: 07/18/2022] [Indexed: 12/15/2022]
Abstract
C1-inhibitor (C1INH) concentrates and the selective bradykinin B2 receptor antagonist icatibant are approved only for treating hereditary angioedema with C1INH deficiency. Yet, they are regularly prescribed off label in other types of bradykinin-mediated angioedema including angiotensin-converting enzyme inhibitor (ACEi)-related and undetermined angioedema. We conducted a retrospective chart review of inpatient prescriptions of C1INH concentrates and icatibant between 2016 and 2020 in the University Hospital of Angers. The first outcome was the proportion of prescriptions with explicit indication. Then, we determined the compliance of prescriptions with European Medicines Agency approvals and the French bradykinin-mediated angioedema reference center guidelines. Finally, we estimated the economic impact of inappropriate prescribing. The therapeutic indication was explicit in 90.4% of prescriptions (n = 66/73). Only 17.8% of prescriptions were for hereditary angioedema with C1INH deficiency, while 31.5% were for ACEi-related and 28.7% for undetermined angioedema. However, most off-label prescriptions were consistent with the French bradykinin-mediated angioedema reference center guidelines (73.3%). We estimated that 13% of drug expenditures were potentially excessive. The predominance of off-label prescriptions may be explained by the infrequency of hereditary angioedema and the absence of approved alternatives in other types of bradykinin-mediated angioedema. Most attacks were related to ACEis. Epinephrine was rarely prescribed as first-line therapy in attacks of unknown origin. Given the high prices of these drugs, we advocate the development of a readily available management algorithm of angioedema to reduce inappropriate prescriptions in our center. In addition, we think that the drug prescription circuit should be redesigned to ensure the traceability of prescribed vials in the dispensing areas.
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Affiliation(s)
- Samuel Rocour
- Department of Dermatology, University Hospital of Angers, Angers, France
| | - Baptiste Cochard
- Department of Pharmacy, University Hospital of Angers, Angers, France.,School of Pharmacy, Health Faculty, University of Angers, Angers, France
| | - Valérie Daniel
- Department of Pharmacy, University Hospital of Angers, Angers, France
| | - Ludovic Martin
- Department of Dermatology, University Hospital of Angers, Angers, France
| | - Mathieu Corvaisier
- Department of Pharmacy, University Hospital of Angers, Angers, France.,School of Pharmacy, Health Faculty, University of Angers, Angers, France.,A4638, Laboratory of Psychology of the Pays de la Loire, University of Angers, Angers, France
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9
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Yeich A, Elhatw A, Ashoor Z, Park K, Craig T. Safety of medications for hereditary angioedema during pregnancy and lactation. Expert Opin Drug Saf 2023; 22:17-24. [PMID: 36744397 DOI: 10.1080/14740338.2023.2177269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hereditary Angioedema (HAE) attacks show an increased frequency and severity for pregnant and lactating females secondary to the hormonal changes. The diagnosis and management of HAE in pregnant and lactating females pose a challenge for physicians due to the rarity of the disease and the paucity of the data for specific management. AREAS COVERED In this manuscript, we discuss the diagnosis and special presentation of HAE types 1 and 2 in pregnant and lactating females, including acute management, short-term prophylaxis, long-term prophylaxis, and drugs that should be avoided. Relevant publications were found through key word search of papers indexed in both Google Scholar and PubMed on 1 July 2022. EXPERT OPINION Treatment of HAE in the past has been mainly provided by experts; however, with more medications and an increasing number of patients, knowledge of how to care for HAE patients during pregnancy and lactation is important to review. Despite approval of additional medications in many countries, plasma-derived C1-inhibitor remains the drug of first choice for treatment in this unique population. Additional research is needed to increase safe access to other therapy options. We hope that future clinical studies, registries, and databases will shed additional light on this subject.
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Affiliation(s)
- Andrew Yeich
- Department of Allergy, Asthma and Immunology, Medical Student, Penn State College of Medicine, Hershey, PA, USA
| | - Ahmed Elhatw
- Department of Allergy, Asthma and Immunology, Resident, Cairo University School of Medicine, Giza, Egypt
| | - Zaynab Ashoor
- Department of Allergy, Asthma and Immunology, Medical Student, Cairo University School of Medicine, Giza, Egypt
| | - Kristen Park
- Department of Allergy, Asthma and Immunology, Medical Student, Penn State College of Medicine, Hershey, PA, USA
| | - Timothy Craig
- Department of Allergy, Asthma, and Immunology, Professor of Medicine, Pediatrics, and Biomedical Sciences, Hershey, PA, USA
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10
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Muacevic A, Adler JR, Gregory GE, Ghaly M, Case J. The Interplay of COVID-19 and Hereditary Angioedema: Preventing an Acute Attack. Cureus 2022; 14:e29189. [PMID: 36507113 PMCID: PMC9731548 DOI: 10.7759/cureus.29189] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/15/2022] [Indexed: 12/15/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare inherited disease that is caused by the inactivation of the C1 esterase inhibitor. In this case report, we present a 51-year-old female previously diagnosed with HAE who tested positive for SARS-Cov-2 (COVID-19). The patient was treated symptomatically. Dexamethasone was used to treat COVID-19 pneumonia. Broad-spectrum antibiotics (vancomycin and meropenem) were utilized to prevent future infection. Although the patient did not experience an acute angioedema attack during her hospital stay, the patient expired due to the exacerbation of COVID-19 pneumonia.
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Maurer M, Aberer W, Caballero T, Bouillet L, Grumach AS, Botha J, Andresen I, Longhurst HJ. The Icatibant Outcome Survey: 10 years of experience with icatibant for patients with hereditary angioedema. Clin Exp Allergy 2022; 52:1048-1058. [PMID: 35861129 DOI: 10.1111/cea.14206] [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: 07/08/2021] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 11/28/2022]
Abstract
In patients with hereditary angioedema (HAE), bradykinin causes swelling episodes by activating bradykinin B2 receptors. Icatibant, a selective bradykinin B2 receptor antagonist, is approved for on-demand treatment of HAE attacks. The Icatibant Outcome Survey (IOS; NCT01034969) is an ongoing observational registry initiated in 2009 to monitor effectiveness/safety of icatibant in routine clinical practice. As of March 2019, 549 patients with HAE type 1 or 2 from the IOS registry had been treated, for 5995 total attacks. This article reviews data published from IOS over time which have demonstrated that effectiveness of icatibant in a real-world setting is comparable to efficacy in clinical trials; one dose is effective for the majority of attacks; early treatment (facilitated by self-administration) leads to faster resolution and shorter attack duration; effectiveness/safety of icatibant has been shown across a broad range of patient subgroups, including children/adolescents and patients with HAE with normal C1 inhibitor levels; and tolerability has been demonstrated in patients aged ≥65 years. Additionally, this review highlights how IOS data have provided valuable insights into patients' diagnostic journeys and treatment behaviors across individual countries. Such findings have helped to inform clinical strategies and guidelines to optimize HAE management and limit disease burden. This research was sponsored by Takeda Development Center Americas, Inc. Takeda Development Center Americas, Inc., provided funding to Excel Medical Affairs for support in writing and editing this manuscript.
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Affiliation(s)
- M Maurer
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - W Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - T Caballero
- Department of Allergy, Hospital Universitario La Paz, Hospital La Paz Institute for Health Research (IdiPaz), Biomedical Research Network on Rare Diseases (CIBERER, U754), Madrid, Spain
| | - L Bouillet
- National Reference Centre for Angioedema, Internal Medicine Department, Grenoble University Hospital, Grenoble, France
| | - A S Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitario Saude ABC, Santo Andre, Brazil
| | - J Botha
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - I Andresen
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - H J Longhurst
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, and University College London Hospitals, London, UK
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12
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Martinet C, Gherri N, Laborde L, Gil-Jardine C, Chauvin A, Lefort H. [Angioedema and anaphylaxis, a family story]. Rev Infirm 2022; 71:27-29. [PMID: 36150835 DOI: 10.1016/j.revinf.2022.05.010] [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] [Indexed: 06/16/2023]
Abstract
Non-allergic angioedema has a worrying morbidity. Clinical examination is central, as C1-esterase inhibitor deficiency will not be documented in the acute phase. In the case of anaphylaxis that does not respond to adrenaline, an early diagnosis can optimise referral of the patient to a reference healthcare establishment for a specific therapeutic protocol (icatibant, C1 inhibitor) recently updated by recommendations.
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Affiliation(s)
- Camille Martinet
- Structure des urgences, Hôpital d'instruction des armées Laveran, 13384 Marseille, France.
| | - Nadia Gherri
- Structure des urgences, Hôpital d'instruction des armées Laveran, 13384 Marseille, France
| | - Léon Laborde
- Antenne médicale, 17(e) régiment du génie parachutiste (RGP), 42 avenue du 10(e)-Dragon, 82000 Montauban, France
| | - Cédric Gil-Jardine
- Structure des urgences, CHU Pellegrin, rue de la Pelouse-de-Douet, 33000 Bordeaux, France
| | - Anthony Chauvin
- Structure des urgences, CHU Lariboisière, 2 rue Ambroise-Paré, 75010 Paris, France
| | - Hugues Lefort
- Structure des urgences, Hôpital d'instruction des armées Laveran, 13384 Marseille, France
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13
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Le TTA, Smith W, Hissaria P. Real-world off-label use of icatibant for acute management of non-hereditary angioedema. Intern Med J 2021; 51:419-423. [PMID: 33738947 DOI: 10.1111/imj.15241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/09/2020] [Accepted: 10/04/2020] [Indexed: 11/27/2022]
Abstract
We retrospectively examined the indications and efficacy of off-label use of the bradykinin B2 receptor antagonist icatibant. The clinical heterogeneity, variability of response to icatibant and lack of efficacy of adrenaline described in this audit highlights both the need for biomarkers that can rapidly distinguish between histaminergic and non-histaminergic angioedema, and for guidelines to improve the utility of icatibant in the non-hereditary angioedema setting.
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Affiliation(s)
- Thanh-Thao Adriana Le
- Clinical Immunology/Allergy Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - William Smith
- Clinical Immunology/Allergy Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Pravin Hissaria
- Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Human Immunology, SA Pathology, Adelaide, South Australia, Australia
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Honda D, Ohsawa I, Mano S, Rinno H, Tomino Y, Suzuki Y. Icatibant promotes patients' behavior modification associated with emergency room visits during an acute attack of hereditary angioedema. Intractable Rare Dis Res 2021; 10:142-145. [PMID: 33996362 PMCID: PMC8122312 DOI: 10.5582/irdr.2021.01010] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hereditary angioedema due to C1-inhibitor (C1-INH) deficiency (HAE-C1-INH) induces an acute attack of angioedema. In 2018, icatibant available for self-possession and subcutaneous self-administration was licensed for on-demand treatment in addition to intravenous C1-INH administration in Japan. We retrospectively evaluated the percentage of attacks in critical parts at emergency room (ER) visits and the time until visiting ER for C1-INH administration before and after the initial prescription of icatibant. The percentage of attacks in critical parts at ER visits before the prescription was 69.2%, but that was 80.0% when patients visited ER for additional C1-INH administration after the self-administration of icatibant. The time from the onset of an acute attack to visiting ER for the additional treatment after the self-administration of icatibant significantly increased from 6.2 h to 19.2 h (p < 0.001). Icatibant, therefore, promoted the patients' behavior modification associated with ER visits for C1-INH administration during an acute attack of HAE-C1-INH.
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Affiliation(s)
- Daisuke Honda
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Isao Ohsawa
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
- Nephrology Unit, Internal Medicine, Saiyu Soka Hospital, Saitama, Japan
- Address correspondence to:Isao Ohsawa, Nephrology Unit, Internal Medicine, Saiyu Soka Hospital, 1-7-22 Matsubara, Soka city, Saitama 340-0041, Japan. E-mail:
| | - Satoshi Mano
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hisaki Rinno
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yasuhiko Tomino
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
- Medical Corporation SHOWAKAI, Tokyo, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
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15
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Wang Y, Jomphe C, Marier JF, Martin P. Population Pharmacokinetics and Exposure-Response Analyses to Guide Dosing of Icatibant in Pediatric Patients With Hereditary Angioedema. J Clin Pharmacol 2020; 61:555-564. [PMID: 33091166 PMCID: PMC7984404 DOI: 10.1002/jcph.1768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 06/25/2020] [Accepted: 10/01/2020] [Indexed: 11/23/2022]
Abstract
Elevated bradykinin levels are responsible for the development of clinical symptoms in patients with hereditary angioedema (HAE). Icatibant is a bradykinin type 2 receptor antagonist indicated for the acute treatment of HAE attacks. A population modeling and simulation approach was used to examine sources of variability impacting icatibant pharmacokinetics (PK) and provide guidance on icatibant dosing in pediatric patients with HAE. An exposure‐response analysis was performed for the time to onset of symptom relief (TOSR). Data from 141 adults (133 healthy, 8 with HAE) who received subcutaneous icatibant 30 mg and 31 pediatric patients with HAE who received 0.4 mg/kg (capped at 30 mg) were included in the analysis. Icatibant PK was described by a 2‐compartment model with linear elimination. Complete absorption of icatibant was expected within 1 hour of dosing. The apparent clearance and central volume of distribution were 15.4 L/h and 20.4 L, respectively. Icatibant PK was mainly dependent on body weight. The mean TOSR was very short (1.38 hours). A flat exposure‐response was observed, confirming that the relationship plateaued at the level of exposure observed in pediatric patients. Simulations confirmed that weight band–based dosing regimens (10 mg [12‐25 kg], 15 mg [26‐40 kg], 20 mg [41‐50 kg], 25 mg [51‐65 kg], and 30 mg [>65 kg]) resulted in exposure similar to the 0.4‐mg/kg dose. This analysis showed that icatibant undergoes rapid absorption, reaches levels required for therapeutic response, and promptly relieves HAE symptoms. A weight band–based dosing regimen is appropriate in pediatric patients with HAE.
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Affiliation(s)
- Yi Wang
- Takeda Pharmaceutical Company Limited, Lexington, Massachusetts, USA
| | - Claudia Jomphe
- Certara Strategic Consulting, Princeton, New Jersey, USA
| | | | - Patrick Martin
- Takeda Pharmaceutical Company Limited, Lexington, Massachusetts, USA
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16
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Nowicki RJ, Grubska-Suchanek E, Porêbski G, Kowalski ML, Jahnz-Różyk K, Matuszewski T, Rudnicka L, Kulus M, Barañska-Rybak W, Czajkowski R, Doniec Z, Kowalewski C, Krêcisz B, Lange M, Narbutt J, Olszewska M, Sokołowska-Wojdyło M, Szczerkowska-Dobosz A, Śpiewak R, Trzeciak M, Wilkowska A. Angioedema. Interdisciplinary diagnostic and therapeutic recommendations of the Polish Dermatological Society (PTD) and Polish Society of Allergology (PTA). Postepy Dermatol Alergol 2020; 37:445-51. [PMID: 32994763 DOI: 10.5114/ada.2020.98226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 11/17/2022] Open
Abstract
Angioedema is a non-inflammatory oedema of the subcutaneous tissue and/or mucosal membranes. It most commonly coexists with urticaria wheals and is considered to be a deep form of urticaria. Less commonly, it occurs in isolation and can take two basic forms: acquired angioedema and hereditary angioedema. Currently, there are 4 defined types of acquired angioedema and 7 types of hereditary angioedema. Treatment of angioedema depends on its form and etiological factors. Especially the genetic form, i.e. hereditary angioedema, is a considerable challenge for medical specialists, particularly dermatologists and allergists.
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17
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Chatterjee S, Maity A, Chowdhury S, Islam MA, Muttinini RK, Sen D. In silico analysis and identification of promising hits against 2019 novel coronavirus 3C-like main protease enzyme. J Biomol Struct Dyn 2020; 39:5290-5303. [PMID: 32608329 DOI: 10.1080/07391102.2020.1787228] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 12/22/2022]
Abstract
The recent outbreak of the 2019 novel coronavirus disease (COVID-19) has been proved as a global threat. No particular drug or vaccine has not yet been discovered which may act specifically against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and causes COVID-19. For this highly infectious virus, 3CL-like main protease (3CLpro) plays a key role in the virus life cycle and can be considered as a pivotal drug target. Structure-based virtual screening of DrugBank database resulted in 20 hits against 3CLpro. Atomistic 100 ns molecular dynamics of five top hits and binding energy calculation analyses were performed for main protease-hit complexes. Among the top five hits, Nafarelin and Icatibant affirmed the binding energy (g_MMPBSA) of -712.94 kJ/mol and -851.74 kJ/mol, respectively. Based on binding energy and stability of protein-ligand complex; the present work reports these two drug-like hits against SARS-CoV-2 main protease.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Shilpa Chatterjee
- Department of Biomedical Science, Chosun University, Gwangju, South Korea
| | - Arindam Maity
- School of Pharmaceutical Technology, Adamas University, Kolkata, India
| | - Suchana Chowdhury
- BCDA College of Pharmaceutical Technology, Hridaypur, Kolkata, India
| | - Md Ataul Islam
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,School of Health Sciences, University of Kwazulu-Natal, Durban, South Africa
| | | | - Debanjan Sen
- BCDA College of Pharmaceutical Technology, Hridaypur, Kolkata, India
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18
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Lesage A, Gibson C, Marceau F, Ambrosi HD, Saupe J, Katzer W, Loenders B, Charest-Morin X, Knolle J. In Vitro Pharmacological Profile of a New Small Molecule Bradykinin B 2 Receptor Antagonist. Front Pharmacol 2020; 11:916. [PMID: 32636746 PMCID: PMC7316994 DOI: 10.3389/fphar.2020.00916] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/05/2020] [Indexed: 12/18/2022] Open
Abstract
We here report the discovery and early characterization of Compound 3, a representative of a novel class of small molecule bradykinin (BK) B2 receptor antagonists, and its superior profile to the prior art B2 receptor antagonists Compound 1 and Compound 2. Compound 3, Compound 2, and Compound 1 are highly potent antagonists of the human recombinant B2 receptor (Kb values 0.24, 0.95, and 1.24 nM, respectively, calcium mobilization assay). Compound 3 is more potent than the prior art compounds and icatibant in this assay (Kb icatibant 2.81 nM). The compounds also potently inhibit BK-induced contraction of endogenous B2 receptors in a human isolated umbilical vein bioassay. The potencies of Compound 3, Compound 2, Compound 1, and icatibant are (pA2 values) 9.67, 9.02, 8.58, and 8.06 (i.e. 0.21, 0.95, 2.63, and 8.71 nM), respectively. Compound 3 and Compound 2 were further characterized. They inhibit BK-induced c-Fos signaling and internalization of recombinant human B2 receptors in HEK293 cells, and do not antagonize the venous effects mediated by other G protein-coupled receptors in the umbilical vein model, including the bradykinin B1 receptor. Antagonist potency of Compound 3 at cloned cynomolgus monkey, dog, rat, and mouse B2 receptors revealed species selectivity, with a high antagonist potency for human and monkey B2 receptors, but several hundred-fold lower potency for the other B2 receptors. The in vitro off-target profile of Compound 3 demonstrates a high degree of selectivity over a wide range of molecular targets, including the bradykinin B1 receptor. Compound 3 showed a lower intrinsic clearance in the microsomal stability assay than the prior art compounds. With an efflux ratio of 1.0 in the Caco-2 permeability assay Compound 3 is predicted to be not a substrate of efflux pumps. In conclusion, we discovered a novel chemical class of highly selective and very potent B2 receptor antagonists, as exemplified by Compound 3. The compound showed excellent absorption in the Caco-2 assay, predictive of good oral bioavailability, and favourable metabolic stability in liver microsomes. Compound 3 has provided a significant stepping stone towards the discovery of the orally bioavailable B2 antagonist PHA-022121, currently in phase 1 clinical development.
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Affiliation(s)
- Anne Lesage
- Pharvaris Netherlands B.V., Leiden, Netherlands
| | | | - François Marceau
- Axe Microbiologie-Infectiologie et Immunologie, Research Center, CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Jörn Saupe
- AnalytiCon Discovery GmbH, Potsdam, Germany
| | | | | | - Xavier Charest-Morin
- Axe Microbiologie-Infectiologie et Immunologie, Research Center, CHU de Québec-Université Laval, Québec, QC, Canada
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19
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Roche JA, Roche R. A hypothesized role for dysregulated bradykinin signaling in COVID-19 respiratory complications. FASEB J 2020; 34:7265-7269. [PMID: 32359101 PMCID: PMC7267506 DOI: 10.1096/fj.202000967] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [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: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 01/13/2023]
Abstract
As of April 20, 2020, over time, the COVID-19 pandemic has resulted in 157 970 deaths out of 2 319 066 confirmed cases, at a Case Fatality Rate of ~6.8%. With the pandemic rapidly spreading, and health delivery systems being overwhelmed, it is imperative that safe and effective pharmacotherapeutic strategies are rapidly explored to improve survival. In this paper, we use established and emerging evidence to propose a testable hypothesis that, a vicious positive feedback loop of des-Arg(9)-bradykinin- and bradykinin-mediated inflammation → injury → inflammation, likely precipitates life threatening respiratory complications in COVID-19. Through our hypothesis, we make the prediction that the FDA-approved molecule, icatibant, might be able to interrupt this feedback loop and, thereby, improve the clinical outcomes. This hypothesis could lead to basic, translational, and clinical studies aimed at reducing COVID-19 morbidity and mortality.
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Affiliation(s)
- Joseph A Roche
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Renuka Roche
- College of Health and Human Services, Eastern Michigan University, Ypsilanti, MI, USA
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20
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van de Veerdonk FL, Netea MG, van Deuren M, van der Meer JW, de Mast Q, Brüggemann RJ, van der Hoeven H. Kallikrein-kinin blockade in patients with COVID-19 to prevent acute respiratory distress syndrome. eLife 2020; 9:57555. [PMID: 32338605 PMCID: PMC7213974 DOI: 10.7554/elife.57555] [Citation(s) in RCA: 193] [Impact Index Per Article: 48.3] [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: 04/09/2020] [Accepted: 04/26/2020] [Indexed: 01/08/2023] Open
Abstract
COVID-19 patients can present with pulmonary edema early in disease. We propose that this is due to a local vascular problem because of activation of bradykinin 1 receptor (B1R) and B2R on endothelial cells in the lungs. SARS-CoV-2 enters the cell via ACE2 that next to its role in RAAS is needed to inactivate des-Arg9 bradykinin, the potent ligand of the B1R. Without ACE2 acting as a guardian to inactivate the ligands of B1R, the lung environment is prone for local vascular leakage leading to angioedema. Here, we hypothesize that a kinin-dependent local lung angioedema via B1R and eventually B2R is an important feature of COVID-19. We propose that blocking the B2R and inhibiting plasma kallikrein activity might have an ameliorating effect on early disease caused by COVID-19 and might prevent acute respiratory distress syndrome (ARDS). In addition, this pathway might indirectly be responsive to anti-inflammatory agents. The COVID-19 pandemic represents an unprecedented threat to global health. Millions of cases have been confirmed around the world, and hundreds of thousands of people have lost their lives. Common symptoms include a fever and persistent cough and COVID-19 patients also often experience an excess of fluid in the lungs, which makes it difficult to breathe. In some cases, this develops into a life-threatening condition whereby the lungs cannot provide the body's vital organs with enough oxygen. The SARS-CoV-2 virus, which causes COVID-19, enters the lining of the lungs via an enzyme called the ACE2 receptor, which is present on the outer surface of the lungs’ cells. The related coronavirus that was responsible for the SARS outbreak in the early 2000s also needs the ACE2 receptor to enter the cells of the lungs. In SARS, the levels of ACE2 in the lung decline during the infection. Studies with mice have previously revealed that a shortage of ACE2 leads to increased levels of a hormone called angiotensin II, which regulates blood pressure. As a result, much attention has turned to the potential link between this hormone system in relation to COVID-19. However, other mouse studies have shown that ACE2 protects against a build-up of fluid in the lungs caused by a different molecule made by the body. This molecule, which is actually a small fragment of a protein, lowers blood pressure and causes fluid to leak out of blood vessels. It belongs to a family of molecules known as kinins, and ACE2 is known to inactivate certain kinins. This led van de Veerdonk et al. to propose that the excess of fluid in the lungs seen in COVID-19 patients may be because kinins are not being neutralized due to the shortage of the ACE2 receptor. This had not been hypothesized before, even though the mechanism could be the same in SARS which has been researched for the past 17 years. If this hypothesis is correct, it would mean that directly inhibiting the receptor for the kinins (or the proteins that they come from) may be the only way to stop fluid leaking into the lungs of COVID-19 patients in the early stage of disease. This hypothesis is unproven, and more work is needed to see if it is clinically relevant. If that work provides a proof of concept, it means that existing treatments and registered drugs could potentially help patients with COVID-19, by preventing the need for mechanical ventilation and saving many lives.
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Affiliation(s)
- Frank L van de Veerdonk
- Departments of Internal Medicine, Radboudumc Center for Infectious Diseases (RCI), Radboudumc, Nijmegen, Netherlands
| | - Mihai G Netea
- Departments of Internal Medicine, Radboudumc Center for Infectious Diseases (RCI), Radboudumc, Nijmegen, Netherlands.,Department for Genomics and Immunoregulation, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, Germany
| | - Marcel van Deuren
- Departments of Internal Medicine, Radboudumc Center for Infectious Diseases (RCI), Radboudumc, Nijmegen, Netherlands
| | - Jos Wm van der Meer
- Departments of Internal Medicine, Radboudumc Center for Infectious Diseases (RCI), Radboudumc, Nijmegen, Netherlands
| | - Quirijn de Mast
- Departments of Internal Medicine, Radboudumc Center for Infectious Diseases (RCI), Radboudumc, Nijmegen, Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboudumc Center for Infectious Diseases (RCI), Radboudumc, Nijmegen, Netherlands
| | - Hans van der Hoeven
- Intensive Care, Radboudumc Center for Infectious Diseases (RCI), Radboudumc, Nijmegen, Netherlands
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21
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Abstract
BACKGROUND Hereditary angioedema due to C1-inhibitor deficiency (HAE-C1INH) is a rare genetic disease that runs in the family. As a result of the disease, acute swellings of the subcutaneous tissue and mucous membranes of the digestive and respiratory systems, including the larynx, occur. Any attack of the disease involving the throat and larynx is particularly dangerous and requires knowledge of clinical determinants of the disease and its proper management. MATERIALS AND METHODS The study included adult consecutive HAE-C1INH patients having follow-up visits in our centre. The group was examined with a structured clinical questionnaire, concerning the last 6 months and focusing particularly on laryngeal swelling attacks. RESULTS 55 subjects (F/M - 35/20, age range - 18-76) were included in the study. Laryngeal attacks occurred in 19 individuals (34.5%): 1-3, 4-6, and ≥7 attacks in 9, 8 and 2 patients, respectively, two of whom required intubation. In comparison to other patients, subjects with laryngeal attacks were characterised by significantly more frequent: (1) facial attacks, (2) severe disease activity, (3) the occurrence of female patients, (4) mental stress as a trigger of attacks. All patients with laryngeal attacks had a rescue medication at home and 15/19 (78%) patients could use it at home. Most of them used plasma-derived C1-inhibitor 17/19 (89.5%) and icatibant, 8/19 (42.1%). DISCUSSION HAE-C1INH patients with laryngeal attacks require particular attention. Proper training regarding the identification of these patients, adequate management, access to emergency services and emergency drugs are essential to ensure the safety of subjects with this localization of HAE-C1INH attacks.
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Affiliation(s)
| | - Grzegorz Porebski
- Zakład Alergologii Klinicznej i Środowiskowej, Uniwersytet Jagielloński Collegium Medicum w Krakowie
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22
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Hide M. [POINTS OF REVISE IN THE INTERNATIONAL WAO/EAACI GUIDELINE FOR THE MANAGEMENT OF HEREDITARY ANGIOEDEMA-THE 2017 REVISION AND UPDATE]. Arerugi 2019; 68:16-19. [PMID: 30787237 DOI: 10.15036/arerugi.68.16] [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] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Michihiro Hide
- Department of Dermatology, Graduate School of Biomedical and Health Sciences, Hiroshima University
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23
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Hakl R, Kuklínek P, Krčmová I, Králíčková P, Freiberger T, Janků P, Vlková M, Litzman J. Treatment of Hereditary Angioedema Attacks with Icatibant and Recombinant C1 Inhibitor During Pregnancy. J Clin Immunol 2018; 38:810-815. [PMID: 30280305 DOI: 10.1007/s10875-018-0553-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 01/29/2018] [Accepted: 09/25/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Hereditary angioedema (HAE) is a rare disease caused by a C1 inhibitor (C1-INH) deficit. Clinically, HAE is manifested by repeated episodes of localized subcutaneous or submucosal oedema attacks. Managing HAE patients in pregnancy is challenging, since there are only limited data on the safety and efficacy of various therapeutic approaches. METHODS We present our clinical experience treating acute HAE attacks during pregnancy in six consecutive patients. RESULTS During the pregnancies, 79 HAE attacks occurred. The most frequent were abdominal 53 (67.1%) followed by peripheral 21 (26.6%), facial 10 (12.7%), and laryngeal 10 (12.7%) oedemas; 13 (16.5%) attacks were combined. Fifty (63.3%) attacks were treated with recombinant human C1-INH (rhC1-INH); 17 (21.5%) with plasma-derived, pasteurized, nanofiltered C1-INH (pnfC1-INH); 13 (16.5%) with icatibant; and 1 (1.3%) with plasma-derived, nanofiltered C1-INH (nfC1-INH). Treatment had to be repeated in 5 attacks (6.3%). All six deliveries (one caesarean section and five spontaneous vaginal deliveries) were complication free. All pregnancies went to the full term and the patients delivered healthy babies with a birth weight ranging from 2850 to 3690 g. No congenital abnormalities were detected in the neonates. No abortions occurred. CONCLUSIONS Our results show good C1-INH or icatibant treatment efficacy for HAE attacks in pregnancy. The treatment by the first drug used was effective in 93.7% of all attacks. In 6.3% of attacks, a second treatment had to be used. No adverse effects were observed.
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Affiliation(s)
- Roman Hakl
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno, Brno, Czech Republic.
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Pavel Kuklínek
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno, Brno, Czech Republic
| | - Irena Krčmová
- Department of Clinical Immunology and Allergy, University Hospital, Hradec Kralove, Czech Republic
| | - Pavlína Králíčková
- Department of Clinical Immunology and Allergy, University Hospital, Hradec Kralove, Czech Republic
| | - Tomáš Freiberger
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Petr Janků
- Department of Obstetrics and Gynecology, University Hospital Brno, Brno, Czech Republic
| | - Marcela Vlková
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiří Litzman
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
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24
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Federici C, Perego F, Borsoi L, Crosta V, Zanichelli A, Gidaro A, Tarricone R, Cicardi M. Costs and effects of on-demand treatment of hereditary angioedema in Italy: a prospective cohort study of 167 patients. BMJ Open 2018; 8:e022291. [PMID: 30061443 PMCID: PMC6067408 DOI: 10.1136/bmjopen-2018-022291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To explore treatment behaviours in a cohort of Italian patients with hereditary angioedema due to complement C1-inhibitor deficiency (C1-INH-HAE), and to estimate how effects and costs of treating attacks in routine practice differed across available on-demand treatments. DESIGN Cost analyses and survival analyses using attack-level data collected prospectively for 1 year. SETTING National reference centre for C1-INH-HAE. PARTICIPANTS 167 patients with proved diagnosis of C1-INH-HAE, who reported data on angioedema attacks, including severity, localisation and duration, treatment received, and use of other healthcare services. INTERVENTIONS Attacks were treated with either icatibant, plasma-derived C1-INH (pdC1-INH) or just supportive care. MAIN OUTCOME MEASURES Treatment efficacy in reducing attack duration and the direct costs of acute attacks. RESULTS Overall, 133 of 167 patients (79.6%) reported 1508 attacks during the study period, with mean incidence of 11 attacks per patient per year. Only 78.9% of attacks were treated in contrast to current guidelines. Both icatibant and pdC1-INH significantly reduced attack duration compared with no treatment (median times from onset 7, 10 and 47 hours, respectively), but remission rates with icatibant were 31% faster compared with pdC1-INH (HR 1.31, 95% CI 1.14 to 1.51). However, observed treatment behaviours suggest patterns of suboptimal dosing for pdC1-INH. The average cost per attack was €1183 (SD €789) resulting in €1.58 million healthcare costs during the observation period (€11 912 per patient per year). Icatibant was 54% more expensive than pdC1-INH, whereas age, sex and prophylactic treatment were not associated to higher or lower costs. CONCLUSIONS Both icatibant and pdC1-INH significantly reduced attack duration compared with no treatment, however, icatibant was more effective but also more expensive. Treatment behaviours and suboptimal dosing of pdC1-INH may account for the differences, but further research is needed to define their role.
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Affiliation(s)
- Carlo Federici
- Centre for Research on Health and Social Care Management (CeRGAS), SDA Bocconi University, Milan, Italy
| | - Francesca Perego
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
| | - Ludovica Borsoi
- Centre for Research on Health and Social Care Management (CeRGAS), SDA Bocconi University, Milan, Italy
| | - Valentina Crosta
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
| | - Rosanna Tarricone
- Government, Health and Non Profit Division, SDA Bocconi University, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
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25
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Farkas H, Kőhalmi KV. Icatibant for the treatment of hereditary angioedema with C1-inhibitor deficiency in adolescents and in children aged over 2 years. Expert Rev Clin Immunol 2018; 14:447-460. [PMID: 29757016 DOI: 10.1080/1744666x.2018.1476851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 12/12/2022]
Abstract
INTRODUCTION Hereditary angioedema (HAE) due to C1-inhibitor deficiency (C1-INH-HAE) is a rare disorder with life-threatening complications if untreated. It begins during childhood, and reduces the patient's quality of life. Therefore, the availability of an easily administered agent to relieve unpredictable HAE episodes is indispensable for this age group. Areas covered: Randomized, double-blind, placebo-controlled, open-label extensions and prospective observational studies have proven the safety and efficacy of the subcutaneously administered bradykinin B2 receptor antagonist, icatibant, in the acute treatment of HAE episodes in adult C1-INH-HAE patients. Recently, a Phase 3, multicenter, open-label, non-randomized, single-arm study demonstrated the efficacy, safety, and tolerability of icatibant as an acute treatment for pediatric patients aged 2 years to less than 18 years. Expert commentary: The clinical study in pediatric patients showed that icatibant undergoes rapid absorption, reaches a therapeutic level, and promptly relieves the symptoms. It is well tolerated, and the subcutaneous preparation, presented in a pre-filled syringe, ensures ease of use. It can be administered anytime, anywhere, and instantly - even by the patients themselves, or - in the case of children and adolescents - by a caregiver. Icatibant may greatly contribute to the improvement of the quality of life of pediatric patients.
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Affiliation(s)
- Henriette Farkas
- a Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
| | - Kinga Viktória Kőhalmi
- a Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
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Longhurst H. Optimum Use of Acute Treatments for Hereditary Angioedema: Evidence-Based Expert Consensus. Front Med (Lausanne) 2018; 4:245. [PMID: 29594115 PMCID: PMC5857575 DOI: 10.3389/fmed.2017.00245] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 12/18/2017] [Indexed: 11/13/2022] Open
Abstract
Acute treatment of hereditary angioedema due to C1 inhibitor deficiency has become available in the last 10 years and has greatly improved patients’ quality of life. Two plasma-derived C1 inhibitors (Berinert and Cinryze), a recombinant C1 inhibitor (Ruconest/Conestat alpha), a kallikrein inhibitor (Ecallantide), and a bradykinin B2 receptor inhibitor (Icatibant) are all effective. Durably good response is maintained over repeated treatments and several years. All currently available prophylactic agents are associated with breakthrough attacks, therefore an acute treatment plan is essential for every patient. Experience has shown that higher doses of C1 inhibitor than previously recommended may be desirable, although only recombinant C1 inhibitor has been subject to full dose–response evaluation. Treatment of early symptoms of an attack, with any licensed therapy, results in milder symptoms, more rapid resolution and shorter duration of attack, compared with later treatment. All therapies have been shown to be well-tolerated, with low risk of serious adverse events. Plasma-derived C1 inhibitors have a reassuring safety record regarding lack of transmission of virus or other infection. Thrombosis has been reported in association with plasma-derived C1 inhibitor in some case series. Ruconest was associated with anaphylaxis in a single rabbit-allergic volunteer, but no further anaphylaxis has been reported in those not allergic to rabbits despite, in a few cases, prior IgE sensitization to rabbit or milk protein. Icatibant is associated with high incidence of local reactions but not with systemic effects. Ecallantide may cause anaphylactoid reactions and is given under supervision. For children and pregnant women, plasma-derived C1 inhibitor has the best evidence of safety and currently remains first-line treatment.
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Affiliation(s)
- Hilary Longhurst
- Honorary Consultant Immunologist, Department of Clinical Biochemistry and Immunology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Haegarda--a subcutaneous C1 esterase inhibitor for prevention of hereditary angioedema. Med Lett Drugs Ther 2018; 60:39-40. [PMID: 29485978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Hide M, Fukunaga A, Maehara J, Eto K, Hao J, Vardi M, Nomoto Y. [EFFICACY, PHARMACOKINETICS, AND SAFETY OF ICATIBANT FOR THE TREATMENT OF JAPANESE PATIENTS WITH AN ACUTE ATTACK OF HEREDITARY ANGIOEDEMA: A PHASE 3 OPEN-LABEL STUDY]. Arerugi 2018; 67:139-147. [PMID: 29553114 DOI: 10.15036/arerugi.67.139] [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] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) is characterized by paroxysmal edema of the skin, gastrointestinal mucosa, and upper respiratory tract. PURPOSE This study investigated icatibant, a selective bradykinin B2 receptor antagonist, as treatment for Japanese patients with an acute HAE attack. METHODS This was an open-label, single-arm, Phase 3 study of Japanese adults with HAE type I or II. Icatibant (30 mg) was administered (by a healthcare professional [HCP] or self-administered) as a subcutaneous injection in the abdomen. RESULTS Eight patients (4 cutaneous, 3 abdominal, 1 laryngeal) were treated with icatibant (all single injection; 3 self-administered, 5 HCP-administered). The median time to onset of symptom relief was 1.75 hours (95% confidence interval, 1.00 to 2.50); all patients had onset of relief within 5 hours. The estimated time to maximum icatibant concentration in the circulation was 1.79 hours and the maximum concentration was 405 ng/mL. There were 3 patients who experienced 3 adverse events (2 HAE attacks and 1 headache); 7 patients experienced an injection site reaction. CONCLUSION Although our study was limited by the small number of patients, we found that icatibant was an effective and well-tolerated treatment for Japanese patients with acute HAE attacks, regardless of whether it was administered by a HCP or self-administered.
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Affiliation(s)
- Michihiro Hide
- Department of Dermatology, Institute of Biomedical and Health Sciences, Hiroshima University
| | | | - Junichi Maehara
- Emergency and General Medicine Center, Saiseikai Kumamoto Hospital
| | - Kazunori Eto
- Department of Gastroenterology, Tomakomai City Hospital
| | | | | | - Yuji Nomoto
- Internal Medicine Department, Niigata City General Hospital
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Johnson NM, Phillips MA. New Treatments for Hereditary Angioedema. Skin Therapy Lett 2018; 23:6-8. [PMID: 29357215] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Hereditary angioedema is characterized by severe, episodic edema of the subcutaneous and mucosal tissue. The disease carries significant morbidity and mortality due to involvement of the gastrointestinal tract and upper airway. Recent advances in the treatment of hereditary angioedema include new techniques used to isolate and purify human-derived C1 inhibitor, the production of a recombinant form of C1 inhibitor, and the development of drugs that target the kallikrein-kinin pathway. This paper reviews the mechanisms, efficacy, and adverse reactions associated with these medications.
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Affiliation(s)
- Nathan M Johnson
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA; Carilion Clinic Dermatology & Mohs Surgery, Roanoke, VA, USA
| | - Mariana A Phillips
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA; Carilion Clinic Dermatology & Mohs Surgery, Roanoke, VA, USA
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Zanichelli A, Maurer M, Aberer W, Caballero T, Longhurst HJ, Bouillet L, Fabien V, Andresen I. Long-term safety of icatibant treatment of patients with angioedema in real-world clinical practice. Allergy 2017; 72:994-998. [PMID: 27926986 PMCID: PMC5434903 DOI: 10.1111/all.13103] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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] [Accepted: 11/30/2016] [Indexed: 11/25/2022]
Abstract
The Icatibant Outcome Survey (IOS) is an observational study monitoring safety and effectiveness of icatibant in the real‐world setting. We analyzed safety data from 3025 icatibant‐treated attacks in 557 patients (enrolled between July 2009 and February 2015). Icatibant was generally well tolerated. Excluding off‐label use and pregnancy, 438 patients (78.6%) did not report adverse events (AEs). The remaining 119 (21.4%) patients reported 341 AEs, primarily gastrointestinal disorders (19.6%). Of these, 43 AEs in 17 patients (3.1%) were related to icatibant. Serious AEs (SAEs) occurred infrequently. A total of 143 SAEs occurred in 59 (10.6%) patients; only three events (drug inefficacy, gastritis, and reflux esophagitis) in two patients were considered related to icatibant. Notably, no SAEs related to icatibant occurred in patients with cardiovascular disease, nor in those using icatibant at a frequency above label guidelines. Additionally, no major differences were noted in AEs occurring in on‐label vs off‐label icatibant users.
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Affiliation(s)
- A. Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; ASST Fatebenefratelli Sacco; Milan Italy
| | - M. Maurer
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - W. Aberer
- Department of Dermatology and Venerology; Medical University of Graz; Graz Austria
| | - T. Caballero
- Department of Allergy; Hospital La Paz Institute for Health Research (IdiPaz); Biomedical Research Network on Rare Diseases (CIBERER, U754); Madrid Spain
| | | | - L. Bouillet
- National Reference Centre for Angioedema; Internal Medicine Department; Grenoble University Hospital; Grenoble France
| | - V. Fabien
- Shire; Zug Switzerland at time of data analysis; now with Vifor Pharma, Glattbrugg, Switzerland
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Abstract
BACKGROUND Compartment syndrome of the upper extremity is a surgical emergency that, when left untreated, can have dire consequences. Its causes are numerous, one of which is the uncommon entity hereditary angioedema, an autosomal dominant disease resulting in edema in a variety of potential locations, including the extremities. This is only the second time hereditary angioedema has been mentioned in the literature as a cause of compartment syndrome. METHODS We present a case of hereditary angioedema leading to hand and forearm compartment syndrome in a 13-year-old pediatric patient. Diagnosis of hereditary angioedema was made by our Rheumatology colleagues with physical exam and a thorough history, and confirmed by laboratory studies. RESULTS Our patient presented with compartment syndrome of the hand and forearm and underwent hand and volar forearm fasciotomies. She was subsequently worked up for hereditary angioedema with laboratory results confirming the diagnosis. She was discharged after a 5-day hospitalization with prophylactic C1-inhibitor therapy. CONCLUSIONS Hereditary angioedema is a rare but known cause of compartment syndrome of the upper extremity, and must be considered when patients present with compartment syndrome of unknown etiology. This disease can be diagnosed by laboratory studies and symptoms can be controlled with medical therapy.
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Affiliation(s)
| | | | | | - Hani Matloub
- Medical College of Wisconsin, Milwaukee, USA,Zablocki VA Medical Center, Milwaukee, WI, USA,Hani Matloub, Department of Plastic Surgery, Medical College of Wisconsin, 8700 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Longhurst HJ, Zanichelli A, Caballero T, Bouillet L, Aberer W, Maurer M, Fain O, Fabien V, Andresen I. Comparing acquired angioedema with hereditary angioedema (types I/II): findings from the Icatibant Outcome Survey. Clin Exp Immunol 2017; 188:148-153. [PMID: 27936514 PMCID: PMC5343339 DOI: 10.1111/cei.12910] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2016] [Indexed: 11/26/2022] Open
Abstract
Icatibant is used to treat acute hereditary angioedema with C1 inhibitor deficiency types I/II (C1-INH-HAE types I/II) and has shown promise in angioedema due to acquired C1 inhibitor deficiency (C1-INH-AAE). Data from the Icatibant Outcome Survey (IOS) were analysed to evaluate the effectiveness of icatibant in the treatment of patients with C1-INH-AAE and compare disease characteristics with those with C1-INH-HAE types I/II. Key medical history (including prior occurrence of attacks) was recorded upon IOS enrolment. Thereafter, data were recorded retrospectively at approximately 6-month intervals during patient follow-up visits. In the icatibant-treated population, 16 patients with C1-INH-AAE had 287 attacks and 415 patients with C1-INH-HAE types I/II had 2245 attacks. Patients with C1-INH-AAE versus C1-INH-HAE types I/II were more often male (69 versus 42%; P = 0·035) and had a significantly later mean (95% confidence interval) age of symptom onset [57·9 (51·33-64·53) versus 14·0 (12·70-15·26) years]. Time from symptom onset to diagnosis was significantly shorter in patients with C1-INH-AAE versus C1-INH-HAE types I/II (mean 12·3 months versus 118·1 months; P = 0·006). Patients with C1-INH-AAE showed a trend for higher occurrence of attacks involving the face (35 versus 21% of attacks; P = 0·064). Overall, angioedema attacks were more severe in patients with C1-INH-HAE types I/II versus C1-INH-AAE (61 versus 40% of attacks were classified as severe to very severe; P < 0·001). Median total attack duration was 5·0 h and 9·0 h for patients with C1-INH-AAE versus C1-INH-HAE types I/II, respectively.
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Affiliation(s)
- H J Longhurst
- Department of Immunology, Barts Health NHS Trust, London, UK
| | - A Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Luigi Sacco Hospital Milan, Milan, Italy
| | - T Caballero
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPaz), Biomedical Research Network on Rare Diseases (CIBERER, U754), Madrid, Spain
| | - L Bouillet
- National Reference Centre for Angioedema, Internal Medicine Department, Grenoble University Hospital, Grenoble, France
| | - W Aberer
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - M Maurer
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - O Fain
- Department of Internal Medicine, DHU i2B, Saint Antoine Hospital, University Paris 6, Paris, France
| | - V Fabien
- Shire, Zug, Switzerland at the time of data analysis. Now with Vifor Pharma, Glattbrugg, Switzerland
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Bouillet L, Boccon-Gibod I, Launay D, Gompel A, Kanny G, Fabien V, Fain O. Hereditary angioedema with normal C1 inhibitor in a French cohort: Clinical characteristics and response to treatment with icatibant. Immun Inflamm Dis 2017; 5:29-36. [PMID: 28250922 PMCID: PMC5322159 DOI: 10.1002/iid3.137] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 01/22/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 12/29/2022]
Abstract
Introduction The clinical characteristics and icatibant‐treatment outcomes of patients with hereditary angioedema with normal C1 inhibitor (HAE‐nC1 INH) are limited. Methods We retrospectively analyzed data from French HAE patients enrolled in the Icatibant Outcome Survey registry (from July 2009 to September 2013) to compare disease characteristics and the effectiveness and safety of acute icatibant‐treated angioedema attacks in patients with HAE‐nC1 INH, HAE with C1 INH deficiency (type I), or dysfunction (type II). Results One center in Grenoble contributed 22 patients with HAE‐nC1 INH and a family history of HAE while 15 centers across France contributed 153 patients with HAE type I and seven patients with HAE type II. Patients with HAE‐nC1 INH compared to HAE type I, respectively, were more likely to be female (88.1% vs. 63.4%), older at median age of disease onset (21 years vs. 15 years), and have a greater rate of abdominal (80% vs. 61%) and laryngeal (23% vs. 14%) attacks. Icatibant was effective in both groups though the median time to resolution of attack was significantly longer in the HAE‐nC1 INH group (20.0 h, 37 attacks) versus the HAE type I group (14.0 h, 67 attacks). Icatibant was self‐administered for 96.1% of attacks in patients with HAE‐nC1 INH and 75.8% in patients with HAE type I. No serious adverse side effects related to icatibant were reported. Conclusions These data help further define the disease characteristics of HAE‐nC1 INH in the French population and extend the limited data reporting the safe and effective use of icatibant in acute treatment of angioedema in French patients diagnosed with HAE‐nC1 INH.
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Affiliation(s)
- Laurence Bouillet
- Department of Internal Medicine National Reference Centre for Angioedema (CREAK) Université Grenoble Alpes, Joint Unit 1036 INSERM-CNRS-CEA CHU Grenoble France
| | - Isabelle Boccon-Gibod
- Department of Internal Medicine National Reference Centre for Angioedema (CREAK) Université Grenoble Alpes, Joint Unit 1036 INSERM-CNRS-CEA CHU Grenoble France
| | - David Launay
- U995 Lille Inflammation Research International Center (LIRIC)University of LilleLilleFrance; Inserm, U995LilleFrance; département de médecine interne et immunologie cliniqueCHU LilleLilleFrance; National Reference Centre for Angioedema (CREAK)LilleFrance
| | - Anne Gompel
- Gynaecology and Endocrinology Unit Paris Descartes University, Cochin-Port Royal Hospital Paris France
| | - Gisele Kanny
- EA 7299 Internal Medicine, Clinical Immunology and Allergology Lorraine University, University Hospital Vandoeuvre-lès-Nancy France
| | | | - Oliver Fain
- Department of Internal Medicine Saint-Antoine Hospital (AP-HP) Paris 6 University, DHUi2B Paris France
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Straka BT, Ramirez CE, Byrd JB, Stone E, Woodard-Grice A, Nian H, Yu C, Banerji A, Brown NJ. Effect of bradykinin receptor antagonism on ACE inhibitor-associated angioedema. J Allergy Clin Immunol 2016; 140:242-248.e2. [PMID: 27913306 DOI: 10.1016/j.jaci.2016.09.051] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [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: 07/11/2016] [Revised: 08/23/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The B2 receptor antagonist icatibant is approved for treatment of attacks of hereditary angioedema. Icatibant has been reported to decrease time-to-resolution of angiotensin-converting enzyme (ACE) inhibitor-associated angioedema in 1 study of European patients. OBJECTIVE We sought to test the hypothesis that a bradykinin B2 receptor antagonist would shorten time-to-resolution from ACE inhibitor-associated angioedema. METHODS Patients with ACE inhibitor-associated angioedema (defined as swelling of lips, tongue, pharynx, or face during ACE inhibitor use and no swelling in the absence of ACE inhibitor use) were enrolled at Vanderbilt University Medical Center from October 2007 through September 2015 and at Massachusetts General Hospital in 2012. C1 inhibitor deficiency and patients with bowel edema only were excluded. Patients were randomized within 6 hours of presentation to subcutaneous icatibant 30 mg or placebo at 0 and 6 hours later. Patients assessed severity of swelling using a visual analog scale serially following study drug administration or until discharge. RESULTS Thirty-three patients were randomized and 31 received treatment, with 13 receiving icatibant and 18 receiving placebo. One patient randomized to icatibant did not complete the visual analog scale and was excluded from analyses. Two-thirds of patients were black and two-thirds were women. Time-to-resolution of symptoms was similar in placebo and icatibant treatment groups (P = .19 for the primary symptom and P > .16 for individual symptoms of face, lip, tongue, or eyelid swelling). Frequency of administration of H1 and H2 blockers, corticosteroids, and epinephrine was similar in the 2 treatment groups. Time-to-resolution of symptoms was similar in black and white patients. CONCLUSIONS This study does not support clinical efficacy of a bradykinin B2 receptor antagonist in ACE inhibitor-associated angioedema.
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Affiliation(s)
- Brittany T Straka
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Claudia E Ramirez
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - James B Byrd
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth Stone
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | | | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn
| | | | - Nancy J Brown
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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Abstract
Hereditary angioedema (HAE) is a rare disorder resulting from decreased functional levels of C1-inhibitor (C1-INH), which manifests as periodic episodes of localized edema which can be extremely painful, debilitating and even fatal if the swelling affects the larynx. HAE can complicate many aspects of obstetric/gynecologic care, and an awareness of the disease is critical for clinicians involved in the care of women because of potential HAE-related complications pertaining to pregnancy, labor and delivery, and other women's health issues. This article provides a review of published literature specific to HAE and its management in female patients, including important concerns regarding obstetric/gynecologic care. A growing body of relevant experience is presented to help guide the care of women with HAE.
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Affiliation(s)
- Aleena Banerji
- Massachusetts General Hospital, Cox 201, 55 Fruit Street, Boston, MA, USA
| | - Marc Riedl
- University of California, San Diego, La Jolla, CA, USA
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Abstract
Intraperitoneal administration of concanavalin A (ConA, 25 mg/kg b.w.), a cell-binding plant lectin was used for inducing inflammatory ascites, and potential inhibitors were tested in 1 h and 2.5 h experiments, i.e. still before the major influx of leucocytes. At the end of the experiment the peritoneal fluid was collected and measured. The ConA-induced ascites was significantly (p<0.01) and dose-dependently inhibited by icatibant (HOE-140), a synthetic polypeptide antagonist of bradykinin receptors. Aprotinin, a kallikrein inhibitor protein also had significant (p<0.01), but less marked inhibitory effect. L-NAME, an inhibitor of NO synthesis, and atropine methylnitrate, an anticholinergic compound, were ineffective. It is concluded, that the kallikrein/kinin system contributes to the mediation of the ConA-induced ascites by increasing subperitoneal vascular permeability, independent of the eventual vasodilation produced by NO. It is known, that membrane glycoproteins are aggregated by the tetravalent ConA and the resulting distortion of membrane structure may explain the activation of the labile prekallikrein. Complete inhibition of the ConA-induced ascites could not be achieved by aprotinin or icatibant, which indicates the involvement of additional mediators.
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Affiliation(s)
- Károly Baintner
- Dept. of Physiology, Faculty of Animal Science, University of Kaposvár , Kaposvár , Hungary
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Zanichelli A, Mansi M, Azin GM, Wu MA, Periti G, Casazza G, Vacchini R, Suffritti C, Cicardi M. Efficacy of on-demand treatment in reducing morbidity in patients with hereditary angioedema due to C1 inhibitor deficiency. Allergy 2015; 70:1553-8. [PMID: 26304015 DOI: 10.1111/all.12731] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Angioedema due to hereditary deficiency of C1 inhibitor causes temporarily disability. Guidelines recommend early on-demand treatment of attacks to reduce morbidity. In this prospective observational study, we evaluated the efficacy of on-demand approach. METHODS From January 2009 to August 2014, data on attacks and treatments were collected from 227 patients from our centre in Milan. RESULTS A total of 4244 attacks were reported; 50% were treated with approved therapies (pdC1-INH or icatibant), 15% were with tranexamic acid, and 35% were not treated. Attack locations were peripheral cutaneous (46%), abdominal (34%), multiple (12%), facial (5%) and laryngeal (3%). Attack severities were moderate (48%), mild (28%) and severe (24%). Median attack duration (data available for 2393 attacks) with approved therapies was 10 h, significantly shorter than without treatment (45 h) or with tranexamic acid (38 h). Most of the treatments were self-administered: 93% with icatibant and 59% with pd-C1-INH. Median attack duration with icatibant was 8 and 11.5 h with pd-C1 INH. Median time from onset of symptoms to drug administration was 1 h with icatibant and 2 h with pd-C1INH and median time from drug administration to complete resolution was 5.5 and 8 h, respectively. Second treatment was required in 12.7% of icatibant-treated attacks and in 1.9% of pdC1-INH-treated attacks. CONCLUSION This study provides evidence that on-demand treatment is effective in reducing disease-related morbidity. The use of on-demand treatment in Italy has increased up to 50% of attacks in the last years, reflecting a better adherence to international guidelines.
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Affiliation(s)
- A. Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco; Università degli Studi di Milano; Ospedale Luigi Sacco; Milan Italy
| | - M. Mansi
- Department of Biomedical and Clinical Sciences Luigi Sacco; Università degli Studi di Milano; Ospedale Luigi Sacco; Milan Italy
| | - G. M. Azin
- Department of Biomedical and Clinical Sciences Luigi Sacco; Università degli Studi di Milano; Ospedale Luigi Sacco; Milan Italy
| | - M. A. Wu
- Department of Biomedical and Clinical Sciences Luigi Sacco; Università degli Studi di Milano; Ospedale Luigi Sacco; Milan Italy
| | - G. Periti
- Department of Biomedical and Clinical Sciences Luigi Sacco; Università degli Studi di Milano; Ospedale Luigi Sacco; Milan Italy
| | - G. Casazza
- Department of Biomedical and Clinical Sciences Luigi Sacco; Università degli Studi di Milano; Ospedale Luigi Sacco; Milan Italy
| | - R. Vacchini
- Department of Biomedical and Clinical Sciences Luigi Sacco; Università degli Studi di Milano; Ospedale Luigi Sacco; Milan Italy
| | - C. Suffritti
- Department of Biomedical and Clinical Sciences Luigi Sacco; Università degli Studi di Milano; Ospedale Luigi Sacco; Milan Italy
| | - M. Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco; Università degli Studi di Milano; Ospedale Luigi Sacco; Milan Italy
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Abstract
Hereditary angioedema (HAE) is a rare but serious and potentially life threatening autosomal dominant condition caused by low or dysfunctional C1 esterase inhibitor (C1-INH) or uncontrolled contact pathway activation. Symptoms are characterized by spontaneous, recurrent attacks of subcutaneous or submucosal swellings typically involving the face, tongue, larynx, extremities, genitalia or bowel. The prevalence of HAE is estimated to be 1:50,000 without known racial differences. It causes psychological stress as well as significant socioeconomic burden. Early treatment and prevention of attacks are associated with better patient outcome and lower socioeconomic burden. New treatments and a better evidence base for management are emerging which, together with a move from hospital-centered to patient-centered care, will enable individualized, tailored treatment approaches.
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Affiliation(s)
- Iman H Nasr
- a Department of Immunology, Barts Health NHS Trust , London , UK
| | - Ania L Manson
- a Department of Immunology, Barts Health NHS Trust , London , UK
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Abstract
INTRODUCTION Angioedema is a localized and self-limiting edema of the subcutaneous and submucosal tissue. Hereditary angioedema with C1 inhibitor deficiency (C1-INH-HAE) is the best characterized form of hereditary angioedema. In C1-INH-HAE, the reduced plasma levels of C1-INH cause instability of the contact system with release of bradykinin, the key mediator of angioedema. C1-INH-HAE is characterized by recurrent skin swelling, abdominal pain, and potentially life-threatening upper airways obstruction. Knowledge of the molecular mechanisms leading from C1-INH deficiency to angioedema allowed the development of several therapies. AREAS COVERED The aim of this review article is to discuss the safety of currently available treatments of C1-INH-HAE. The authors give an insight on the mechanism of action and safety profile of drugs for treatment of acute attacks and for short- and long-term prophylaxis. Evidence from systematic reviews, clinical trials, retrospective studies, and case reports is summarized in this review. EXPERT OPINION C1-INH-HAE is a disabling, life-threatening condition that lasts life-long. Different therapeutic approaches with different drugs provide significant benefit to patients. Safety profiles of these therapies are critical for optimal therapeutic decision and need to be known by C1-INH-HAE treating physicians for appropriate risk/benefit evaluation.
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Affiliation(s)
- Andrea Zanichelli
- a University of Milan, Luigi Sacco Hospital, Department of Biomedical and Clinical Sciences "Luigi Sacco" , Milan, Italy +39 02 50 31 98 29 ; +39 02 50 31 98 28 ;
| | - Maddalena Alessandra Wu
- a University of Milan, Luigi Sacco Hospital, Department of Biomedical and Clinical Sciences "Luigi Sacco" , Milan, Italy +39 02 50 31 98 29 ; +39 02 50 31 98 28 ;
| | - Arnaldo Andreoli
- a University of Milan, Luigi Sacco Hospital, Department of Biomedical and Clinical Sciences "Luigi Sacco" , Milan, Italy +39 02 50 31 98 29 ; +39 02 50 31 98 28 ;
| | - Marta Mansi
- a University of Milan, Luigi Sacco Hospital, Department of Biomedical and Clinical Sciences "Luigi Sacco" , Milan, Italy +39 02 50 31 98 29 ; +39 02 50 31 98 28 ;
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Bas M, Greve J, Strassen U, Khosravani F, Hoffmann TK, Kojda G. Angioedema induced by cardiovascular drugs: new players join old friends. Allergy 2015; 70:1196-200. [PMID: 26119220 DOI: 10.1111/all.12680] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2015] [Indexed: 12/11/2022]
Abstract
During the last years, two new cardiovascular drug classes, namely inhibitors of DPP IV or neprilysin, have been developed. In both cases, there is clinical evidence for their potential to induce angioedema as known already from blockers of the renin-angiotensin-aldosterone system (RAAS). The majority of angioedema induced by DPP IV inhibitors occurs during concomitant treatment with ACEi and is therefore likely mediated by overactivation of bradykinin type 2 receptors (B2). In striking contrast, the molecular pathways causing angioedema induced by neprilysin inhibitors, that is, sacubitril, are unclear, although a contribution of bradykinin appears likely. Nevertheless, there is no clinical evidence suggesting that inhibition of B2 might relieve the symptoms and/or prevent invasive treatment including coniotomy or tracheotomy in angioedema caused by these drugs. Therefore, the risk of angioedema should always be considered, especially in ambulatory care situations where patients have no rapid access to intensive care.
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Affiliation(s)
- M. Bas
- Otorhinolaryngology Department; University Hospital Rechts der Isar; Munich Technical University; Munich Germany
| | - J. Greve
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery; Ulm University Medical Center; Ulm Germany
| | - U. Strassen
- Otorhinolaryngology Department; University Hospital Rechts der Isar; Munich Technical University; Munich Germany
| | - F. Khosravani
- Institute of Pharmacology and Clinical Pharmacology; Heinrich Heine University; Düsseldorf Germany
| | - T. K. Hoffmann
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery; Ulm University Medical Center; Ulm Germany
| | - G. Kojda
- Institute of Pharmacology and Clinical Pharmacology; Heinrich Heine University; Düsseldorf Germany
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Khosravani F, Suvorava T, Dao VTV, Brockmann N, Kocgirli O, Herbst FF, Valcaccia S, Kassack MU, Bas M, Kojda G. Stability of murine bradykinin type 2 receptor despite treatment with NO, bradykinin, icatibant, or C1-INH. Allergy 2015; 70:285-94. [PMID: 25477154 DOI: 10.1111/all.12556] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Little is known about factors which trigger and/or contribute to hereditary angioedema or ACE-inhibitor-mediated angioedema including variations in bradykinin type 2 receptor (B2R) expression and activity. METHODS Protein and mRNA expression of B2R and the increase of intracellular calcium (iCa) in response to bradykinin were monitored in porcine and murine endothelial cells in response to NO donors or bradykinin. B2R protein expression was evaluated in skin, heart, and lung of (i) mice with endothelial-specific overexpression of eNOS (eNOS(tg) ), (ii) in eNOS(-/-) mice and (iii) in C57BL/6 mice treated with the NO donor pentaerythritol tetranitrate (PETN), the NOS inhibitor l-nitroarginine (L-NA), plasma pool C1-INH, and the B2R antagonist icatibant. Aortic reactivity to bradykinin was investigated including eNOS(-/-) mice. RESULTS B2R protein and mRNA expression remained unchanged in cells subjected to L-NA, NO donors, and bradykinin in a time- and concentration-dependent manner. Likewise, increases of iCa in murine brain endothelial cells remained unchanged. B2R protein levels were similar in eNOS(tg) and eNOS(-/-) as compared to transgene-negative littermates. Likewise, treatment of C57BL/6 mice with PETN, L-NA, C1-INH or icatibant did not change B2R protein expression. In aortic rings of C57BL/6 mice, bradykinin induced B2R-dependent constrictions which were attenuated by endothelial NO and abolished by diclofenac indicating the functional importance of B2R-induced activation of endothelial NO synthase and cyclooxygenase. CONCLUSION These data suggest that alterations of B2R protein expression induced by NO, bradykinin, C1-INH, or icatibant unlikely contribute to bradykinin-induced angioedema. This finding does not rule out a role for NO in bradykinin-induced extravasation and/or angioedema.
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Affiliation(s)
- F. Khosravani
- Institute of Pharmacology and Clinical Pharmacology; Heinrich-Heine-University; Düsseldorf Germany
| | - T. Suvorava
- Institute of Pharmacology and Clinical Pharmacology; Heinrich-Heine-University; Düsseldorf Germany
| | - V. T.-V. Dao
- Institute of Pharmacology and Clinical Pharmacology; Heinrich-Heine-University; Düsseldorf Germany
| | - N. Brockmann
- Institute of Pharmaceutical and Medicinal Chemistry; Heinrich-Heine-University; Düsseldorf Germany
| | - O. Kocgirli
- Institute of Pharmacology and Clinical Pharmacology; Heinrich-Heine-University; Düsseldorf Germany
| | - F. F. Herbst
- Institute of Pharmacology and Clinical Pharmacology; Heinrich-Heine-University; Düsseldorf Germany
| | - S. Valcaccia
- Institute of Pharmacology and Clinical Pharmacology; Heinrich-Heine-University; Düsseldorf Germany
| | - M. U. Kassack
- Institute of Pharmaceutical and Medicinal Chemistry; Heinrich-Heine-University; Düsseldorf Germany
| | - M. Bas
- Otorhinolaryngology Department; University Hospital Rechts der Isar; Munich Technical University; Munich Germany
| | - G. Kojda
- Institute of Pharmacology and Clinical Pharmacology; Heinrich-Heine-University; Düsseldorf Germany
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Laine O, Leppänen I, Koskela S, Antonen J, Mäkelä S, Sinisalo M, Vaheri A, Mustonen J. Severe Puumala virus infection in a patient with a lymphoproliferative disease treated with icatibant. Infect Dis (Lond) 2014; 47:107-11. [PMID: 25496418 DOI: 10.3109/00365548.2014.969304] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Early identification of patients at risk of a severe course of hantaviral disease and lack of effective medication represent a global challenge in the treatment of this emerging infection. We describe a 67-year-old female patient with a history of chronic lymphoproliferative disease involving the spleen and an extremely severe acute Puumala hantavirus infection. She was treated with the bradykinin receptor antagonist icatibant and recovered. She is the second patient with a spleen abnormality and severe Puumala infection treated with icatibant in our hospital. We suggest that patients with spleen abnormalities may be more susceptible to severe hantavirus disease. The activation of the kinin-kallikrein system and the formation of bradykinin in hantavirus-infected endothelial cells indicate that the role of bradykinin receptor antagonist icatibant in the treatment of hantavirus disease is worth studying.
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Affiliation(s)
- Outi Laine
- From the Department of Internal Medicine, Tampere University Hospital , Tampere , Finland
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Malbrán A, Riedl M, Ritchie B, Smith WB, Yang W, Banerji A, Hébert J, Gleich GJ, Hurewitz D, Jacobson KW, Bernstein JA, Khan DA, Kirkpatrick CH, Resnick D, Li H, Fernández Romero DS, Lumry W. Repeat treatment of acute hereditary angioedema attacks with open-label icatibant in the FAST-1 trial. Clin Exp Immunol 2014; 177:544-53. [PMID: 24749847 DOI: 10.1111/cei.12358] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2014] [Indexed: 11/30/2022] Open
Abstract
Hereditary angioedema (HAE) is characterized by potentially life-threatening recurrent episodes of oedema. The open-label extension (OLE) phase of the For Angioedema Subcutaneous Treatment (FAST)-1 trial (NCT00097695) evaluated the efficacy and safety of repeated icatibant exposure in adults with multiple HAE attacks. Following completion of the randomized, controlled phase, patients could receive open-label icatibant (30 mg subcutaneously) for subsequent attacks. The primary end-point was time to onset of primary symptom relief, as assessed by visual analogue scale (VAS). Descriptive statistics were reported for cutaneous/abdominal attacks 1-10 treated in the OLE phase and individual laryngeal attacks. Post-hoc analyses were conducted in patients with ≥ 5 attacks across the controlled and OLE phases. Safety was evaluated throughout. During the OLE phase, 72 patients received icatibant for 340 attacks. For cutaneous/abdominal attacks 1-10, the median time to onset of primary symptom relief was 1·0-2·0 h. For laryngeal attacks 1-12, patient-assessed median time to initial symptom improvement was 0·3-1·2 h. Post-hoc analyses showed the time to onset of symptom relief based on composite VAS was consistent across repeated treatments with icatibant. One injection of icatibant was sufficient to treat 88·2% of attacks; rescue medication was required in 5·3% of attacks. No icatibant-related serious adverse events were reported. Icatibant provided consistent efficacy and was well tolerated for repeated treatment of HAE attacks.
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Affiliation(s)
- A Malbrán
- Hospital Británico de Buenos Aires, Buenos Aires, Argentina
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Baş M, Greve J, Hoffmann TK, Reshef A, Aberer W, Maurer M, Kivity S, Farkas H, Floccard B, Arcoleo F, Martin L, Sitkauskiene B, Bouillet L, Schmid-Grendelmeier P, Li H, Zanichelli A. Repeat treatment with icatibant for multiple hereditary angioedema attacks: FAST-2 open-label study. Allergy 2013; 68:1452-9. [PMID: 24111645 DOI: 10.1111/all.12244] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The For Angioedema Subcutaneous Treatment (FAST)-2, a phase III, double-blind, randomized, multicenter, placebo-controlled study (ClinicalTrials.gov identifier: NCT00500656), established the efficacy and safety of single injections of icatibant, a bradykinin B₂ receptor antagonist, in the treatment of hereditary angioedema (HAE) attacks. Here, we evaluate the efficacy and safety of repeated treatment with icatibant in adult patients experiencing HAE attacks during the FAST-2 open-label extension (OLE) phase. METHODS Patients completing the controlled phase were eligible to participate in the OLE phase and receive open-label icatibant (30 mg subcutaneously) for the treatment of cutaneous, abdominal, and/or laryngeal HAE attack(s) severe enough to warrant treatment. Time to onset of symptom relief was calculated for each attack. Descriptive analyses (median, 95% CIs) were performed for all attacks; post hoc analyses were conducted in patients with at least five icatibant-treated attacks throughout the FAST-2 OLE phase. Safety was also monitored. RESULTS Fifty-four patients received icatibant for 374 attacks (176 cutaneous, 168 abdominal, and 30 laryngeal). For cutaneous and/or abdominal attacks (attacks 2-5), the median times to onset of symptom relief ranged between 2.0 and 2.5 h. For all laryngeal attacks, the median times to regression (start of improvement) of symptoms ranged between 0.3 and 4.0 h. Post hoc analyses showed that the overall median time to onset of symptom relief was 2.0 h. Overall, 89.8% of attacks resolved with a single icatibant injection. No drug-related serious adverse events were reported. CONCLUSIONS These findings have demonstrated the efficacy and safety of repeated icatibant treatment for HAE attacks.
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Affiliation(s)
- M. Baş
- Department of Otorhinolaryngology; Klinikum rechts der Isar; Technische Universität München; Munich Germany
| | - J. Greve
- Department of Otorhinolaryngology, Head and Neck Surgery; University Hospital Ulm; Ulm Germany
| | - T. K. Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery; University Hospital Ulm; Ulm Germany
| | - A. Reshef
- Allergy, Immunology and Angioedema Center; Sheba Medical Center; Tel Hashomer Israel
| | - W. Aberer
- Department of Dermatology and Venerology; Medical University of Graz; Graz Austria
| | - M. Maurer
- Department of Allergy and Clinical Immunology, Allergie-Centrum-Charité; Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - S. Kivity
- Tel Aviv Medical Center; Sackler Medical School; Tel Aviv Israel
| | - H. Farkas
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - B. Floccard
- Service de Reanimation; Hospices Civils de Lyon; Hôpital Edouard Herriot; Lyon France
| | - F. Arcoleo
- Azienda Ospedaliera V. Cervello; Palermo Italy
| | - L. Martin
- Department of Dermatology; Angers University Hospital; Angers France
| | - B. Sitkauskiene
- Department of Pulmonology and Immunology; Lithuanian University of Health Sciences; Kaunas Lithuania
| | - L. Bouillet
- Internal Medicine Department; National Reference Centre for Angioedema; Grenoble University Hospital; Grenoble France
| | | | - H. Li
- Shire Human Genetics Therapies (HGT); Lexington MA USA
| | - A. Zanichelli
- Ospedale Luigi Sacco; Università degli Studi di Milano; Milan Italy
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Abstract
Hereditary angioedema (HAE) is an autosomal dominant, potentially life-threatening condition, manifesting as recurrent and self-limiting episodes of facial, laryngeal, genital, or peripheral swelling with abdominal pain secondary to intra-abdominal edema. The estimated prevalence of HAE in the general population is one individual per 50,000, with reported ranges from 1:10,000 to 1:150,000, without major sex or ethnic differences. Various treatment options for acute attacks and prophylaxis of HAE are authorized and available in the market, including plasma-derived (Berinert®, Cinryze®, and Cetor®) and recombinant (Rhucin® and Ruconest™) C1 inhibitors, kallikrein inhibitor-ecallantide (Kalbitor®), and bradykinin B2 receptor antagonist-icatibant (Firazyr®). Some of these drugs are used only to treat HAE attacks, whereas others are only approved for prophylactic therapies and all of them have improved disease outcomes due to their different mechanisms of action. Bradykinin and its binding to B2 receptor have been demonstrated to be responsible for most of the symptoms of HAE. Thus icatibant (Firazyr®), a bradykinin B2 receptor antagonist, has proven to be an effective and more targeted treatment option and has been approved for the treatment of acute attacks of HAE. Rapid and stable relief from symptoms of cutaneous, abdominal, or laryngeal HAE attacks has been demonstrated by 30 mg of icatibant in Phase III clinical trials. Self-resolving mild to moderate local site reactions after subcutaneous injection of icatibant were observed. Icatibant is a new, safe, and effective treatment for acute attacks of HAE. HAE has been reported to result in enormous humanistic burden to patients, affecting both physical and mental health, with a negative impact on education, career, and work productivity, and with substantial economic burdens. The timely and proper use of disease-specific treatments could improve patients’ quality of life, reduce the disease-specific morbidity and mortality, and, last but not least, reduce costs associated with hospitalizations and emergency room visits. Therefore, the paradigm of HAE treatment has the potential to evolve significantly, thereby exponentially improving a patient’s quality of life.
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Affiliation(s)
- Aasia Ghazi
- University of Texas Medical Branch, Division of Allergy and Clinical Immunology, Galveston, TX, USA
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Blasco AJ, Lázaro P, Caballero T, Guilarte M. Social costs of icatibant self-administration vs. health professional-administration in the treatment of hereditary angioedema in Spain. Health Econ Rev 2013; 3:2. [PMID: 23398817 PMCID: PMC3584739 DOI: 10.1186/2191-1991-3-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 02/01/2013] [Indexed: 06/01/2023]
Abstract
BACKGROUND Icatibant is the only subcutaneous treatment for acute Type I and Type II hereditary angioedema with C1-esterase inhibitor deficiency (HAE-C1-INH) licensed for self-administration in Europe. AIM To compare the economic impact of two icatibant administration strategies: health professional-administration only (strategy 1) versus including the patient self-administration option (strategy 2). METHODS Economic evaluation model based on the building of a decision tree. Both strategies are assumed to have equivalent effectiveness. The payer (Spanish National Health System) and the social perspectives were considered. All relevant cost-generating factors were taken into account. The time horizon was one year. Sources of information included scientific evidence, official data and experts' opinion. A deterministic sensitivity analysis was carried out to quantify the underlying uncertainty in the model. RESULTS From the social perspective, which considers both direct (health care costs) and indirect costs (productivity losses), strategy 2 would result into average savings of €121.30 per acute attack compared to strategy 1. For Spain, this would achieve in an annual savings of €551,371. The reduction in direct costs accounts for 74% of the savings and lower indirect costs account for the remaining 26%. Savings per acute attack may range from €79.50 to €169.80; accordingly, the annual savings in Spain may vary between €90,319 and €2,315,360. CONCLUSION Costs related to the management of acute HAE attacks with C1 inhibitor deficiency may be substantially reduced through interventions targeting home treatment by training patients to self-administer icatibant.
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Affiliation(s)
- Antonio J Blasco
- Advanced Techniques in Health Services Research (TAISS), Madrid, Spain
| | - Pablo Lázaro
- Advanced Techniques in Health Services Research (TAISS), Madrid, Spain
| | - Teresa Caballero
- Allergy Service, Hospital La Paz Health Research Center (IdiPaz), Biomedical Research Network on Rare Diseases-U754 (CIBERER), Madrid, Spain
| | - Mar Guilarte
- Allergy Section, Department of Internal Medicine, Hospital Universitario Vall d´Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Floccard B, Hautin E, Bouillet L, Coppere B, Allaouchiche B. An evidence-based review of the potential role of icatibant in the treatment of acute attacks in hereditary angioedema type I and II. Core Evid 2012; 7:105-14. [PMID: 23055948 PMCID: PMC3467996 DOI: 10.2147/ce.s24743] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Icatibant, a first-in-class B2 bradykinin receptor antagonist, appears to have a favorable efficacy and safety profile for the treatment of acute attacks of hereditary angioedema in adults. AIMS To update the evidence and provide an overview of the available data on icatibant. EVIDENCE REVIEW Peer reviewed articles published and listed in Medline Search and published updated guidelines for the treatment of acute attacks in hereditary angioedema type I and II in adults were reviewed. The validity and quality of evidence were evaluated. PLACE IN THERAPY Clinical evidence for the treatment of acute hereditary angioedema attacks with icatibant is strong. Approximately 10% of the patients require a second dose. No serious adverse reactions have been reported. The only significant side effects consistently registered by 90% of patients are transient local pain, swelling, and erythema at the local injection site. CONCLUSION Subcutaneously administered 30 mg icatibant has been shown to be a safe and efficacious treatment in clinical trials. It is the only specific treatment authorized for self-administration by the subcutaneous route offering increased patient independence.
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Affiliation(s)
- Bernard Floccard
- Département d'Anesthésie Réanimation, Centre de Référence des Angioedèmes à Bradykinine, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon
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Meini S, Bellucci F, Catalani C, Cucchi P, Giolitti A, Giuliani S, Quartara L, Rotondaro L, Zappitelli S, Maggi CA. Comparison of the molecular interactions of two antagonists, MEN16132 or icatibant, at the human kinin B₂ receptor. Br J Pharmacol 2011; 162:1202-12. [PMID: 21108627 PMCID: PMC3051391 DOI: 10.1111/j.1476-5381.2010.01133.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [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: 06/04/2010] [Revised: 09/22/2010] [Accepted: 10/28/2010] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Icatibant is a well-known kinin B₂ receptor antagonist currently used for angiooedema attacks. MEN16132 is a non-peptide B₂ receptor antagonist, more potent and long lasting than icatibant in different models. Here we studied the reasons for these differences between the two antagonists. EXPERIMENTAL APPROACH Rate of reversibility (over about 3 h) of the functional receptor blockade exerted by the antagonists was compared (inositol phosphates accumulation assay) in CHO cells expressing the human B₂ receptor and in human synovial cells. Antagonist pretreated cells were washed with medium and the time taken to restore bradykinin (BK) response measured. Antagonist affinity was measured by radioligand binding to wild type and mutated B₂ receptors. KEY RESULTS Recovery of BK-induced responses was slower in cells pretreated with MEN16132 than in those treated with icatibant. The affinity of icatibant (for the [³H]-BK or the B₂ receptor antagonist [³H]-MEN11270 binding site) was compared to that of MEN16132 using a panel of point-mutated receptors with mutations located at the transmembrane regions of the B₂ receptor, previously shown to decrease MEN16132 high affinity interaction. No consistent decrease of icatibant affinity was observed. From the different affinity of MEN16132 derivatives at wild type and W86A (transmembrane 2 region) receptors, and by evaluating its antagonist profile at the D266A/D284A double mutant receptor, a model of the MEN16132-B₂ receptor complex is proposed. CONCLUSIONS AND IMPLICATIONS MEN16132 dissociated from the B₂ receptor compartment more slowly than icatibant and interacted at a deeper level in transmembrane regions of the receptor.
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Affiliation(s)
- S Meini
- Department of Pharmacology, Menarini Ricerche, Florence, Italy.
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Meini S, Cucchi P, Catalani C, Bellucci F, Giuliani S, Maggi CA. Bradykinin and B₂ receptor antagonism in rat and human articular chondrocytes. Br J Pharmacol 2011; 162:611-22. [PMID: 20946124 PMCID: PMC3041251 DOI: 10.1111/j.1476-5381.2010.01062.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [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: 04/28/2010] [Revised: 09/02/2010] [Accepted: 09/15/2010] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE In osteoarthritis (OA), bradykinin (BK) is known to contribute to pain and synovitis, but not to cartilage degradation. Here, we investigated effects of BK and its antagonists on chondrocytes, cells involved in cartilage homeostasis. EXPERIMENTAL APPROACH BK receptor density and affinities of BK, its analogues and antagonists were measured in cultured human and rat chondrocytes by radioligand binding. Effects of BK were assessed by accumulation of inositol phosphates (IP) and release of interleukin (IL)-6 and IL-8. KEY RESULTS Density of [³H]-BK binding sites was higher (13-30-fold) and BK evoked a greater (48-fold) IP production, in human than in rat chondrocytes. The BK B₂ receptor antagonists MEN16132 and icatibant displayed similar binding affinity. MEN16132 was 40-fold more potent than icatibant in the IP assay. In human chondrocytes, BK increased release (over 24 h) of IL-6 and IL-8, effects blocked by MEN16132 but not by the B₁ receptor antagonist Lys-[Leu⁸][desArg⁹]BK. BK-induced release of IL-6, but not of IL-8, was partially inhibited by indomethacin (10 µM) and nordihydroguaiaretic acid (10 µM). Antagonists for the prostanoid EP receptors (AH6809 10 µM; L-798,196, 200 nM; L-161,982, 1 µM) were ineffective. Dexamethasone (100 nM) partially inhibited release of both IL-6 and IL-8. Inhibitors of intracellular downstream signalling pathways (SB203580 10 µM; PD98059, 30 µM; SP600125, 30 µM; BAY-117085, 5 µM) indicated the involvement of p38 MAPK and the activation of NF-κB. CONCLUSION AND IMPLICATIONS BK mediated inflammatory changes and cartilage degradation and B₂ receptor blockade would, therefore, be a potential treatment for OA.
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Affiliation(s)
- S Meini
- Department of Pharmacology, Menarini Ricerche S.p.A., Florence, Italy.
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Abstract
Icatibant (Firazyr(®)) is a novel subcutaneous treatment recently licensed in the European Union for acute hereditary angioedema. Hereditary angioedema, resulting from inherited partial C1 inhibitor deficiency, is a disabling condition characterized by intermittent episodes of bradykinin-mediated angioedema. Icatibant blocks bradykinin B2 receptors, attenutating the episode. Randomized double-blind, placebo-controlled trials of icatibant, showed significant superiority over oral tranexamic acid in 74 European patients and a trend to improvement in a similar US trial comparing icatibant with placebo in 55 patients. Outcomes for several endpoints did not reach significance in the US trial, perhaps because of low participant numbers and confounding factors: a further trial is planned. Open label studies have shown benefit in multiple treatments for attacks at all sites. Approximately 10% of patients require a second dose for re-emergent symptoms, usually 10 to 27 hours after the initial treatment. Its subcutaneous route of administration, good tolerability and novel mode of action make icatibant a promising addition to the limited repertoire of treatments for hereditary angioedema.
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