Hereditary angioedema

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Hereditary angioedema
Classification and external resources
Swollen hand during a hereditary angioedema attack..jpg
Swollen right hand during a hereditary angioedema attack.
ICD-10 D84.1 (ILDS D84.110)
ICD-9 277.6
OMIM 106100
DiseasesDB 1821
MedlinePlus 001456
eMedicine article/1048994
MeSH D054179

Hereditary angioedema (types I, II and III) (also known as "HAE") is a rare, autosomal dominantly inherited blood disorder that causes episodic attacks of swelling that may affect the face, extremities, genitals, gastrointestinal tract and upper airways.[1][2]:152 Swellings of the intestinal mucosa may lead to vomiting and painful, colic-like intestinal spasms that may mimic intestinal obstruction. Airway edema may be life-threatening. Episodes may be triggered by trauma, surgery, dental work, menstruation, some medications, viral illness and stress; however, this is not always readily determined.[3] This disorder affects approximately one in 10,000–50,000 people.

HAE type I primarily caused because of abnormally low concentration some complex blood proteins (C1 esterase inhibitors), also called complements. These help to control various body functions such as the flow of body fluids in and out of cells. It is responsible for approximately 80-85% of this disorder.

HAE type II is a more infrequent form of this disorder. It occurs due to the fabrication of atypical complement proteins and accounts for about 15-20% of this disorder . Type III is not common and was documented recently. This type mainly afflicts females and it is influenced by contact with estrogens and also by hormone replacement therapy (e.g. oral contraceptives and pregnancy) and this is not connected with the deficiency of C1-INH.

HAE type III is not necessarily caused by C1-INH deficiency; it is credited to a rise in the action of the enzyme kininogenase’s and this then leads to rise in the levels of bradykinin. Some patients who have the type III HAE will have an alteration in the F12 gene and this produces a protein which participates in the clotting of blood .[4] Some patients with type III HAE have a mutation in the F12 gene which produces a protein involved in blood clotting.[5]

The underlying cause of HAE is attributed to autosomal dominant inheritance of mutations in the C1 inhibitor (C1-INH gene or SERPING1 gene),[6][7] which is mapped to chromosome 11 (11q12-q13.1).To date there are over 300 known genetic mutations that result in a deficiency of functional C1 Inhibitor. 2-4 The majority of HAE patients have a family history; however, 25% are the result of new mutations.[8] The low level of C1 inhibitor in the plasma leads to increased activation of pathways that release bradykinin, the chemical responsible for the angioedema due to increased vascular permeability, and the pain seen in individuals with HAE.

The most common form of the disorder is HAE type I, which is the result of abnormally low levels of certain complex proteins in the blood (C1 esterase inhibitors), known as complements. They help to regulate various body functions (e.g., flow of body fluids in and out of cells). HAE type II is a more uncommon form of the disorder. It occurs as the result of the production of abnormal complement proteins and accounts for about 15-20% of this disorder.[9] Type III is a very rare recently documented form: It predominantly affects females and it is influenced by exposure to estrogens or hormone replacement therapy (e.g. oral contraceptives and pregnancy) and is not associated with C1-INH deficiency. HAE type III is not due to C1 INH deficiency; it is linked to an increase in kininogenase activity leading to elevated levels of bradykinin.[4] Some patients with type III HAE have a mutation in the F12 gene which produces a protein involved in blood clotting.[5]

Pathogenesis[edit]

Due to the fact that Hereditary Angioedema is an autosomal inheritable disease, there is no gender discrimination in the transmission. In other words, it is not a sex-linked disorder; both sexes are equally likely to receive the mutated gene from their parent(s). The figure below (courtesy of US National Library Of Medicine) depicts autosomal dominant transmission. Here, the father (individual A) with a mutated gene for HAE, has the disease while his wife (individual B) with 2 non-mutated copies of the C1 inhibitor gene and does not have the disease. The possibility of a cross between them gives the possibilities as shown: - two of their offspring will have the disease (HEA) while the others would not.;[10][11]

The affected father who has HAE has mutation on one of his genes (C1-INH). Each one of his children, notwithstanding his/her sex, will have a 50% chance to inherit the mutated C1-INH gene from him. HAE is generally referred to as a “dominant” condition due to the fact that it only takes a mutation in one of the two C1-INH genes in a carrier to cause the disease .[12][13]

The prevalence of HAE is relatively low - between 1 in every 10,000 to 1 in every 50,000 persons. Most of people with HAE acquire a C1 esterase inhibitor (C1-INH) mutation from one of their parents. A parent with HAE usually has a 50% probability of transmitting this condition on to one of his/her children of either sex as shown in the figure (HEA Inheritance). In occasions when HAE is not inherited and occurs in people with no previous history of it. This is due to the fact that there are new impulsive or spontaneous changes in the sperm or egg cell that is responsible for this specific pregnancy. In a review of patients who do not have a history of HAE in their family, but who have relatively low levels of mutated C1-INH with persistent angioedema, 25% of new patients who had HAE had C1-INH changes that do not show signs of being inherited but rather new.

The mutational changes in 1 or both of the carriers’ C1 inhibitor genes could have only occurred spontaneously, and just like in the example above, their offspring in this case will have a 50% probability of acquiring the mutated gene from either parent that has HAE.

Diagnosis[edit]

Complement tests
C4 (C) FB (A) C3 CH50 Conditions
 · PSG, C3 NeF AA
 ·  · HA, C4D
 ·  ·  · TCPD
 · /↓ SLE
inflammation

Recognizing HAE is often difficult due to the wide variability in disease expression. The course of the disease is diverse and unpredictable, even within a single patient over their lifetime. This disease may be similar in its presentation to other forms of angioedema resulting from allergies or other medical conditions, but it is significantly different in cause and treatment. When hereditary angioedema is misdiagnosed as an allergy it is most commonly treated with steroids and epinephrine, drugs that are usually ineffective in treating a hereditary angioedema episode. Other misdiagnoses have resulted in unnecessary exploratory surgery for patients with abdominal swelling and other hereditary angioedema patients report that their abdominal pain was wrongly diagnosed as psychosomatic.

HAE accounts for only a small fraction of all cases of angioedema. To avoid potentially fatal consequences such as upper airway obstruction and unnecessary abdominal surgery, the importance of a correct diagnosis cannot be over-emphasized.[14]

Consider Hereditary Angioedema (HAE) if a patient presents with:

  • Recurrent angioedema (without urticaria)
  • Recurrent episodes of abdominal pain and vomiting
  • Laryngeal edema
  • Positive family history of angioedema

[15][16] A blood test, ideally taken during an episode, can be used to diagnose the condition. Measure: serum complement factor 4 (C4), C1 inhibitor (C1-INH) antigenic protein, C1 inhibitor (C1-INH) functional level if available.

Analysis of complement C1 inhibitor levels may play a role in diagnosis. C4 and C2 are complementary components.

Prevention[edit]

Treatment with ACE inhibitors is contraindicated in this condition, as these drugs can lead to bradykinin accumulation, which can precipitate disease episodes.[17][18]

Long-term prophylaxis

Patients in whom episodes occur at least once a month or who are at high risk of developing laryngeal edema require long-term prophylaxis. There are now several phase III clinical trials recently published in HAE prophylaxis and therapy and these have led to the licensing of pdC1INH (Berinert®, CSL Behring; Cinryze®, ViroPharma; Cetor-n®, Sanquin) in many parts of the world; bradykinin receptor antagonist (Icatibant, Firazyr®, Jerini/Shire) in Europe; kallikrein inhibitor(Ecallantide, Kalbitor®, Dyax) in the United States; and recombinant C1-INH replacement therapy (rhC1INH; conestat alfa; Rhucin®, Pharming) in Europe. Tranexamic acid has been showed to be relatively ineffective therapy. Danazol prophylaxis remains an option but therapeutic agents are now being used more for prophylaxis because of danazol adverse events.[19] For patients requiring long-term prophylaxis, home therapy which allows patients to self-administer product, is considered an integral part of allowing patients a normal quality of life.

Short-term prophylaxis

Short-term prophylaxis is normally administered before surgery or dental treatment. In Germany, C1-INH concentrate is used for this and given 1–11/2 hours before the procedure. In countries where C1-inhibitor concentrate is not available or only available in an emergency (laryngeal edema), high-dose androgen treatment is administered for 5–7 days.

Management[edit]

The aim of acute treatment is to halt progression of the edema as quickly as possible, which can be life-saving, particularly if the swelling is in the larynx. In Germany, most acute treatment consists of C1 inhibitor concentrate from donor blood, which must be administered intravenously; however, in most European countries, C1 inhibitor concentrate is only available to patients who are participating in special programs. In emergency situations where C1 inhibitor concentrate is not available, fresh frozen plasma (FFP) can be used as an alternative, as it also contains C1 inhibitor.

Other treatment modalities can stimulate the synthesis of C1 inhibitor, or reduce C1 inhibitor consumption. Purified C1 inhibitor, derived from human blood, has been used in Europe since 1979. Several C1 inhibitor treatments are now available in the U.S. Food and Drug Administration and two C1 inhibitor products are now available in Canada. Berinert P (CSL Behring), which is pasteurized, was approved by the F.D.A. in 2009 for acute attacks. Cinryze (ViroPharma), which is nanofiltered, was approved by the F.D.A. in 2008 for prophylaxis. Rhucin (Pharming) is a recombinant C1 inhibitor under development that does not carry the risk of infectious disease transmission due to human blood-borne pathogens.[20]

Newer treatments attack the contact cascade. Ecallantide (Kalbitor, Dyax) inhibits plasma kallikrein, and was approved by the F.D.A. (but not in Europe) for acute attacks in 2009. Icatibant (Firazyr, Jerini) inhibits the bradykinin B2 receptor, and was approved in Europe.[20] Approved by the FDA on August 25, 2011.[21] In hereditary angioedema, specific stimuli that have previously led to attacks may need to be avoided in the future. It does not respond to antihistamines, corticosteroids, or epinephrine.

Epidemiology[edit]

Data regarding the epidemiology of angioedema is limited. The incidence of HAE is one in 10,000–50,000 people in the United States and Canada. Mortality rates are estimated at 15–33%, resulting primarily from laryngeal edema and asphyxiation. HAE leads to 15,000–30,000 emergency department visits per year.[22][23]

Society and Culture[edit]

Hereditary angioedema was featured in the third season of House M.D. in the episode "Fools for Love". Hereditary angioedema was determined to have been passed on to a husband and wife from their mutual father.

Research[edit]

Clinical development of several new active substances, which intervene in the disease process in different ways, is currently ongoing.

Pharming Group NV announced on 24 June 2010 that the European Medicines Agency has adopted a positive opinion on conestat alfa (trade name Ruconest), a C1-inhibitor for the treatment of acute angioedema attacks.[24]

Ecallantide, a peptide inhibitor of kallikrein, has received orphan status for HAE and has shown positive results in phase III trials.[25]

Icatibant (marketed as Firazyr) is a selective bradykinin receptor antagonist, which has been approved in Europe and was approved in the USA by the FDA in Aug 2011.[26] After initial borderline results this drug was shown to be effective in phase III trials.[27]

Cinryze has been approved by the FDA in October 2008.[28]

Patients' organizations[edit]

There are national associations for HAE patients and their families in a number of countries around the world. These national associations are members of the global organization HAEi - International Patient Organization for C1-Inhibitor Deficiencies. HAEi is dedicated to raising awareness of C1 inhibitor deficiencies around the world. It is a non-profit international network established to promote co-operation, co-ordination and information sharing between HAE specialists and national HAE patient associations in order to help facilitate the availability of effective diagnosis and management of C1 inhibitor deficiencies throughout the world. The Assistance Fund Inc. is a nonprofit organization that has co-pay assistance for medications that treat HAE and is open to any who has insurance.

Visit the HAEi website [3] for further information on national associations.

References[edit]

  1. ^ "What is Hereditary Angioedema?". HAE Canada. 
  2. ^ Konrad, Bork (2010). "Diagnosis and treatment of hereditary angioedema with normal C1 inhibitor". Allergy, Asthma & Clinical Immunology 6 (1): 15. doi:10.1186/1710-1492-6-15. 
  3. ^ What is Hereditary Angioedema
  4. ^ a b [1]
  5. ^ a b [Type III hereditary angioedema: defined, but not understood. Kaplan A. Ann Allergy Asthma Immunol. 2012 Sep;109(3):153-4. doi: 10.1016/j.anai.2012.07.007. No abstract available.]
  6. ^ [Normal C1 inhibitor hereditary angioedema. Kittisupamongkol W. Am J Med. 2009 May;122(5):e7; author reply e9. doi: 10.1016/j.amjmed.2008.11.011. No abstract available.]
  7. ^ Colobran, Roger; Lois, Sergio; de la Cruz, Xavier; Pujol-Borrell, Ricardo; Hernández-González, Manuel; Guilarte, Mar. Clinical Immunology. Feb2014, Vol. 150 Issue 2, p143-148. 6p. DOI: 10.1016/j.clim.2013.11.013. :
  8. ^ Madsen, Flemming; Attermann, J&phgr;rn; Linneberg, Allan. Acta Dermato-Venereologica. 2012, Vol. 92 Issue 5, p475-479. 5p. DOI: 10.2340/00015555-1389.
  9. ^ [Overview of hereditary angioedema caused by C1-inhibitor deficiency: assessment and clinical management. Bork K, Davis-Lorton M.]
  10. ^ Ferraro, M. F.; Moreno, A. S.; Castelli, E. C.; Donadi, E. A.; Palma, M. S.; Arcuri, H. A.; Lange, A. P.; Bork, K.; Sarti, W.; Arruda, L. K. Allergy. Oct2011, Vol. 66 Issue 10, p1384-1390. 7p. 2 Diagrams, 1 Chart. DOI: 10.1111/j.1398-9995.2011.02658.x.
  11. ^ Bafunno, Valeria; Bova, Maria; Loffredo, Stefania; Divella, Chiara; Petraroli, Angelica; Marone, Gianni; Montinaro, Vincenzo; Margaglione, Maurizio; Triggiani, Massimo. Annals of Human Genetics. Mar2014, Vol. 78 Issue 2, p73-82. 10p. DOI: 10.1111/ahg.12052.
  12. ^ [Genetic test indications and interpretations in patients with hereditary angioedema. Weiler CR, van Dellen RG. Mayo Clin Proc. 2006 Jul;81(7):958-72. Review.]
  13. ^ [2]
  14. ^ http://caep.ca/sites/default/files/caep/files/2012_conference_-_management_of_angioedema_in_the_er.pdf
  15. ^ Zingale LC, Beltrami L, Zanichelli A, et al. (October 2006). "Angioedema without urticaria: a large clinical survey". CMAJ 175 (9): 1065–70. doi:10.1503/cmaj.060535. PMC 1609157. PMID 17060655. 
  16. ^ http://haecanada.com/files/DiagnosticAlgorithm100527.pdf
  17. ^ Dendorfer A, Wolfrum S, Wagemann M, Qadri F, Dominiak P (May 2001). "Pathways of bradykinin degradation in blood and plasma of normotensive and hypertensive rats". Am. J. Physiol. Heart Circ. Physiol. 280 (5): H2182–8. PMID 11299220. 
  18. ^ Kuoppala A, Lindstedt KA, Saarinen J, Kovanen PT, Kokkonen JO (April 2000). "Inactivation of bradykinin by angiotensin-converting enzyme and by carboxypeptidase N in human plasma". Am. J. Physiol. Heart Circ. Physiol. 278 (4): H1069–74. PMID 10749699. 
  19. ^ Hereditary angioedema: beyond international consensus - circa December 2010 - The Canadian Society of Allergy and Clinical Immunology Dr. David McCourtie Lecture
  20. ^ a b Morgan
  21. ^ Firazyr [package insert]. Lexington, MA: Shire Orphan Therapies, Inc; 2011.
  22. ^ From the: Pinnacle Health System, Harrisburg Hospital, Department of Internal Medicine, 111 South Front Street, Harrisburg, PA 17101, Update on treatment for her
  23. ^ "Update on treatment of hereditary angioedema" Buyantseva, Larisa, Sardana, Niti and Craig, Timothy
  24. ^ Pharming: Pharming Receives Positive Opinion From European Medicines Agency On Rhucin Product name in Europe changed to Ruconest
  25. ^ Lehmann A (August 2008). "Ecallantide (DX-88), a plasma kallikrein inhibitor for the treatment of hereditary angioedema and the prevention of blood loss in on-pump cardiothoracic surgery". Expert Opin Biol Ther 8 (8): 1187–99. doi:10.1517/14712598.8.8.1187. PMID 18613770. 
  26. ^ Jerini AG (2008-07-15). "Jerini Receives European Commission Approval for Firazyr (Icatibant) in the Treatment of HAE - Press release". Retrieved 2008-07-28. 
  27. ^ Bernstein JA (January 2008). "Hereditary angioedema: a current state-of-the-art review, VIII: current status of emerging therapies". Ann. Allergy Asthma Immunol. 100 (1 Suppl 2): S41–6. doi:10.1016/S1081-1206(10)60585-6. PMID 18220151. 
  28. ^ Reuters: UPDATE 1-US clears Lev Pharma drug for rare swelling disease

External links[edit]