Abstract
Hereditary angioedema (HAE) is a rare disease that causes episodic attacks of subcutaneous and submucosal edema, which can be painful, incapacitating, and potentially fatal. These attacks are mediated by excessive bradykinin production, as a result of uncontrolled activation of the plasma kallikrein/kinin system, which is caused by a C1 esterase inhibitor deficiency or dysfunction in HAE types 1 and 2, respectively. For many years, treatment options were limited to therapies with substantial adverse effects, insufficient efficacy, or difficult routes of administration. Increased insights in the pathophysiology of HAE have paved the way for the development of new therapies with fewer side effects. In the last two decades, several targeted novel therapeutic strategies for HAE have been developed, for both long-term prophylaxis and on demand treatment of acute attacks. This article reviews the advances in the development of more effective and convenient treatment options for HAE and their anticipated effects on morbidity, mortality, and quality of life. The emergence of these improved treatment options will presumably change current HAE guidelines, but adherence to these recommendations may become restricted by high treatment costs. It will therefore be essential to determine the indications and identify the patients that will benefit most from these newest treatment generations. Ultimately, current preclinical research into gene therapies may eventually lead the way towards curative treatment options for HAE. In conclusion, an increasing shift towards the use of highly effective long-term prophylaxis is anticipated, which should drastically abate the burden on patients with hereditary angioedema.
Highlights
Hereditary angioedema (HAE) is a rare, disabling disorder, with symptoms ranging from disfiguring and incapacitating peripheral swellings, painful abdominal episodes, to potentially fatal laryngeal or oropharyngeal edema [1]
Treatment options were limited to fresh frozen plasma (FFP) infusions, antifibrinolytics, progestins, and attenuated androgens (AA)
Clinical efficacy was demonstrated in the phase 3 Clinical Studies for Optimal Management in Preventing Angioedema with low-volume subcutaneous C1-inhibitor replacement Therapy (COMPACT) trial, in which a total of 83% of patients receiving the recommended dose of self-administered 60 IU/kg twice weekly were free of attacks in the long-term extension arm [35]
Summary
Hereditary angioedema (HAE) is a rare, disabling disorder, with symptoms ranging from disfiguring and incapacitating peripheral swellings, painful abdominal episodes, to potentially fatal laryngeal or oropharyngeal edema [1]. Clinical efficacy was demonstrated in the phase 3 Clinical Studies for Optimal Management in Preventing Angioedema with low-volume subcutaneous C1-inhibitor replacement Therapy (COMPACT) trial, in which a total of 83% of patients receiving the recommended dose of self-administered 60 IU/kg twice weekly were free of attacks in the long-term extension arm [35] This treatment improved HAErelated quality of life (QoL) [36]. Berotralstat, the first approved oral PKa inhibitor for LTP, was investigated in liquid formulation for ODT in the ZENITH-1 study This phase 2 trial showed that a single dose of 750 mg reduced symptom severity and use of additional rescue medication, with a favourable safety profile [60]. This contrasts to congenital factor IX deficiency (haemophilia B) for instance, in which only small antigenic increases of factor IX by gene therapy can induce marked reductions in disease severity [72]
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