Oro-Facial Angioedema: An Overview

Despite its relatively common occurrence and life-threatening potential, the management of angioedema in the emergency department (ED) is lacking in terms of a structured approach. It is paramount to distinguish the different etiologies of angioedema from one another and more specifically differentiate histaminergic-mediated angioedema from bradykinin-mediated angioedema, especially in lieu of the more novel treatments that have recently become available for bradykinin-mediated angioedema. With this background in mind, this consensus parameter for the evaluation and management of angioedema attempts to provide a working framework for emergency physicians (EPs) in approaching the patient with angioedema in terms of diagnosis and management in the ED. This consensus parameter was developed from a collaborative effort among a group of EPs and leading allergists with expertise in angioedema. After rigorous debate, review of the literature, and expert opinion, the following consensus guideline document was created. The document has been endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM).

Bradykinin and the Pathogenesis of Hereditary Angioedema

Introduction: Acquired C1 esterase deficiency is a rare, life-threatening phenomenon that has been reported in association with lymphoproliferative and autoimmune disorders. Diagnosis is made based on the clinical presentation of angioedema and low C1 and C1q esterase inhibitor activity in a patient without a previous hereditary diagnosis. Treatment is aimed at addressing the underlying condition and plasma-derived C1 esterase inhibitor (C1-INH) concentrate, but clinical response can vary. Description: 75 year-old female with a past medical history of chronic lymphocytic leukemia (CLL) presented with spontaneous mouth and neck swelling unrelieved by antihistamines. Epinephrine and Solumedrol were administered, however the neck swelling worsened and the patient was intubated for airway protection. CT imaging of the neck revealed extensive subcutaneous neck edema. Attempts at extubation were limited by the patient’s persistent angioedema which was visualized by bronchoscopy. Glucocorticoids were ineffective as the patient had a reported allergy to Prednisone, therefore were further avoided. C1 esterase inhibitor (C1-INH) function was initially low at 7mg/dL, and repeat remained low at 10mg/dL with a C4 of .7mg/dL. C1q later returned low at < 1.2Eq/mL. The patient did not improve after treatment with plasma-derived C1-INH (Berinert). She eventually required tracheostomy placement, but had difficulty with subsequent downsizing due to persistent laryngeal edema with limited therapeutic options. Eventually, after 4 weeks, the patient was successfully decannulated. Discussion: There are no definitive guidelines for treatment of acquired C1 esterase deficiency, however therapies often follow the same course for hereditary forms including plasma-derived C1-INH. Often, these patients may not respond or require increased doses. If Berinert is ineffective, some immunologists and allergists have seen favorable outcomes and recommend treatment with the kallikrein inhibitor, ecallantide and the bradykinin B2 antagonist icatibant. To date, therapies targeted at prevention of angioedema in acquired cases have not been as successful as in hereditary forms, therefore, treatment is directed at the underlying condition, such as immunotherapy or chemotherapy for CLL.

8. Hereditary angioedema

French protocol for the diagnosis and management of hereditary angioedema.

Hereditary angioedema and COVID-19 during pregnancy: Two case reports

Non-hereditary angioedema (AE) with normal C1 esterase inhibitor (C1INH) can be presumably bradykinin- or mast cell-mediated, or of unknown cause. In this systematic review, we searched PubMed, EMBASE, and Scopus to provide an overview of the efficacy of different treatment options for the abovementioned subtypes of refractory non-hereditary AE with or without wheals and with normal C1INH. After study selection and risk of bias assessment, 61 articles were included for data extraction and analysis. Therapies were described for angiotensin-converting enzyme inhibitor-induced AE (ACEi-AE), for idiopathic AE, and for AE with wheals. Described treatments consisted of ecallantide, icatibant, C1INH, fresh frozen plasma (FFP), tranexamic acid (TA), and omalizumab. Additionally, individual studies for anti-vitamin K, progestin, and methotrexate were found. Safety information was available in 26 articles. Most therapies were used off-label and in few patients. There is a need for additional studies with a high level of evidence. In conclusion, in acute attacks of ACEi-AE and idiopathic AE, treatment with icatibant, C1INH, TA, and FFP often leads to symptom relief within 2 h, with limited side effects. For prophylactic treatment of idiopathic AE and AE with wheals, omalizumab, TA, and C1INH were effective and safe in the majority of patients.

In the vast majority of patients with hereditary angioedema (HAE), angioedema attacks are due to the quantitative or functional deficiency of C1-esterase inhibitor (C1-INH), which leads to increased vascular permeability and unregulated release of bradykinin. Exogenous administration of C1-INH is a rational way to restore the concentration and functional activity of this protein, regulate the release of bradykinin, and attenuate or prevent subcutaneous and submucosal edema associated with HAE. Recent international guidelines for the management of HAE include C1-INH as an option for acute treatment of HAE. In addition, these guidelines recommend C1-INH as first-line treatment for long-term prophylaxis and as the therapy of choice for short-term/preprocedural prophylaxis. Several C1-INH products are available, with approved indications varying across regions. For the acute treatment of HAE, both plasma-derived and recombinant C1-INH formulations have been shown to be effective and well tolerated in adolescents and adults with HAE, with onset of relief within 30 min to a few hours. Plasma-derived C1-INH is approved for use in children, and recombinant C1-INH is being evaluated in this population. Intravenous (IV) and subcutaneous (SC) formulations of C1-INH have been approved for routine prophylaxis to prevent HAE attacks in adolescents and adults. Both formulations when administered twice weekly have been shown to reduce the frequency and severity of HAE attacks. The SC formulation of C1-INH obviates the need for repeated venous access and may facilitate self-administration of HAE prophylaxis at home, as recommended in HAE treatment guidelines. As with most rare diseases, the costs of HAE treatment are high; however, the development of additional acute and prophylactic medications for HAE may result in competitive pricing and help drive down the costs of HAE treatment.

Hereditary angioedema (HAE) is a serious and potentially life-threatening condition that causes acute attacks of swelling, pain and reduced quality of life. People with Type I HAE (approximately 80% of all HAE cases) have insufficient amounts of C1 esterase inhibitor (C1-INH) protein; people with Type II HAE (approximately 20% of all cases) may have normal C1-INH concentrations, but, due to genetic mutations, these do not function properly. A few people, predominantly females, experience HAE despite having normal C1-INH levels and C1-INH function (rare Type III HAE). Several new drugs have been developed to treat acute attacks and prevent recurrence of attacks. There is currently no systematic review and meta-analysis that included all preventive medications for HAE. To assess the benefits and harms of interventions for the long-term prevention of HAE attacks in people with Type I, Type II or Type III HAE. We used standard, extensive Cochrane search methods. The latest search date was 3 August 2021. We included randomised controlled trials in children or adults with HAE that used medications to prevent HAE attacks. The comparators could be placebo or active comparator, or both; approved and experimental drug trials were eligible for inclusion. There were no restrictions on dose, frequency or intensity of treatment. The minimum length of four weeks of treatment was required for inclusion; this criterion excluded the acute treatment of HAE attacks. We used standard Cochrane methods. Our primary outcomes were 1. HAE attacks (number of attacks per person, per population) and change in number of HAE attacks; 2. mortality and 3. serious adverse events (e.g. hepatic dysfunction, hepatic toxicity and deleterious changes in blood tests). Our secondary outcomes were 4. quality of life; 5. severity of breakthrough attacks; 6. disability and 7. adverse events (e.g. weight gain, mild psychological changes and body hair). We used GRADE to assess certainty of evidence for each outcome. We identified 15 studies (912 participants) that met the inclusion criteria. The studies included people with Type I and II HAE. The studies investigated avoralstat, berotralstat, subcutaneous C1-INH, plasma-derived C1-INH, nanofiltered C1-INH, recombinant human C1-INH, danazol, and lanadelumab for the prevention of HAE attacks. We did not find any studies on the use of tranexamic acid for prevention of HAE attacks. All drugs except avoralstat reduced the number of HAE attacks compared with placebo. For breakthrough attacks that occurred despite prophylactic treatment, intravenous and subcutaneous forms of C1-INH and lanadelumab reduced attack severity. It is not known whether other drugs have a similar effect, as the severity of breakthrough attacks in people taking drugs other than C1-INH and lanadelumab was not reported. For quality of life, avoralstat, berotralstat, C1-INH (all forms) and lanadelumab increased quality of life compared with placebo; there were no data for danazol. Four studies reported on changes in disability during treatment with C1-INH, berotralstat and lanadelumab; all three drugs decreased disability compared with placebo. Adverse events, including serious adverse events, did not occur at a rate higher than placebo. However, serious adverse event data and other adverse event data were not available for danazol, which prevented us from drawing conclusions about the absolute or relative safety of this drug. No deaths were reported in the included studies. The analysis was limited by the small number of studies, the small number of participants in each study and the lack of data on older drugs, therefore the certainty of the evidence is low. Given the rarity of HAE, it is not surprising that drugs were rarely directly compared, which does not allow conclusions on the comparative efficacy of the various drugs for people with HAE. Finally, we did not identify any studies that included people with Type III HAE. Therefore, we cannot draw any conclusions about the efficacy or safety of any drug in people with this form of HAE. The available data suggest that berotralstat, C1-INH (subcutaneous, plasma-derived, nanofiltered and recombinant), danazol and lanadelumab are effective in lowering the risk or incidence (or both) of HAE attacks. In addition, C1-INH and lanadelumab decrease the severity of breakthrough attacks (data for other drugs were not available). Avoralstat, berotralstat, C1-INH (all forms) and lanadelumab increase quality of life and do not increase the risk of adverse events, including serious adverse events. It is possible that danazol, subcutaneous C1-INH and recombinant human C1-INH are more effective than berotralstat and lanadelumab in reducing the risk of breakthrough attacks, but the small number of studies and the small size of the studies means that the certainty of the evidence is low. This and the lack of head-to-head trials prevented us from drawing firm conclusions on the relative efficacy of the drugs.

Bradykinin-mediated angioedema: factors prompting ED visits

Hereditary angioedema is associated with an increased risk of venous thromboembolism

A Variant in XPNPEP2 Is Associated with Angioedema Induced by Angiotensin I–Converting Enzyme Inhibitors

Recognition and Differential Diagnosis of Hereditary Angioedema in the Emergency Department.

Rituximab-induced Elimination of Acquired Angioedema Due to C1-Inhibitor Deficiency

Angioedema Hereditário (AEH) é uma doença pouco conhecida por profissionais da saúde, portanto subdiagnosticada. O objetivo do estudo, foi analisar artigos referentes à temática abordada dos últimos 5 anos. AEH é uma doença genética rara e grave do sistema imunológico, de caráter autossômico dominante, causada pela deficiência de inibidor de C1 esterase (C1-INH). Classificada em 3 fenótipos: deficiência quantitativa do inibidor de C1-INH, disfunção de C1-INH e C1-INH normal. Mutações em diversos genes estão associadas ao fenótipo do AEH, pacientes com deficiência e disfunção da proteína C1-INH possuem mutações no gene SERPING1 e pacientes com C1-INH normal, podem apresentar mutações nos genes F12, angiopoietina (ANGPT1), plasminogênio (PLG) ou cininogênio (KNG1). Os sintomas do AEH são caracterizados por edemas recorrentes em várias partes do corpo, tanto em pele como órgãos internos. Para a elaboração deste estudo realizou-se uma revisão integrativa da literatura, os artigos foram pesquisados ​​em três bases de dados eletrônicas, Google Scholar, PubMed e Scielo, utilizando os descritores “angioedema hereditário”, “mutações”, “bradicinina”, “C1-INH”, “SERPING1”, “plasminogênio”, “angiopoietina”, “F12” e “cininogênio”, conectados por operadores boleanos AND e OR. A pesquisa no banco de dados revelou um total de 874 artigos, após triagem, 32 artigos foram avaliados. Com a pesquisa tornou-se possível compreender não somente os mecanismos percursores que levam ao desenvolvimento da doença, mas também as mutações genéticas responsáveis pelas diversas formas de manifestações clínicas do AEH, corroborando a construção de conhecimento dos profissionais envolvidos no diagnóstico e tratamento da patologia.