Hereditary Angioedema


Article Author:
Ali Abdulkarim


Article Editor:
Timothy Craig


Editors In Chief:
Timothy Craig
Yoon Kim
Robert Hostoffer


Managing Editors:
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Scott Dulebohn
Sobhan Daneshfar
William Gossman
Pritesh Sheth
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Richard Ciresi
Hajira Basit
Phillip Hynes


Updated:
3/25/2019 12:34:32 AM

Introduction

Hereditary angioedema (HAE) is an autosomal dominant disease caused by the lack of or a dysfunctional C1-inhibitor protein. For this reason, the nomenclature has developed to replace the initial use of type 1, 2 or 3 HAE. Instead, the names are HAE with deficient C1-inhibitor (type 1), HAE with dysfunctional C1-inhibitor (type 2), and HAE with normal C1-inhibitor. Though unique in the testing that leads to the diagnosis, they all behave similarly with angioedema.[1]

Etiology

Type I hereditary angioedema (HAE) (HAE with deficient C1-inhibitor) is due to a deficiency in C1 inhibitor. C1 inhibitor is a broad-spectrum serine protease inhibitor that's a member of the serpin superfamily. It inhibits several complement proteases (C1r, C1s, MASP-1, and MASP-2) and contact system proteases (plasma kallikrein and activated Hageman factor [coagulation factors XIIa and XIIf], fibrinolytic protease plasmin and the coagulation protease factor XIa). C1 inhibitor deficiency is due to mutations in the SERPING1 gene. More than 150 different mutations have been identified in patients with HAE. In type, I HAE the different SERPING1 mutations identified were missense, nonsense, frameshift, deletion, and insertion. This results in truncated or misfolded proteins that eventually cannot be secreted, hence a deficiency in C1 INH levels characterizes type 1. While in type 2 (HAE with dysfunctional C1-inhibitor), SERPING1 mutations associated with it include residues at or near the active site on the reactive mobile loop that result in a mutant C1 inhibitor protein that is secreted but dysfunctional. For this reason in type II HAE, the C1 INH antigen level in plasma is normal or even elevated while the protein function is decreased.[1]

Epidemiology

The estimated prevalence is 1 in 50,000.[2][3] The presentation is usually during the first two decades of life, which varies from acquired angioedema with deficient C1-inhibitor that often presents after the fourth decade of life.  A family history of angioedema helps in the diagnosis, but 25% of cases are new spontaneous mutations. Genetic testing is usually not essential since the biologic tests are relatively accurate after the age of 1 year.

History and Physical

The symptoms vary in severity, location, and duration, but the organs involved include the upper airway, skin and gastrointestinal tract. In the latter bowel obstruction creates the symptoms. The skin swelling is deforming, but not pruritic; however, if extreme can be painful. The main fear is upper airway swelling that can proceed to asphyxiation. Fortunately, upper airway involvement accounts for only 1% to 3% of attacks.

The attacks last 2 to 5 days, usually slowly increasing and then resolving even without therapy.  Triggers, such as trauma, infections, stress or procedures are identified in 40% of attacks. Prodromal symptoms, including a rash, referred to as erythema marginatum, occur before the majority of attacks, but the sensitivity and especially specificity are questionable. Other triggers include ACE-inhibitors and estrogens.[4][3]

Evaluation

The tests that are used include C4, which is commonly the initial screening test.[5][6] The confirmatory tests include C1-inhibitor protein and function, which are both low in type 1 HAE. Type 2 HAE has a low function, but normal or excessive quantity of C1-inhibitor that is defective. Type 3 HAE has all normal tests and at this time appears to be composed of patients with a gain of function of Factor 12 of the coagulation pathway and other poorly defined groups of patients that appear to have angioedema from bradykinin but of unknown mechanism. C1q is usually reserved for those with the late-onset disease to exclude acquired angioedema since it is low in most cases of acquired angioedema with deficient C1-inhibitor, but normal in HAE. In all the diseases described above, the cause of the swelling is secondary to overproduction of bradykinin. Angiotensin-converting enzyme inhibitors (ACE-I) also cause angioedema, but in this case secondary to the lack of catabolism of bradykinin.

Treatment / Management

Treatment is unique from angioedema associated with histamine since antihistamines, corticosteroids, and epinephrine have little effect on the swelling. Instead, medications that either inhibitor production of bradykinin or compete with the receptor are utilized. [7][8]Most experts divide therapy into 3 types: treatment of attacks, short-term prevention of attacks and long-term prevention of attacks. The drugs used for treating attacks include ecallantide, icatibant, C1-inhibitor derived from human plasma or recombinant C1-inhibitor. In addition, fresh frozen plasma can be used, but due to allosensitization is avoided unless one of the previous drugs are not available. Because of the short half-life of icatibant and ecallantide neither are effective to prevent attacks. C1-inhibitor obviously works by replacing the dysfunctional or deficit C1-inhibitor, and it has a long half-life and can be used for the treatment of attacks, short-term prophylaxis, such as before a procedure, and long-term prophylaxis to prevent attacks when indicated. Similarly, recent data demonstrate that recombinant C1-inhibitor can be used for attacks and long-term prophylaxis and most experts suspect it is also effective for short-term prophylaxis.[1]

Two other therapies, which have recently fallen out of favor, include antifibrinolytics and androgens. Androgens induce production of C1-inhibitor and are very effective in preventing attacks, but have no benefit in treating an attack. Short-term prophylaxis is tolerated well and is effective for pre-procedure of other short-term events; however, the toxicity of androgens limit their use for long-term prophylaxis. Most experts recommend not exceeding 200 mg of danocrine a day. Adverse effects include hyperlipidemia, obesity, androgenic effects in females, and disposition problems.[9][10]

Antifibrinolytics include tranexamic acid and aminocaproic acid, and both have minimal effectiveness in prevention and treatment of attacks. Presently, multiple other therapies are in the investigation including an oral kallikrein inhibitor and a monoclonal antibody that inhibits kallikrein. Table one includes the drugs that are currently available, and that may be available in the next few years.

Medications Used for Treatment of HAE

In addition to medications, management includes avoidance of triggers, estrogens and ACE-inhibitors and a management plan. The management plan should include long-term prophylaxis if indicated, therapy to use before dental and surgical procedures and a backup plan for treatment of attacks. Most patients should be taught self-treatment to enhance freedom and quality of life. Serial assessment is essential to ensure that morbidity is minimal and therapy is effective.

Differential Diagnosis

While hereditary angioedema is bradykinin-mediated, other types of angioedema can be mediated by histamine or other mechanisms, hence they have different methods of management and differentiating them is crucial for it. Unfortunately, there isn't a single valid diagnostic test to differentiate between histamine-mediated and bradykinin-mediated angioedemas; however, there are some features of each one that can guide the diagnosis and consequently, the treatment.Histamine-Mediated Angioedema

Angioedema secondary to histamine often is associated with urticaria and pruritus. Triggers may include viruses, drugs, food; however, in most chronic cases an external trigger cannot be identified and is often autoimmune mediated. Histamine can be released from mast cells by IgE hypersensitivity, or by non-IgE mediated mechanisms such as opiates, contrast, vancomycin and physical causes such as cold, heat, vibration, pressure, water or sun. Significant abdominal pain is not usual. Most cases are rapid in onset and respond quickly to antihistamines, epinephrine and or steroids. In some cases, the angioedema if refractory and more aggressive therapy such omalizumab or cyclosporine are necessary.  The main distinctions from bradykinin disease are the minimal abdominal complaints, the presence of urticaria, response to antihistamines, rapid onset and resolution, and sometimes, accompanying symptoms and signs of anaphylaxis.

Bradykinin-Mediated Angioedema

Bradykinin-mediated angioedema includes hereditary angioedema, acquired angioedema, and angiotensin-converting enzyme induced angioedema. It is not commonly associated with itching, and urticaria does not occur. It progressives at a slower rate than histamine-mediated angioedema, usually over several hours. If untreated, attacks tend to be more persistent and severe than histamine-mediated attacks, with abdominal involvement in approximately 50% of cases. Although not a proper method for diagnosis, lack of response to treatment with epinephrine, antihistaminics, and corticosteroids can give an important clue for follow up.[11]

Enhancing Healthcare Team Outcomes

Hereditary angioedema is a complex disorder that is best managed by an allergist, immunologist, pulmonologist, and an internist. Once treated these patients may be followed by the primary care provider and nurse practitioner. A multidisciplinary team approach will provide the best patient outcome.

Treatment is unique from angioedema associated with histamine since antihistamines, corticosteroids, and epinephrine have little effect on the swelling. Instead, medications that either inhibitor production of bradykinin or compete with the receptor are utilized.

The primary care providers should educate the patient on avoidance of triggers and consider long term prophylaxis. Most patients should be taught self-treatment to enhance freedom and quality of life. Serial assessment is essential to ensure that morbidity is minimal and therapy is effective.[12][13][14] [Level V]

 


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Hereditary Angioedema - Questions

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During which period of life does hereditary angioedema usually first appear?



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In a patient with known hereditary angioedema, which of the following symptoms would be concerning?



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During an attack of hereditary angioedema, what is the most common blood finding?



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Which of the following is true about hereditary angioedema (HAE)?



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Which of the following can help differentiate non allergic angioedema from anaphylaxis?



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A 17-year-old teenager frequently develops swelling of his face and pharynx. He now presents with difficulty breathing. What is the most likely disease?



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Which of the following is associated with hereditary angioedema?



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A 14-year-old child frequently develops swelling of his buccal mucosa. He now has difficulty with breathing. What disease presents with these findings?



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A 13-year-old female has had repeated episodes of swelling of her feet, hands, and neck. The swelling occurs after exercise or emotional stress and can last up to 3 days. On two occasions, the swelling was accompanied by abdominal pain, diarrhea, and vomiting. Physical exam, CBC, erythrocyte sedimentation rate, and chemistry panel have been normal. An older brother and a paternal uncle have similar symptoms. What is the most likely diagnosis?



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A 10-year-old female presents to the emergency room with a 3-hour history of swelling of the face. She reports that 1 hour prior the onset of the swelling, she felt numbness in that area. She denies past episodes. At the 8 years of age, she had an appendectomy due to abdominal pain however the pathology report came back as normal. Her father mentions that he had episodes of swelling of his hands and feet when he was a teenager which resolved by itself in a couple of days. Her vital signs are normal, and her physical exam is remarkable for nonpitting nontender swelling of her cheeks and lips with no erythema. What is the most reliable and cost-effective screening test to be done?



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A 11-year-old boy presents to the emergency department with a history of vomiting , abdominal pain and facial edema. His mother said that he had experimented swelling of the eye and lips in several occasions. An immunological study was ordered and showed normal B and T cells functions and low levels of C1 inhibitor. What is the most likely diagnosis?



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How can hereditary angioedema be distinguished from acquired angioedema secondary to a lymphoma?



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Which of the following drugs would work well for presurgery prophylaxis in patients with hereditary angioedema?



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What makes the swelling more likely to be secondary to hereditary angioedema?



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Which of the following is a true statement about airway attacks in hereditary angioedema (HAE)?



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Hereditary Angioedema - References

References

Exposure-Response Model of Subcutaneous C1-Inhibitor Concentrate to Estimate the Risk of Attacks in Patients With Hereditary Angioedema., Zhang Y,Tortorici MA,Pawaskar D,Pragst I,Machnig T,Hutmacher M,Zuraw B,Cicardi M,Craig T,Longhurst H,Sidhu J,, CPT: pharmacometrics & systems pharmacology, 2018 Jan 9     [PubMed]
Angioedema in the emergency department: a practical guide to differential diagnosis and management., Bernstein JA,Cremonesi P,Hoffmann TK,Hollingsworth J,, International journal of emergency medicine, 2017 Dec     [PubMed]
Lumry WR, Overview of epidemiology, pathophysiology, and disease progression in hereditary angioedema. The American journal of managed care. 2013 Jun;     [PubMed]
Zuraw BL, Clinical practice. Hereditary angioedema. The New England journal of medicine. 2008 Sep 4;     [PubMed]
Frank MM,Gelfand JA,Atkinson JP, Hereditary angioedema: the clinical syndrome and its management. Annals of internal medicine. 1976 May;     [PubMed]
Cicardi M,Zuraw BL, Angioedema Due to Bradykinin Dysregulation. The journal of allergy and clinical immunology. In practice. 2018 Jul - Aug;     [PubMed]
Mehmood A,Abdullah HMA,Inayat F,Ullah W, Wolf in the sheep's clothing: intestinal angioedema mimicking infectious colitis. BMJ case reports. 2018 Dec 13;     [PubMed]
Buttgereit T,Maurer M, [Classification and pathophysiology of angioedema]. Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete. 2019 Feb;     [PubMed]
Hahn J,Bock B,Muth CM,Pfaue A,Friedrich D,Hoffmann TK,Greve J, [The ulm emergency algorithm for the acute treatment of drug-induced, bradykinin-mediated angioedema]. Medizinische Klinik, Intensivmedizin und Notfallmedizin. 2018 Sep 19;     [PubMed]
Henry Li H,Riedl M,Kashkin J, Update on the Use of C1-Esterase Inhibitor Replacement Therapy in the Acute and Prophylactic Treatment of Hereditary Angioedema. Clinical reviews in allergy     [PubMed]
Giavina-Bianchi P,Kalil J, Improving the Management of Hereditary Angioedema. Clinics (Sao Paulo, Brazil). 2018 May 17;     [PubMed]
Agboola F,Lubinga S,Carlson J,Lin GA,Dreitlein WB,Pearson SD, The Effectiveness and Value of Lanadelumab and C1 Esterase Inhibitors for Prophylaxis of Hereditary Angioedema Attacks. Journal of managed care     [PubMed]
Riedl MA,Banerji A,Manning ME,Burrell E,Joshi N,Patel D,Machnig T,Tai MH,Watson DJ, Treatment patterns and healthcare resource utilization among patients with hereditary angioedema in the United States. Orphanet journal of rare diseases. 2018 Oct 12;     [PubMed]
Cardarelli WJ, Economic burden limiting proper healthcare delivery, management, and improvement of patient outcomes. The American journal of managed care. 2018 Aug;     [PubMed]

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