Hereditary Angioedema Medication

Updated: Aug 30, 2018
  • Author: Michael M Frank, MD; Chief Editor: Michael A Kaliner, MD  more...
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Medication

Medication Summary

The goals of pharmacotherapy for hereditary angioedema (HAE) are to reduce morbidity and to prevent complications. Medication may be used for acute or preventive treatment.

In Europe, purified C1 inhibitor (C1-INH) has been available for treatment of acute attacks for decades, but it has not been available in the United States until recently. [13, 38, 39] In October 2008, the US Food and Drug Administration (FDA) approved the use of C1-INH (Cinryze) at a dose of 1000 units IV 2-3 times/week for prophylaxis to prevent attacks. In October 2009, the FDA approved C1-INH (Berinert) at a dose of 20 units/kg IV for the treatment of acute abdominal and facial angioedema attacks in adolescents and adults with HAE. [7] In January 2012, an additional indication for laryngeal angioedema was approved by the FDA. Use was expanded to include children younger than 12 years in July 2016. The first subcutaneous C1-INH concentrate (Haegarda) was approved by the FDA in June 2017 for HAE prophylaxis in adults and adolescents. [51]

The recombinant C1 esterase inhibitor (rhC1-INH), Ruconest, was approved by the FDA in July 2014. It is indicated for adolescents and adults to treat acute attacks of HAE. Effectiveness was not established in patients with HAE that involved laryngeal attacks. Approval was supported by a phase 3 trial (n=75) that showed relief of symptoms of HAE attacks was achieved faster with rhC1-INH compared with placebo as assessed by patient questionnaire and visual analog scale. [2, 3]

Berinert and Ruconest are also approved for patient self-administration after proper training by a healthcare professional.

In December 2009, ecallantide (Kalbitor), a kallikrein inhibitor, at a dose of 30 mg SC was approved for the treatment of acute attacks. [8] A 2013 study showed that ecallantide can be safely used to treat multiple episodes of acute HAE. [28] The trial involved 147 patients who received treatment for 625 HAE episodes. Patients received ecallantide 30 mg SC for acute HAE attack symptoms, with no limit on the number of episodes treated. [28] The primary end point was change in patient-reported mean symptom complex severity (MSCS) score at 4 hours. Results showed no reduction of efficacy with repeated use of ecallantide. In addition, no new safety signals were detected. [28]

In August 2011, icatibant (Firazyr), a selective bradykinin B2 receptor antagonist, was approved for treatment of acute attacks of HAE in adults at a dose of 30 mg SC in the abdominal area.

In August 2018, the FDA approved lanadelumab, a monoclonal antibody that targets kallikrein, for prophylaxis of HAE. Approval was based on the HELP clinical trial which investigated the efficacy and safety of lanadelumab for long-term prophylaxis against angioedema attacks in hereditary angioedema (HAE). Of 125 patients, 113 completed the trial. All lanadelumab dosing regimens significantly reduced the mean monthly attack rates of HAE compared to placebo (P < 0.001) over the 26-week duration of the study. The 300 mg SC every 2 week regimen reduced attacks by 92.8% from baseline in patient with < 2 attacks per month and by 88.2% in patients whose baseline was 2 to < 3 attacks per month. [52]

Purified C1-INH, fresh frozen plasma (FFP), or attenuated androgen is given prophylactically prior to surgery.

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Blood Products

Class Summary

These agents are used to improve the clinical aspects of the disease.

Fresh frozen plasma

Infuse prior to airway manipulation (eg, dental extraction) to prevent angioedema. Administering 2 units of FFP sustains complement control and prevents development of angioedema. Improved screening programs greatly reduce risk of hepatitis. FFP is not recommended for treatment of acute attacks.

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Androgens and Androgen Derivatives

Class Summary

Some agents in this class may increase levels of C1 inhibitor and C4 component of complement. [40, 41, 42]

Danazol (Danocrine)

Danazol reduces the frequency of attacks in most patients, especially those involving the airway. For prophylaxis, the dose is adjusted to lowest dose that controls symptoms.

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C1-Inhibitor Concentrates

Class Summary

Depending on the particular brand, these concentrates are approved by the U.S. FDA for routine prophylaxis against angioedema attacks and as treatment for acute attacks.

C1 esterase inhibitor recombinant (Ruconest)

Human recombinant C1 esterase inhibitor purified from the milk of genetically modified (transgenic) rabbits; restores level of functional C1 esterase inhibitor in a patient’s plasma, thereby treating the acute attack of swelling. It is indicated for treatment of acute HAE attacks in adults and adolescents. It is administered as an IV infusion over 5 minutes.

 

C1 inhibitor human (Berinert, Cinryze, Haegarda)

Serine proteinase inhibitor that increases plasma concentration of C1 inhibitor activity. Berinert is indicated for treatment of acute abdominal, facial, or laryngeal attacks of HAE in adults and children. Cinryze and Haegarda are indicated for routine prophylaxis in adults and adolescents. Berinert and Cinryze are administered as an IV infusion, whereas, Haegarda is administered as a SC injection.

C1 inhibitor human (Berinert, Cinryze, Haegarda)

Serine proteinase inhibitor that increases plasma concentration of C1 inhibitor activity. Berinert is indicated for treatment of acute abdominal, facial, or laryngeal attacks of HAE in adults and children. Cinryze and Haegarda are indicated for routine prophylaxis in adults and adolescents. Berinert and Cinryze are administered as an IV infusion, whereas, Haegarda is administered as a SC injection.

C1 esterase inhibitor recombinant (Ruconest)

Human recombinant C1 esterase inhibitor purified from the milk of genetically modified (transgenic) rabbits; restores level of functional C1 esterase inhibitor in a patient’s plasma, thereby treating the acute attack of swelling. It is indicated for treatment of acute HAE attacks in adults and adolescents. It is administered as an IV infusion over 5 minutes.

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Kallikrein Inhibitors

Class Summary

Kallikrein converts kininogen to bradykinin. Bradykinin is a potent vasodilator that increases vascular permeability resulting in swelling and pain associated with HAE. Arresting this conversion can be used for treatment and prophylaxis of HAE.

Ecallantide (Kalbitor)

A human plasma kallikrein inhibitor, ecallantide binds to plasma kallikrein and blocks its binding site. It reduces conversion of kininogen to bradykinin. This agent is indicated for acute attacks of HAE. It is available as an injectable solution; 10 mg/mL per single-use vial.

Lanadelumab (Takhzyro, lanadelumab-flyo)

Human monoclonal antibody (IgG1 kappa-light chain) that targets plasma kallikrein and inhibits proteolytic activity to control excess bradykinin generated with HAE. It is indicated for prophylaxis to prevent attacks of HAE in adults and adolescents aged 12 years or older. Self-administered as a SC injection every 2-4 weeks.

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Bradykinin Receptor Antagonists

Class Summary

Bradykinin receptor antagonists such as icatibant inhibit bradykinin from binding the B2 receptor and thereby treat the clinical symptoms of an acute attack. Recommended dose of icatibant is 30 mg SC in the abdominal area. It is available as a single-use, prefilled syringe, which delivers a dose of 30 mg (10 mg/mL).

Icatibant (Firazyr)

Bradykinin B2 receptor antagonist indicated for acute attacks of hereditary angioedema (HAE).

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Antifibrinolytic Agents

Class Summary

These agents act through the inhibition of plasmin. They are potent inhibitors of fibrinolysis and can reverse states that are associated with excessive fibrinolysis. [19]

Aminocaproic acid (Amicar)

Aminocaproic acid is a lysine analog that inhibits fibrinolysis via inhibition of plasminogen activator substances; to a lesser degree, through antiplasmin activity.

It is widely distributed. Half-life is 1-2 h. For inhibition of angioedema, several days of treatment may be required. Hepatic metabolism is minimal. This agent can be used PO/IV.

Tranexamic acid (Cyklokapron)

An alternative to aminocaproic acid, tranexamic acid inhibits fibrinolysis by displacing plasminogen from fibrin.

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