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认识和管理一种罕见的血管性水肿的重要性:C1 抑制剂缺乏引起的遗传性血管性水肿。

The importance of recognizing and managing a rare form of angioedema: hereditary angioedema due to C1-inhibitor deficiency.

机构信息

Department of Clinical Research, Allergy and Asthma Clinical Research, Inc., Walnut Creek, CA, USA.

Department of Internal Medicine, Northern CA VA Health Care System, Martinez Outpatient Clinic, Martinez, CA, USA.

出版信息

Postgrad Med. 2021 Aug;133(6):639-650. doi: 10.1080/00325481.2021.1905364. Epub 2021 Jul 6.

Abstract

The majority of angioedema cases encountered in clinical practice are histamine-mediated (allergic); however, some cases are bradykinin-related (non-allergic) and do not respond to standard anti-allergy medications. Among bradykinin-related angioedema, hereditary angioedema (HAE) is a rare, but chronic and debilitating condition. The majority of HAE is caused by deficiency (type 1) or abnormal function (type 2) of the naturally occurring protein, C1-inhibitor (C1-INH)-a major inhibitor of proteases in the contact (kallikrein-bradykinin cascade), fibrinolytic pathway, and complement systems. Failure to recognize HAE and initiate appropriate intervention can lead to years of pain, disability, impaired quality of life (QoL) and, in cases of laryngeal involvement, it can be life-threatening. HAE must be considered in the differential diagnosis of non-urticarial angioedema, particularly for patients with a history of recurrent angioedema attacks, family history of HAE, symptom onset in childhood/adolescence, prodromal signs/symptoms before swellings, recurrent/painful abdominal symptoms, and upper airway edema. Management strategies for HAE include on-demand treatment for acute attacks, short-term prophylaxis prior to attack-triggering events/procedures, and long-term or routine prophylaxis for attack prevention. Patients should be evaluated at least annually to assess need for routine prophylaxis. HAE specific medications like plasma-derived and recombinant C1-INH products, kallikrein inhibitors, and bradykinin B2 receptor antagonists, have improved management of HAE. While the introduction of intravenous C1-INH represented a major breakthrough in routine HAE prophylaxis, some patients fail to achieve adequate control and others have psychological barriers or experience complications related to intravenous administration. Subcutaneous (SC) C1-INH, SC monoclonal antibody (mAb)-based therapies, and an oral kallikrein inhibitor offer effective alternatives for HAE attack prevention and may facilitate self-administration. HAE management should be individualized, with QoL improvement being a key goal. This can be achieved with broader availability of existing options for routine prophylaxis, including greater global availability of C1-INH(SC), mAb-based therapy, oral treatments, and multiple on-demand therapies.

摘要

在临床实践中遇到的大多数血管性水肿病例都是由组胺介导的(过敏);然而,有些病例与缓激肽有关(非过敏),且对标准抗过敏药物没有反应。在与缓激肽相关的血管性水肿中,遗传性血管性水肿(HAE)是一种罕见但慢性和使人衰弱的疾病。大多数 HAE 是由天然存在的蛋白质 C1 抑制剂(C1-INH)的缺乏(1 型)或异常功能(2 型)引起的,C1-INH 是接触(激肽-缓激肽级联)、纤维蛋白溶解途径和补体系统中蛋白酶的主要抑制剂。未能识别 HAE 并启动适当的干预可能导致多年的疼痛、残疾、生活质量受损(QoL),并且在喉部受累的情况下,可能危及生命。在非荨麻疹性血管性水肿的鉴别诊断中必须考虑 HAE,特别是对于反复发作的血管性水肿发作史、HAE 家族史、儿童/青少年发病、肿胀前前驱症状/症状、反复发作/疼痛的腹部症状和上呼吸道水肿的患者。HAE 的管理策略包括急性发作的按需治疗、发作触发事件/程序前的短期预防、以及预防发作的长期或常规预防。患者应至少每年评估一次,以评估常规预防的需求。HAE 特异性药物,如血浆衍生和重组 C1-INH 产品、激肽抑制剂和缓激肽 B2 受体拮抗剂,改善了 HAE 的管理。虽然静脉内 C1-INH 的引入代表了常规 HAE 预防的重大突破,但有些患者无法实现充分控制,而有些患者则存在心理障碍或与静脉内给药相关的并发症。皮下(SC)C1-INH、SC 单克隆抗体(mAb)为基础的治疗和口服激肽抑制剂为 HAE 发作预防提供了有效的替代方案,并可能促进自我给药。HAE 的管理应个体化,改善生活质量是关键目标。这可以通过更广泛地提供常规预防的现有选择来实现,包括更广泛地提供 SC 中的 C1-INH、基于 mAb 的治疗、口服治疗和多种按需治疗。

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