WAO Global Hereditary Angioedema (HAE) Practice Parameter Timothy J. Craig, DO Professor of Medicine and Pediatrics Distinguished Educator Chief, Allergy, Asthma, and Immunology Program Director Director of Clinical Allergy and Respiratory Research Pennsylvania State University College of Medicine Hershey, Pennsylvania, USA WAO Global Hereditary Angioedema Practice Parameter Chair: Tim Craig, USA General Advisor: Richard F. Lockey, USA Steering Committee Members: Konrad Bork, Germany Tom Bowen, Canada Henrik Boysen, Belgium Marco Cicardi, Italy Henriette Farkas, Hungary Anete Grumach, Brazil (SLAAI) Connie Katelaris, Australia (APAAACI) Hilary Longhurst, UK William Lumry, USA (ACAAI) Marcus Maurer, Germany (EAACI) Bruce Ritchie, Canada Bruce Zuraw, USA (AAAAI) Emel Aygören Pürsün, Germany Inmaculada Martinez-Saguer, Germany Sponsors of the WAO HAE Program Company Financial Supporter CSL Behring XX Dyax XX Viropharma XX Shire XX (via Jerini) Pharming (did not yet have a product on the market) WAO Global Hereditary Angioedema Practice Parameter OBJECTIVES: 1. Produce an evidence based guideline for care of HAE patients throughout the world 2. Develop a document that would be a reference for HCP 3. To develop a document that could be used at the bedside 4. Have a document that could be utilized in all countries 5. Develop a guideline that would be approved by the global allergy community 6. Develop a power point program for use by all members of the WAO 7. Lastly, and most importantly, to improve care for the patients with Hereditary Angioedema and to improve access of therapies to all patients, in all countries around the world. Is there a need for this? Active Cleaved: Inactive What Is C1-Inhibitor? Human plasma protein …that mediates inflammation Key regulator of four biochemical pathways 1. 2. 3. 4. Complement Contact Fibrinolytic Coagulation C1-Inhibitor deficiency can cause: – debilitating pain – disfiguring swelling – asphyxiation & death Autosomal Dominant Defect Crowder JR, Crowder TR. Five generations of angioneurotic edema. Arch Inter Med 1917; 20:840-52 HAE Is Caused By C1 Inhibitor Mutations Bissler JJ, et al. Proc Assoc Am Physicians. 1997;109:164-173. Davis AE 3rd. Annu Rev Immunol. 1988;6:595-628. Verpy E, et al. Am J Hum Genet. 1996;59:308-319. Zuraw BL, Herschbach J. J Allergy Clin Immunol. 2000;105:541-546. C1-INH involved in 3 systems → C1-INH depletion Factor XIIa C1-INH Factor XII Contact System C1-INH Prekallikrein HMW-K Kallikrein Increased vascular permeability ANGIOEDEMA Complement System C1rs Plasminogen Bradykinin C1 Plasmin Fibrinolytic System C4 C2 C1INH Null Mice and Vascular Permeability C1INH gene B2BKR gene Evans blue C1INH therapy +/+ +/+ No No +/+ +/+ Yes No -/+/+ Yes No Adapted from Han ED, et al. J Clin Invest. 2002;109:1057-1063. -/+/+ Yes Yes -/-/Yes No In Vivo Generation of Kinins in HAE From Nussberger J, et al. J Allergy Clin Immunol. 1999;104:1321-1322; with permission. How Does BK Cause Angioedema? Increased vascular permeability VE-cadherin Actin stress fibers Nonstimulated Stimulated From Tiruppathi C, et al. Vascul Pharmacol. 2003;39:173-185; with permission. Common triggers of HAE attacks Trauma Menstruation Angioedem Angioedema a attack Infection Medications Stress Treatment of HAE • Conceptually divide into three categories – Long-term prophylaxis • Minimize attack frequency and severity • Prevent hospitalizations and emergency room visits – Short-term prophylaxis • Prevent attacks after trauma • Prevent attacks during important life events – Treatment of acute attacks • Terminate ongoing attack • Prevent morbidity and mortality Therapeutic Implications PK Adapted from Zuraw BL. Immunol Allergy Clin North Am. 2006;26:691-708. Drug Advantages Disadvantages Best use Status Plasmaderived C1-INH • Extensive clinical experience • Corrects the fundamental defect • long half-life • Infectious risk • Needs IV access • Limited supply • Acute attacks • Short-term • Long-term prophylaxis • Prodromes • Berinert P: approved in EU, USA, Canada, Argentina • Cinryze: approved in EU, USA • Cetor in the EU, Turkey Recombinant C1-INH • Corrects the fundamental defect • No human virus risk • Scalable supply • Needs IV access • Short half-life • Potential for allergic reactions • Acute attacks • Short prophylaxis • Prodrome? • Rhucin: approved in the EU Ecallantide • More potent than C1-INH • No infectious risk • Subcutaneous administration • Antibodies may cause allergic reaction or neutralization • Short half-life • Acute attacks in office • Kalbitor: approved in the USA Icatibant • No infectious risk • Stable at room temperature • Subcutaneous • Short half-life • Local pain or irritation • Home treatment of acute attacks? • Firazyr: approved in EU, USA, Brazil In Summary Global document is now being evidence based From here it will go to the steering committee for approval Than it will go to WAO leadership Finally out to all the Allergy Associations for their approval Power Point slides will go through the same process Thank you. Questions? tcraig@psu.edu