C1 Esterase Inhibitor (human) - University of Washington
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Transcript C1 Esterase Inhibitor (human) - University of Washington
C1 ESTERASE
INHIBITOR (HUMAN)
For the prevention and treatment of
acute attacks of Hereditary Angioedema
Reid Nakagawa
November 31, 2013
OUTLINE
Hereditary Angioedema
Definition
Clinical Manifestations
Epidemiology
Treatment
Pathophysiology
C1 esterase inhibitor (human)
Indications & Usage
Dosing & Administration
Mechanism of Action
Pharmacokinetics
Drug Interactions
Adverse Effects
Precautions
Pregnancy & Lactation
Reconstitution
Place in Practice
ANGIOEDEMA
Angioedema is the result of localized blood vessel dilation and increased
permeability that causes rapid swelling of the subcutaneous, mucosal,
and submucosal tissues.
Hereditary Angioedema Triggers:
Dental work, trauma, anxiety, stress, etc.
Attacks can occur spontaneously in the absence of triggers
EPIDEMIOLOGY
Affects approximately 1 in 50,000 individuals (1:10,000 – 1:150,000)
Males and females are affected equally
The prevalence of HAE is highest in Europe and North America
Mean age of onset is 8 to 12 years
75% experience first attack by the age of 15 years
PATHOPHYSIOLOGY
Hereditary Angioedema (HAE) is an autosomal dominant disorder
where there is a deficiency or dysfunction in endogenous C1 esterase
inhibitor (C1-INH)
Type 1: deficiency in C1-INH (~85%)
Type II HAE: dysfunctional CI-INH (~15%)
HAE with normal C1-INH: mutations in Factor XII?
Acquired C1-INH deficiency: associated with autoimmune disorders
C1 esterase inhibitor (C1-INH) is a member of the serine protease
inhibitors “serpin” superfamily. It is an inhibitor of the kinin-generating,
coagulation, and fibrinolytic pathways.
CLINICAL MANIFESTATIONS
Prodromal symptoms: fatigue, irritability, nausea, myalgias, flu-like
symptoms, erythema marginatum
Affected areas: Skin, GI tract, GU tract, and upper airway
Edema involves the subcutaneous, mucosal, and submucosal tissues
Urticaria and pruritis are absent,
Severity: inconvenient cutaneous edema - life-threatening laryngeal edema
Duration of attacks: 48-96 hours
TREATMENT
Patients with HAE tend not to respond to epinephrine, antihistamines,
or glucocorticoids
Plasma kalikrein inhibitor
Ecallantide (Kalbitor)
Bradykinin receptor antagonist
Icatibant acetate (Firazyr)
C1 esterase inhibitor
C1 esterase inhibitor, human (Cinryze, Berinert)
C1 ESTERASE INHIBITOR
C1 ESTERASE INHIBITOR
INDICATIONS & USAGE:
For routine prophylaxis against angioedema attacks in adolescent and adult patients
with Hereditary Angioedema (Cinryze).
For the treatment of acute abdominal, facial, or laryngeal attacks of Hereditary
Angioedema in adult and adolescent patients (Berinert).
MECHANISM OF ACTION
PHARMACOKINETICS / DYNAMICS
Single Dose
Double Dose
Cbaseline (units/mL)
0.31 +/- 0.20
0.33 +/- 0.20
Cmax(units/mL)
0.68 +/- 0.08
0.85 +/- 0.12
Tmax (hours)
3.9 +/- 7.3
2.7 +/- 1.9
T1/2 (hours)
56 +/- 36
62 +/- 38
Onset of action: 1 hour or less
Vd: 0.43 dL/kg
No known drug-drug interactions
PRECAUTIONS
Severe hypersensitivity reactions may occur.
CONTRAINDICATION
Thrombotic Events
Thrombotic events have been reported following the administration of high doses of
CI-INH
Transmissible Infectious Agents
C1-INH has the risk of transmitting infectious agents, e.g. HIV, HepC, CJD, etc.
ADVERSE EFFECTS
Common
Headache
7.0% - 28%
Nausea
1.8% - 18%
Rash
3.5% - 10%
Sinusitis
5% or greater
URI
1.8% or greater
Serious
Hypersensitivity
MI
DVT
CVA
PE
PREGNANCY & BREASTFEEDING
Pregnancy Category: C (All Trimesters)
No animal data are available
No adequate and well-controlled studies were conducted in pregnant women
C1-INH should be given to pregnant women only if clearly needed
Breastfeeding:
It is not known whether C1-INH is excreted in breast milk
Caution should be exercised when C1-INH is administered to a nursing mother
STORAGE AND HANDLING
Storage: 2 C – 22 C (36 F – 77 F)
O
O
O
O
Do not freeze
Store the vial in the original container to protect it from light
RECONSTITUTION
DOSING & ADMINISTRATION
For intravenous use only.
Can be given as either an IV push over 10 minutes or as an IV drip over
10 minutes
Administer within 3 hours of reconstitution
HAE, Prophylaxis (Cinryze):
1,000 Units IV push/infusion over 10 minutes Q3 - 4 days
HAE, abdominal, facial, or laryngeal attacks (Berinert):
20 International Units/kg IV infusion at a rate of approximately 4 mL/min
TRADITIONAL PLACE IN PRACTICE
Prophylaxis
The use of C1-INH for prophylaxis against Hereditary Angioedema attacks has been
established
C1-INH can either be administered by a healthcare provider in clinic or
self-administered by the patient at home
Treatment
For acute attacks of HAE in patients presenting to the Emergency Department
Cinryze is FDA approved for treatment of HAE, but has been studied
Dosing: 1,000 units IV over 10 minutes; 2nd dose may be administered 60 minutes after first
dose if no improvement in symptoms is seen
- or 20 units/kg IV; rate not to exceend 4 mL/min
EFFICACY
EFFICACY
TREATMENT TRIAL
37 sites, N = 68 patients
Study drug : 35 patients
1,000 units (10 mL) IV over 10 minutes; repeat x 1 if no symptomatic relief after 60 minutes
Placebo: 33 patients
10 mL NS over 10 minutes
Primary Endpoint
Time from administration of the study drug to unequivocal relief of symptoms at the
defining site
Secondary Endpoints
Percentage of subjects who had an onset of unequivocal relief of symptoms w/in 4
hours after receiving treatment
Time to complete resolution of the attack
TREATMENT TRIAL
Median time to symptom relief
2 hours VS 4 hours
(CI: 1.17 – 4.95) P =0.02
Percentage of subjects with onset of
relief within 4 hours
60% VS 42%; P =0.06
Time to complete resolution of attack
12.3 hours VS 25.0 hours; P =0.004
PROPHYLAXIS TRIAL
N = 22 patients
24 week crossover
Primary Endpoint
Number of attacks of angioedema during each treatment period
Average severity of attacks (on a scale of 1-3)
1-mild
2-moderate
3-severe
Average duration of attacks
Number of open label injections of C1-INH
Total number of days of swelling
PROPHYLAXIS TRIAL
Number of angioedema attacks
6.26 VS 12.73
(CI: 4.21 – 8.73) P<0.001
Average severity of attacks
1.3 +/- 0.85 VS 1.9 +/- 0.36 P<0.001
Average duration of attacks
2.1 +/- 1.13 d VS 3.4 +/- 1.39 d P=0.002
Number of open-label injections
4.7 +/- 8.66 VS 15.4 +/- 8.41 P<0.001
Total number of days of swelling
10.22 +/- 10.73 d VS 29.6 +/- 16.9 d
P<0.001
NEXT FRONTIER
C1-INH in patients with HAE with normal C1-INH levels
Patients are usually refractory to epinephrine, antihistamines, and glucocorticoids
C1-INH has been used in these patients to presumably raise the set point for
activation of kallikrein and generation of bradykinin.
Further research is needed to validate its use in this patient population
C1-INH in patients with Idiopathic Angioedema
2 main types
Histaminergic angioedema
Bradykinergic angioedema
Most patients do not respond to epinephrine, antihistamines, and glucocorticoids
The use of C1-INH in this patient population is currently being discussed by experts
QUESTIONS
REFERENCES
Berinert [package insert]. Kankakee, IL: CSL Behring LLC; 2012
Cinryze [package insert]. Exton, PA: ViroPharm Biologics, Inc.; 2010-
2013.
Lang DM, Aberer W, Bernstein JA, et al. International Consensus on
Hereditary and Acuired Angioedema. Ann Allergy Asthma Immunol
2012;109:395-402.
Zuraw BL, Busse PJ, White M, et al. Nanofiltered C1 Inhibitor
Concentrate for Treatment of Hereditary Angioedema. N Engl J Med
2010;363: 513-22.