Long-term prophylaxis with C1-inhibitor (C1 INH) concentrate in patients with recurrent angioedema caused by hereditary and acquired C1-inhibitor deficiency

rophylaxis with centrate in pati current angioedema caused acquired Cl-inhibitor deficient Bork, MD, and Giinther Witzke, Mainz, Federal Republic of Germany

PhD

A case of hereditary angioedema (HAE) type I (inherited Cl -inhibitor [Cl INH] deficiency) and a case of late-onset acquired Cl INH with angioedema is described. In both patients, long-term prophylaxis with Cl INH had become necessary because treatment with danazol and e-aminocaproic acid was not eflective or not tolerated. Consequently, both patients received a pasteurized concentrate of Cl INH continuously for a period of 1 year in a dosage that kept them free of symptoms. The patient with HAE was administered 500 units of C1 INN intravenously every 4 or 5 days, whereas the patient with acquired angioedema required IO00 units of Cl INH every 5 days. As a result of this long-term prophylaxis, both patients became free or nearly free from their episodes of cutaneous and internal edema. The low plasma levels of CI INN, C4, and C2, rose. In the patient with acquired CI INH deficiency, the swellings increasingly reappeared after IO months, although the patient’s antibody titer did not rise during treatment. No side effects were recorded during therapy. In particular, both patients remained HIV and hepatitis B antibody negative. (J ALLERGY CLINIMMUNOL1989;83:677-82.)

The plasma serpins are proteins that form a tight I : 1 complex with their target protease;the complex is later removed from the circulation and catabolized. Cl-esterase inhibitors (Cl INH) that can inactivate kalli~ei~~ plasmin, Clr, Cls, and the activated coagulation factors XII and XI (Fig. 1) belongs to this superfamily of proteins. HAE is associated with a deficiency of functionally active Cl INH in the blood . This biochemical abnormality was demonto be inherited in an autosomaldominant manner and to be heterogeneousat the biochemical level. Immunochemical studies have defined two major forms of Cl INH deficiency. The predominant form AE type I, common form) is characterizedby reuced tevels of C 1 INH protein causedby a decreased synthetic rate of functional Cl INH.’ Individuals af-

From the Department of Dermatology, Johannes Gutenberg University, Mainz, Federal Republic of Germany. Presented in part at the Eleventh Congress of the International Society on Thrombosis and Haemostasis, Brussels, Belgium, July S-10, 1987. Received for publication Feb. 10, 1988. Accepted for publication Aug. 27, 1988. Reprint requests: Konrad Bork, MD, Department of Dermatology, Johannes Gutenberg University, Langenbeckstrasse 1, 6500 Mainz, Federal Republic of Germany.

Abbreviations used

Cl INH: Inhibitor of first componentof cornHereditaryangioedema CH,,: Total hemolyticcomplement EACA: E-Aminocaproic acid HAE:

fected with the variant form of the disease(HAE type II) have normal or raised C 1 INH protein concentrations but synthesizea functionally defective Cl INI-I species.24 Thns, the low levels of functional Cl INH activity in HAE result from either deficient or defective C 1 INH synthesis. Both types of IIAE are further characterizedby low or absent titers of C2 and Crl, by low CHSo,by the presence of a positive family history, and the onset of symptoms in childhood or early adolescence.The pathogen&s of edema formation is not clearly understood. The reduced levels of functional Cl INH can lead to uEcon~oll~d activation of the classic pathway of complement. This may elicit rise to the release of a C2 kinin5* ’ and/or contact system activation with release of bradykinin7-9that have been assumedto cause the increased vascular permeability responsible for the clinical symptoms.

Bark and Wit&e

who suffer from severe edemaof the internal ~rg~s, require treatment. Peripheral cutaneousedemasof the extremities or of the trunk do not need to be treated. The therapy of choice in acute attacks co~si~ts of replacementtherapy with commercially available C linhibitor concentrates (e.g., Cl-i~act~vator P,

ringwerke AG, MarburgfLahn, West German

[7 I Ci-INH

with fresh, frozen plasma.‘6-‘g En lice-~reat~~i~g ci-Iw

I

C4 C2

i FIG. 1. Inhibition of the initial phases and activation of the coagulation, fibrinolytic, kinin, and complement systems v CT INH.

Characteristics of the rare acquired angioedema are low or absent levels of Cl INH, Clq, Cl, C4, and C2, a low C&,, the lack of heredity, and the onset

of symptoms in middle age. In contrast to HAE, the synthesis of Cl INH is normal or slightly elevated. Increasedactivation of Cl is proposedto bring about accelerated catabolism of Cl INH in this type of acquired angioedema.‘Ox” In all cases, underlying dis-

easeswere reported, nearly all of which consisted of benign or malignant lymphoproliferative disorders or B cell abnormalities with autoantibody production. ‘*

The literature now contains articles of approximately 35 cases of this type. Recently, a new type of acquired

Cl INH deficiency has beenreported.13-Ls Thesecases differ from the other reported casesof acquired angioedema in the following respects:First, no associated diseases,especially no malignant or benign lymphoproliferative disordersor B cell abnormalities with anti-idiotypical

antibodies, could be identified. Sec-

ond, the levels of Cl INH protein were only slightly reduced (60% to 70% of normal; in the other forms of acquired angioedema, usually
progressto glottis edema,or thosepatients

cases, intubation and other intensive care measures may become necessary,depending on the symptoms and the location of the edema. Prophylaxis is necessary in patients who suffer from frequent and/or severe edema. The medication of choice is danazol (e.g., Winobanin, Winthrop GmbH, Norderst~dt, West Germany), 50 to 600 mg daily. ~a~azol is a synthetic androgen.The mode of action is not known for certain. Stanazololhasalsobeentried successfuily. Another possibility is the prophylactic regimen with antifibrinolytic agents, such as EACA or tr~examic acid. In this article, we describetwo patients in whom long-term prophylaxis with C 1 INIi co~~eutrate~was necessarysince it was impossible to resort to danazol or EACA.

For complementinvestigation, plasmawas separatedand tested immediately. The Cl INH, C3, and C4 protein levels were measuredantigenically by standardradioi~~~odiffusion with Partigen M plates (Be~n~we~ke AC). Serum levels of CH,, were determined according to the methodof Heinz et al.*OFunctionally active Cl and C2 were measuredon a molecular basis according to ehe method of Rapp and Borsos.” Cl INH functional activity was estimated according to the method of Alsenz and Lo~s.~’ The presence of anti-cl INH antibodies was established by the use of an ELISA with purified Cl INH, as described elsewhere.I5 For replacement therapy, a concentrate of purified CI INH (Cl-inactivator P, Behringwerke AG,) was used. For this, Cl-inactivator was adsorbed out of the plasma by meansof an ion exchanger, eluted, and then stabilized and heat treated in aqueoussolution at 60” C for IO hours (pasteurization). The heat treatment was followed by further purifications by hydrophobic chromatography on phenylsepharose.The final product, Cl-inactivator P, hasa specific activity of 60 Uimg of protein.” One vial contains 500 units that correspondsto the Cl INH activity present in 500 ml of pooled plasma. Immunization testsin rabbits and guinea pigs yielded no evidencethat the pasteurizaGonprocesselicits rise to new antigenic structures.24For laboratory expcriments, samplesof the Cl-inactivator solution were *&ken from a production batch before heat treatment. After adding sucrose and glycine as stabilizers, these samples were mixed with a defined amount of the particuliar virus to be tested, stirred well, and then incubated at SO” C. Samples were taken before and at various times during

VOLUME E3 NUMBER 3

mg/dl

Duration of replacement therapy

Ci-INH

0

mber of cutaneous

oedemas

1 2 3 4

7 8

5

6

9 10 11 12 months

FIG. 2. Course of the disease and levels of Cl INH (0) and C4 (A) in patient No. 1 during replacement therapy (=) with 500 units of Cl INH concentrate every 4 or 5 days. Normal range of Cl INH, 15 to 35 mg/dl. Normal range of C4, 20 to 50 mgidl.

pasteurization for titration of infectious virus. These experiments demonstratedthat pasteurization at 60” C for 10 hours effectively inactivates HIV-I, Epstein Barr, cytomegalovirus, herpessimplex, poliovirus, and Rous sarcoma virus.*s~*’ The treatmentwith Cl INH concentrateis highly expensive. In Europe, the cost of one vial is approximately $550.00.

RESULTS Patient

No. 1

Casehistory. A 47-year-old white man was first observed for assessmentof HAE. Attacks began at the ageof 9 years and occurred on an averageevery 3 to 4 weeks, sometimes even more often. The episodeswere characterizedby massive cutaneous swelling, often in the face, or by colicky abdominal pains lasting 2 to 6 days. Twelve attacksof lifethreatening laryngeal edemarequired admission with oxygen therapy to the intensive care unit. The family history revealed similar edemasin his mother, who died from, laryngeal edema when she was 52 years of age. All the patient’s eight siblings died from laryngeal edemabefore they reached the age of 10 years. The diagnosis of HAE was madein 1974 and establishedby low or absentCl INH and C4 semm levels. The patient was treated with danazol, of which a dose of 400 mg daily was necessaryto control the symptoms. Lower doseswere ineffective. This dose led to moderatesymptomaticimprovement with no further serious

attacksof angioedema.After 6 months of therapy, the patient refused further treatment with danazol becausehis weight had increased by >lO kg. ietary control of the patient was not effective. Several years later, therapy with EACA was started but had to be stoppedafter 3 monthsbecauseof severalepisodes of thrombophlebitis and phlebothrombosis. On clinical examination, there was no evidence of associateddisease. Laboratory investigations demonstratedessentially normal haematologicand biochemical parameters.Complementinvestigation demonstrateddepressedCl WI-I, C4, and CH,, levels. Clinical and laboratory findings led to the diagnosis of HAE type I. Treatment.The patient sufferedfrom depressive:episodes and several times attemptedsuicide. Control of these episodeswith various tricyclic and tetracyclic antidepressants was not successful.Therefore, and since danazol and EACA were not tolerated or refused, we resorted to replacement therapy with Cl INH during a prolonged period. The patient was treated with Cl INH concentrateintravenously during a period of 1 year. The dose was determined empirically. It correspondedto the lowest dose needed to achieve complete freedomfrom clinical symptoms.The patient required 500 units of Cl INH concentrateevery fourth or fifth day. The clinical condition improved, and the attacks ceased almost completely, as can be observed in Fig. 2. No undesirable side effects caused by the replacement therapy were observed. The results of complement investigations

mg/d I Ci-INW f

c425i

Duration of replacement I

therapy

Number of cutaneous oedemas 5 1 1 I I I 1 I I I I 134

3

2

203,

Number of gastrointestinal , , , , , , ,

attacks , , ,2 ,2 ,1

15-

01

I,

0

I,

1

2

3

I

I

I

I,

4

5

6

7

I

8

,(I

9 10 11 12 months

FIG. 3. Course of the disease and levels of Cl INH (0) and C4 (A) in patient No. 2 during replacement therapy (=I with 1000 units of Cl INH concentrate every 5 days. Normal range of C1 INH, 15 to 35 mg/dl. Normal range of C4, 20 to 50 mgidl.

BLE 1. Laboratory

replacement

investigations carried out in the patients therapy with C’i INH concentrate Patient Before treatment

before and during

Patient

No. 1 After 6 months of therapy

Before treatment

long-term

No. 2 After 6 months crf therapy

al range

Ci INH protein _(mddl)

1

6.4

5.6

8.0

15-35

Cl !NH activity (%I C&o RJ/mU C4 mgidl C2 (U/ml)

0

8

0

I

m-120

0 0 ND ND 0

0 11.6 ND ND 0

0

0

4 20

6.8 20

13-26 20-50 f,500-3,o

ci (uhi) Ci XNH anti-

800

1000

100~000-300,Q~

400

400

0

body titer ND, Not determined.

before treatment and after 6 months of therapy are presented in Table I. During treatment, blood samples were obtained immediately before the next injection of Cl INH concentrate. There was no change in the other laboratory parameters examined, particularly the transaminase and virusmarker levels that were measured regularly.

Patient

No. 2.

Case history. A S-year-old man was first observed with a 5-year history of episodes of recurrent angioedema, mainly involving lips and hands, associated with attacks of severe cramp-like abdominal pain and nausea. The patient had had >lOO attacks. Family history was negative; 12 relatives

Treatment of Cl i

.

were investigated without any evidence of Cl INH deficiency. Treatment with danazol (600 mg per day) for 6 months and with EACA (6 gm per day) failed to reduce the number of attacks. Clinical examination was basically normal. There was no evidence of lymphadenopathyor splenomegaly.Routine blood analysis was normal, No antinuclear antibodies, antitissue antibodies, rheumatoid factors, cryoglobulins, cold agglutinins, monomeric IgM, or antilymphocyte antibodies were found. Quantitative IgG, IgA, IgM, and IgE were normal. No B cell abnormalities could be detected. Cl I CI INH, C4., and C2 were reduced(Table I). Anti-Cl INH antibodies were found in this patient before therapy.15The diagnosis of acquired Cl INH deficiency with angioedema was made on the basis of family and personal history and confirmed by the complement findings. The patient’s angioedema was classified as acquired angioedemawith autoantibodies to Cl INH (AAE II), although the level of Cl INH was markedly reduced, more than usual in this form. Treatment. Therapy with danazol and EACA did not relieve the symptoms sufficiently. A further trial with EACA at a larger dose was refusedby the patient who is a professional trumpeter in a famous symphony orchestra. Therefore, we tried to reduce the cutaneous angioedema,especially the lip swelling, by long-term replacementprophylaxis with Cl INN concentrate. During an attack of angioedemawith swelling of the lips, the patient initially received 500 units. When the edemabecamemore severe within an hour, he was administered another injection of 500 units, after which the edema subsided. This patient needed 1000 units of Cl INH concentrateevery fifth day, and the regimen has been carried out for a period of 1 year. Before treatment, the patient developed one to two skin swellings a week and one to two attacksof abdominal pain every month. In the first few monthsof replacementtherapy, the number and duration of the attacks were markedly reduced (Fig. 3). After 10 months, the number and severity of the attacks slowly increased. Becausethere was no explanation for this, the treatment was stopped after 12 months. Another trial with EACA (10 gm daily) followed. During replacementtherapy with the Cl INH concentrate, Cl INH and C4 serum levels were slightly increased(Fig. 3). The Cl Im antibody titer did not change during the entire treatment period. During treatment, blood samples were obtained immediately before the next injection of Cl INH concentrate. No undesirable side effects caused by replacementtherapy were observed.

In patients with HAE, long-term prophylaxis with danazol, stanozolol, EACA, and tranexamic acid is usually effective, danazol being the medication of

choice. Replacementtherapy with C 1 INH is normally used for the treatment of acute attacks; it is necessary in laryngeal edemaand in life-threatening angioedema of the internal organs. Replacement therapy can be performed with a concentrate of purified Cl INH or with fresh, frozen plasma.Cl INH concentrateis more

appropriate and frequently used. It has been available in Europe for years. In cases of li edema, 500 to 1000 units are injected. edemabegins within 2 or 3 hours of i usually complete within 24 hours. In severe cases, repeatedinjections may be necessary.In addition, intensive care is needed. Complement investigations demonstratedan increasedlevel of Cl IIII-I, C2, C4, and CH,, after injection of C 1 ~n~en~a~~~27This study also demonstratedthat molecular-w~igbt kininogen levels rose after Cl-INH concentrateinfusion and paralleled the clinical course. Tbe biologic half-life of Cl 1NI-I in healthy subjects is 64 &z 1.4 hours.28In casesof acute angioedema, co~s~~~~tion is increased.The clinical effect lasts for severaldays, depending on the plasma levels and dose. Both patients studied benefited from the long-te replacement therapy with C 1 INH. The attackswere reduced in number and severity for a year (patient No, 1) and for 9 months (patient No. 2). The secondpatient respondedto therapy, although apy did not restore the initially low titers of Cl I , a&), C4, or c2. The reason may be that circulating levels of Cl may not correspondto tissue levels. After 10 months, the patient becameresistant to this form of therapy; the reason remains unclear. The resistance does not appear to be related to increased fo~atio~ of antibodies to Cl INH. This patient displayed antibodies to C 1 INH even before therapy, although he had never received Cl INH before, and the antipode titer did not rise during or after replacementtherapy with Cl INH. The causeof the antibody fo~atio~ still has to be clarified. No side effects of long-term ~rop~~l~is with Cl INH were observed, and in particular, no clinical or serologic signs of hepatitis or ~tibod~~s to HIV were detectablebeforeor after treatment.To sum up, longterm substitution with pasteurized Cl INH concentratesis safe and of clinical benefit to a group of patients selectedin accordancewith strict criteria. At least a temporary remission can be achieved. REFERENCES Donaldson VII, Evans RR. A biochemical abnormality in bereditary angioneurotic edema: absenceof serum inhibitor of Cl-esterase. Am J Med 1963;35:3?-44. Rosen FS, CharacheP, Pensky J, Donaldson VII. Hereditary angioneurotic edema: two genetic variants. Science 1965; 18:957-g. Rosen FS, Alper CA, Pensky J, Klemperer MR, Donaldson VII. Genetically determined heterogeneityof the Cl esterase inhibitor in patients with hereditary angioneurotic edema. 3 Clin Invest 1971;50:2143-9. DonaldsonVII, Harrison RA, Rosen FS, Sing DII, Kindness G, Wagner CJ, Awad S. Variability in purified dysfunctional Ci-inhibitor proteins from patients with hereditary angioneurotic edema:functional and analytical gel studies.J Clin Invest 1985;75:124-32.

ark

and

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