What is the management of angioedema?

From the Guidelines

The management of angioedema should prioritize securing the airway, especially in cases of airway compromise, and treatment should be guided by the underlying cause, with options including C1 esterase inhibitor concentrates, ecallantide, icatibant, epinephrine, antihistamines, and corticosteroids. For acute angioedema, the first priority is to maintain the airway, and endotracheal intubation may not be necessary if edema is limited to the anterior tongue and lips, as stated in the 2018 guidelines for the early management of patients with acute ischemic stroke 1. However, edema involving the larynx, palate, floor of mouth, or oropharynx with rapid progression poses a higher risk of requiring intubation.

The treatment approach should target the specific mediator pathway involved, either histamine or bradykinin, which explains why antihistamines work for allergic angioedema but are ineffective for bradykinin-mediated types like HAE or ACE inhibitor-induced angioedema. According to the 2021 guidelines on mitigating disparity in health-care resources between countries for management of hereditary angioedema, all attacks should be treated with C1-INH, icatibant, or ecallantide, and should be treated as early as possible to minimize their duration and severity 1.

For hereditary angioedema (HAE), specific treatments include C1 esterase inhibitor concentrates, ecallantide, or icatibant, as well as symptomatic treatment based on the region of body swelling, such as pain medication and antiemetics for abdominal attacks, and aggressive hydration to prevent third-space sequestration of fluid 1. The most recent and highest quality study, published in 2021, recommends that all patients with HAE should carry an acute attack treatment on their person and be trained on self-administration 1. Patient education about trigger avoidance and emergency action plans is essential, and the treatment approach should be individualized based on the severity and underlying cause of the angioedema.

Some key points to consider in the management of angioedema include:

• Securing the airway, especially in cases of airway compromise
• Targeting the specific mediator pathway involved, either histamine or bradykinin
• Using C1 esterase inhibitor concentrates, ecallantide, or icatibant for HAE
• Providing symptomatic treatment based on the region of body swelling
• Educating patients about trigger avoidance and emergency action plans
• Individualizing treatment based on the severity and underlying cause of the angioedema.

From the FDA Drug Label

ICATIBANT injection, for subcutaneous use Initial U. S. Approval: 2011 INDICATIONS AND USAGE Icatibant injection is a bradykinin B2 receptor antagonist indicated for treatment of acute attacks of hereditary angioedema (HAE) in adults 18 years of age and older. (1) DOSAGE AND ADMINISTRATION 30 mg injected subcutaneously in the abdominal area. (2. 1) If response is inadequate or symptoms recur, additional injections of 30 mg may be administered at intervals of at least 6 hours. (2.1) Do not administer more than 3 injections in 24 hours. (2.1)

The management of hereditary angioedema (HAE) involves the administration of icatibant injection.

• The recommended dose is 30 mg injected subcutaneously in the abdominal area.
• If the response is inadequate or symptoms recur, additional injections of 30 mg may be administered at intervals of at least 6 hours.
• Patients should not receive more than 3 injections in 24 hours.
• Patients may self-administer upon recognition of an HAE attack 2. Key points to consider in the management of HAE include:
• Laryngeal attacks: Patients should seek immediate medical attention after treatment of laryngeal attacks with icatibant injection.
• Dosage administration: Icatibant injection should be administered subcutaneously in the abdominal area.

From the Research

Management of Angioedema

The management of angioedema involves various approaches, depending on the underlying cause and severity of the condition.

• Conventional treatment with antihistamines and corticosteroids is often used for allergic or parallergic reactions 3.
• However, in cases of bradykinin-mediated angioedema, such as hereditary angioedema or acquired angioedema, treatment with a bradykinin inhibitor or C1 esterase inhibitor substitute may be necessary 4, 5.
• For patients with angioedema induced by angiotensin-converting enzyme (ACE) inhibitors, discontinuation of the offending agent is crucial, and treatment with fresh frozen plasma (FFP) or C1 inhibitor concentrate may be effective in severe cases 6, 7.

Treatment Options

Some treatment options for angioedema include:

• Antihistamines and corticosteroids for allergic or parallergic reactions 3
• Bradykinin inhibitors, such as icatibant, for hereditary angioedema 5
• C1 esterase inhibitor substitutes for hereditary angioedema or acquired angioedema 4, 5
• Fresh frozen plasma (FFP) for severe ACE inhibitor-induced angioedema 6
• C1 inhibitor concentrate for ACE inhibitor-induced angioedema 7
• Lanadelumab, a monoclonal antibody that inhibits plasma kallikrein, for preventive measures in hereditary angioedema 5

Prevention

Prevention of angioedema relies on patient history and avoidance of triggering agents, such as:

• ACE inhibitors in patients with congenital or acquired C1-INH deficiency 3
• Estrogens in patients with congenital or acquired C1-INH deficiency 3