What is the management plan for angioedema?

From the Guidelines

The management of angioedema should prioritize securing the airway, identifying and removing triggers, and providing appropriate medications based on the type of angioedema, with a focus on using C1 esterase inhibitor concentrate, icatibant, or ecallantide for bradykinin-mediated angioedema, as recommended by the most recent guidelines 1. The approach to managing angioedema involves several key steps, including:

• Securing the airway, especially in cases involving the airway, with preparation for intubation or cricothyroidotomy if needed
• Identifying and removing triggers, such as discontinuing ACE inhibitors in cases of ACE inhibitor-induced angioedema 1
• Providing appropriate medications based on the type of angioedema, with different treatments required for histamine-mediated versus bradykinin-mediated angioedema For bradykinin-mediated angioedema, such as hereditary angioedema or ACE inhibitor-induced angioedema, medications like C1 esterase inhibitor concentrate (Berinert 20 units/kg IV or Cinryze 1000 units IV), icatibant (30mg SC), or ecallantide (30mg SC) are recommended 1. Long-term management involves:
• Identifying and avoiding triggers
• Discontinuing causative medications, particularly ACE inhibitors
• Prophylactic treatments for recurrent cases, such as attenuated androgens (danazol 200mg daily), tranexamic acid (1-1.5g twice daily), or regular C1 inhibitor infusions for hereditary angioedema Patient education about recognizing symptoms early and having an emergency action plan is essential for prompt treatment of future episodes 1.

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) Patients may self-administer upon recognition of an HAE attack. ( 2. 2) WARNINGS AND PRECAUTIONS Laryngeal attacks: Following treatment of laryngeal attacks with icatibant, advise patients to seek immediate medical attention. ( 5. 1)

The management plan for angioedema includes:

• Administering icatibant 30 mg subcutaneously in the abdominal area 2
• If response is inadequate or symptoms recur, additional injections of 30 mg may be administered at intervals of at least 6 hours
• Not administering more than 3 injections in 24 hours
• Patients may self-administer upon recognition of an HAE attack
• Advising patients to seek immediate medical attention following treatment of laryngeal attacks with icatibant 2

From the Research

Angioedema Management Overview

• Angioedema is a rare and potentially life-threatening disorder characterized by episodic and self-limiting increases in vascular permeability, leading to recurrent attacks of swelling in any part of the body 3.
• The management plan for angioedema depends on the underlying cause, which can be allergic or non-allergic, and the severity of the attack.

Allergic Angioedema Management

• Allergic angioedema can be treated with antihistamines, corticosteroids, and adrenaline 4.
• However, these treatments are ineffective in non-allergic angioedema, which requires alternative therapies such as bradykinin-B2-receptor antagonists or C1-INH concentrate 4.

Non-Allergic Angioedema Management

• Non-allergic angioedema, including hereditary angioedema (HAE), acquired angioedema (AAE), and renin-angiotensin-aldosterone system (RAAS)-blocker-induced angioedema (RAE), requires targeted therapy 4.
• Fresh frozen plasma (FFP) has been used successfully in the treatment of resistant angioedema, including HAE and ACE inhibitor-induced angioedema 3, 5.
• Bradykinin inhibitors, such as icatibant, and C1 esterase inhibitor substitutes are also effective in treating bradykinin-mediated angioedema attacks 4, 6.

Emergency Management

• In cases of acute angioedema with respiratory tract involvement, emergency management may involve intubation, cricothyroidotomy, or the use of epinephrine, antihistamines, and corticosteroids 4, 7.
• Discontinuation of the offending drug, such as an ACE inhibitor, is also crucial in the management of drug-induced angioedema 7.

Long-Term Management

• Patients with hereditary or acquired angioedema may require long-term management with C1 esterase inhibitor sparing therapy and a treat-the-cause approach to reduce the risk of recurrent attacks 6.