There are few studies on NHAE-nC1INH. However, in HAE-nC1INH, the clinical manifestations are highly variable. The overall prevalence of NHAE-nC1INH remains unknown. According to this study, the prevalence of NHAE-nC1INH in Manitoba is approximately 5 per million people, with a population of 1.3 million people.1 HAE-nC1INH tends to present during adulthood, whereas Type I and II HAE usually is present during childhood. HAE-nC1INH predominantly affects women, which is consistent with this study of 3/5 of the study population being women.4,7,9,10 Individuals with HAE-nC1INH have more facial and oropharyngeal angioedema and less frequent gastrointestinal involvement, compared to Type I and II HAE.4,7,10 All patients are at risk for life-threatening laryngeal angioedema. The angioedema lasts 2–5 days without treatment.7,9,10 The episodes are exacerbated with physical trauma, stress, sleep deprivation, illness, menstruation, pregnancy oral contraceptives, hormone replacement therapy, and/or angiotensin-converting enzyme inhibitors.4,7,9,10
Most current treatment options for HAE-nC1INH are aimed to reduce the production and/or biologic effects of bradykinin, which is the main culprit causing the angioedema episodes. To date, there are no randomized, controlled studies of on-demand and prophylactic treatment in patients with HAE-nC1INH or NHAE-nC1INH.5 Numerous randomized, controlled studies have shown success with the on-demand and prophylactic treatments used for Type I and II HAE. Plasma-derived C1INH seems to be effective used both as an on-demand and prophylactic treatment, even though patients with nC1INH have no deficiency or dysfunction of C1INH. A study completed in 2016 by Bork and colleagues concluded a mean duration of an episode acutely treated with pdC1INH was 26.6 hours compared to 64.2 hours without treatment.12 This study concluded a mean duration of an episode acutely treated with pdC1INH was 15 to 15.2 hours compared to 57.6 to 67.2 hours without treatment. Icatibant, a bradykinin-2 receptor antagonist, has also shown to be an effective on-demand treatment. Boccon-Gibod and Bouillet concluded, symptom improvement within a median of 40 minutes with Icatibant.11 In this study, no patients responded successfully to Icatibant. However, some studies have reported individuals having no response or delayed responses to Icatibant. Inactivated plasma kallikrein (eg Ecallantide) and fresh frozen plasma have been shown to be effective in 1 patient in HAE-nC1INH not responding to pdC1INH or Icatibant. Several studies have shown effective response to transexamic acid, an antifibrinolytic, in patients with HAE-nC1INH.4
In this study 4 of 5 had an effective response to pdC1INH for on-demand treatment, and 3 out of 5 had reduction in the number of episodes with pdC1INH. One of the patients who responded to pdC1INH on-demand treatment did not have reduction in the number of episodes with pdC1INH prophylaxis. In addition, one patient had reduction in the number of weekly episodes with pdC1INH prophylaxis, however, still had frequent episodes. No severe or serious adverse effects were reported. One patient responded successfully to tranexamic acid as a prophylactic treatment, and was nonresponsive to C1INH for prophylactic and on-demand treatment, and nonresponsive to Icatibant. Unfortunately public and private insurance in Manitoba will not cover the cost of Icatibant in these individuals; hence few have had the opportunity to try it.
In the McKibbin et al study, all six patients with HAE-nC1INH successfully responded to Icatibant; compared to this study where no patients with NHAE-nC1INH responded to Icatibant for acute treatment. This could be largely due to the small sample size; only 3 of the 5 patients had the opportunity to use Icatibant. Thus larger, double blind placebo controlled studies are required to further analyze the effectiveness of Icatibant in both, NHAE-nC1INH and HAE-nC1INH.
The main limitation of this study is the low number of individuals included. It is very possible that not all individuals treated for this condition in our clinic are accounted for in the study. The diagnosis of NHAE-nC1INH is challenging. It requires a high-level of clinical suspicion, as well as, the patients to be knowledgeable about their family history. Currently, there are no laboratory tests to confirm the diagnosis of NHAE-nC1INH.