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Expert Review and Consensus on the Treat-to-Target Management of Hereditary Angioedema: From Scientific Evidence to Clinical Practice

Caballero T1,2,3, Lleonart-Bellfill R4,5, Pedrosa M1,2,3, Ferrer L6, Guilarte M7,8,9

1Allergy Department, Hospital Universitario La Paz, Madrid, Spain
2Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
3Biomedical Research Network on Rare Diseases (CIBERER U754), Madrid, Spain
4Allergology Department, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Spain
5Institut d’Investigació Biomèdica de Bellvitge - IDIBELL, L’Hospitalet de Llobregat, Spain
6Hospital Clínico Universitario “Lozano Blesa”, Zaragoza, Spain
7Allergy Section, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
8Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
9RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL)

J Investig Allergol Clin Immunol 2023; Vol 33(4) : 238-249
doi: 10.18176/jiaci.0875

Background: Hereditary angioedema with C1 inhibitor deficiency (HAE-C1INH) is a rare disease characterized by swelling episodes. It affects quality of life (QOL) and can be fatal when the upper airways are involved. Treatment is individualized, with therapeutic options including on-demand treatment (ODT) and short- and long-term prophylaxis (STP, LTP). However, available guidelines are not always clear about the selection of treatment, the goals of treatment, or how achievement of these goals is assessed.
Objective: To review available evidence for the management of HAE-C1INH and build a Spanish expert consensus to steer management towards a treat-to-target approach, while addressing some of the less clear aspects of the Spanish guidelines.
Methods: We reviewed the literature on the treat-to-target management of HAE-C1INH, focusing on treatment selection and goals and the tools available to assess whether the goals have been achieved. We discussed the literature based on clinical experience and drew up 45 statements on undefined management aspects. A panel of 53 HAE experts validated the statements through a 2-round Delphi process.
Results: The goals for ODT and STP are to minimize the morbidity and mortality of attacks and to prevent attacks caused by known triggers, respectively, while the main goal of LTP is to decrease the rate, severity, and duration of attacks. Furthermore, when prescribing, clinicians should consider the reduction in adverse effects, while increasing patient QOL and satisfaction. Appropriate instruments for assessing achievement of treatment goals are also indicated.
Conclusions: We provide recommendations on previously unclear aspects of HAE-C1INH management with ODT, STP, and LTP, focusing on clinical and patient-oriented goals.

Key words: Hereditary angioedema, Expert consensus, Treat-to-target, On-demand treatment, Prophylaxis, Treatment, C1 inhibitor