Successful Use of Icatibant Pre-Treatment to Prevent Systemic Reaction during Ldl Apheresis

ABSTRACT

Introduction: Familial hyperlipidemia(FH) is a hereditary condition characterized by elevated low-density lipoprotein (LDL) levels, treated by medications and possibly apheresis when refractory. There's a rare risk of anaphylactoid reactions in 0.2-0.4%. Current literature reports apheresis reactions could be mediated by complement, bradykinin, or cytokine activation. Case Description A 62-year-old man with FH and coronary artery disease, not taking ACE-inhibitors/ARBs, developed recurrent systemic reactions during apheresis after COVID-19 infection 1 month prior. Reactions consisted of headache, facial/tongue swelling, and oral tingling. For 7 years before his COVID-19 infection, he tolerated apheresis with a pre-medication routine of solumedrol and diphenhydramine. After the COVID-19 infection, reactions subsided after stopping the procedure. For his subsequent procedure, prednisone prior was unsuccessful at preventing reactions. For the following infusion, adjunctive prednisone, cetirizine, aspirin, montelukast administered the night prior and morning of the infusion and slowing the infusion rate to the lowest settings were unsuccessful. Complement and tryptase levels were all normal at baseline and following symptomatic treatments (Table 1) suggesting no predisposition to angioedema. Given elevated bradykinin levels are associated with LDL apheresis and these reactions, Icatibant was administered before infusion along with his routine pre-medications, and the apheresis procedure was completed without incident. Discussion(s) Limited documented cases of these reactions during LDL apheresis respond to bradykinin antagonists and none of which began after COVID-19 infection. COVID-19 is associated with significant inflammation, but rarely angioedema. Further investigation is needed as to why this FH patient is more sensitive to the effects of bradykinin after COVID-19 infection. Copyright © 2022