Patients who develop angioedema symptoms after receiving stroke medication, and are not responsive to first-line angioedema therapy, may benefit from Firazyr (icatibant), a recent case report suggests.
The patient, a 61-year-old woman, came to the emergency room with sudden weakness in the left upper and lower extremities, difficulty speaking, and left facial droop. She had a medical history of high blood pressure, diabetes, high blood levels of fat molecules, transient stroke episodes, and heart attacks.
Given her symptoms and clinical history, the team thought she could be having a stroke and conducted a computed tomography (CT) scan of the brain. No changes were detected, and she had only minor impairments due to stroke, as determined by the Initial National Institutes of Health Stroke Scale (NIHHS) score.
While no diagnosis was made, her symptoms continued to progress. She developed moderate-to-severe left hand weakness, left-sided drift, and her speech problem worsened. Also, her NIHHS score increased, suggesting that moderate stroke could be causing her symptoms.
The patient was given thrombolytic therapy – a medicine used to resolve blood clots. Treatment with Activase (alteplase) was initiated at a dose of 0.9 mg/kg.
However, just 20 minutes after Activase treatment the patient developed lip and left tongue edema (swelling). In these cases, discontinuing Activase treatment, followed by taking antihistamines, intravenous glucocorticoids, and epinephrine has relieved symptoms.
But the patient did not respond to that approach; her edema continued to worsen. While no treatment has been defined for patients who do not respond to initial edema therapy, the team decided to treat the patient with Firazyr – a U.S. Food and Drug Administration-approved injectable drug for hereditary angioedema. Twenty minutes later, she started to show signs of improvement.
Additional diagnostic testing for her initial symptoms revealed she had right-sided middle cerebral artery infarct, and she was admitted to the intensive care unit. Six days after hospitalization she was discharged and went home.
The team believes this case underscores the potential of Firazyr as a “treatment option to improve outcomes and avoid emergent and/or invasive airway management” in patients with angioedema triggered by tissue plasminogen activators, like Activase.
Angioedema caused by Activase has been reported previously, however, it is a rare event affecting only 0.9-5.1% of stroke patients. It is not clear which is the underlying mechanism, but it has been suggested that the medication indirectly leads to bradykinin production, which is a main cause of angioedema.
While Firazyr treatment was effective in this case, little is known about its potential side effects in stroke patients. Further studies addressing this issue are still warranted, researchers said.