Pre-dental preventive treatment may not be needed in HAE: Study
Short-term therapy 'should be reconsidered' with long-term prophylaxis use
Short-term preventive treatment before dental procedures may not be necessary for people with hereditary angioedema (HAE) who are already on long-term prophylaxis, according to a new study by researchers in Germany.
It’s well-established that dental procedures and surgeries can act as triggers to increase the risk of the swelling attacks that mark HAE. As such, people with the genetic disorder are typically given short-term prophylaxis — preventive treatment dubbed STP — before such procedures.
In STP, therapies are given immediately before medical, surgical, or dental procedures, or other events capable of triggering an attack, with the aim of minimizing the chances of that happening.
Over the last decade or so, however, several treatment options for long-term prophylaxis, or LTP, have been approved. These therapies are taken regularly to reduce the risk of swelling attacks.
With the increased availability and use of these LTP treatments, there’s been renewed debate about whether STP before certain medical procedures is still necessary. In this study, the researchers conclude it’s likely not, “provided acute treatment is available and other trigger factors are absent,” the team wrote.
Titled “Analysis of prodromal symptoms and need for short-term prophylaxis in angioedema patients under long-term prophylaxis,” the study was published in the Orphanet Journal of Rare Diseases.
1 swelling attack reported in over 100 dental procedures
Seeking to better understand the effects of short-term preventive treatment in the modern era, a team from Ulm University Medical Center surveyed angioedema patients on LTP at their center. The survey was answered by 25 people with HAE, as well as one person with acquired angioedema.
All 26 patients in the study had been on LTP for a median of five years. Among them, 10 said they had not experienced any swelling attacks since starting LTP, while eight reported 1-3 attacks since beginning long-term treatment. Five individuals reported having four or more attacks since starting LTP, with three of these patients noting that they’d experienced more than 10. No data were provided for the three remaining patients.
More than 100 dental procedures were reported by 19 patients. STP was not used for the vast majority of these procedures. Yet, there was just one instance in which a patient experienced a swelling attack following a dental procedure, the researchers noted.
According to the team, these data suggest that it’s very unlikely for HAE patients on LTP to experience swelling related to dental procedures, even without short-term prophylaxis. As such, “for dental procedures, the mandatory use of STP in HAE patients on effective LTP should be reconsidered,” the researchers wrote.
The situation for surgeries was a bit more complex. A total of nine surgical procedures were reported by eight patients. In most of the procedures, STP was used.
In five of these cases, a swelling attack occurred following surgery — and in all of them, the attack occurred even though the patient had been given STP.
Given these data, the researchers said it’s not possible to draw reliable conclusions about whether STP or LTP may help lower the risk of swelling attacks after surgeries. Instead, the team emphasized a need for more research in this area.
For dental procedures, the mandatory use of STP [short-term preventive treatment] in HAE patients on effective LTP [long-term prophylaxis] should be reconsidered.
Overall, per the scientists, these data suggest that, in the modern age of LTP, it may not be necessary to use STP as often.
Indeed, limiting the use of STP may help minimize the treatment burden for patients, as well as costs, the researchers note. The team noted that such considerations should be a part of discussions about best practices for HAE care.
“The data from the present study … do not support the necessity of mandatory STP under LTP in HAE patients,” the researchers wrote. Instead, “treatment decisions should be made through shared decision-making, with the presence of effective and sufficient acute therapy as the foundation of any therapeutic approach,” they wrote.
Researchers also find no attacks followed half of early symptoms
In addition to asking about experiences with dental and surgical procedures, the survey queried patients about their experience with prodromal symptoms — early symptoms that appear before swelling and may serve as warning signs of imminent attacks.
Many patients reported having experienced prodromal symptoms, with the most common being tiredness, reddened skin, and digestive upset. Almost all said that, since starting LTP, their prodromal symptoms had either disappeared entirely or became much less bothersome.
The researchers noted that there were many instances in which patients on LTP reported experiencing prodromal symptoms that were ultimately not followed by a swelling attack. As such, the scientists cautioned that these early symptoms shouldn’t necessarily be a cue for on-demand treatment in HAE patients on LTP.
“Since no attack followed approximately half of the prodromal symptoms and the overall frequency was significantly reduced in our results, general recommendations for acute therapy cannot be given based solely on the occurrence of a prodromal symptom,” the scientists wrote.
Importantly, the scientists noted that “stress is one of the most common triggers for an HAE attack,” and wrote that, “since (dental) medical procedures typically mean stress for patients, this is an important consideration for healthcare providers managing HAE … patients.”
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