Anaphylactoid‐like reactions in a patient with HyperLp(a)lipidemia undergoing LDL apheresis with dextran sulfate adsorption and herbal therapy with the spice turmeric

Abstract

Elevated Lipoprotein (a) (Lp(a)) levels are associated with atherosclerosis and are independent risk factors for coronary artery disease and stroke [Ariyo et al., N Engl J Med 2003;349:2108–2115; Price et al., Atherosclerosis 2001;157:241–249]. Low-density lipoprotein (LDL)-apheresis is the most effective therapy for reducing Lp(a) levels [Parker, Chem Phys Lipids 1994;67–68:331–338; Stefanutti et al., Transfus Apher Sci 2010;42:21–26]. Dextran sulfate-cellulose adsorption (Liposorber®) removes both LDL and Lp(a) particles with minimal effect on high-density lipoprotein levels. During the procedure, high levels of bradykinin are generated as the kallikrein-kinin system is activated by contact with the negatively charged dextran-sulfate cellulose [Krieter et al., Artif Organs 2005;29:47–52]. Bradykinin is a potent vasodilator and a substrate of the angiotension converting enzyme (ACE). ACE inhibitors are contraindicated for apheresis procedures because these drugs prevent bradykinin degradation, which causes anaphylatoid reactions characterized by hypotension, bradycardia, dyspnea, and flushing [Owen and Brecher, Transfusion 1994;34:891–894]. Turmeric is a yellow spice that is used as an herbal remedy to treat a myriad of conditions ranging from abdominal pain to pulmonary infections. Scientific investigations of the ethnomedicinal properties of curcumin, the major derivative of turmeric, suggest that this compound has anti-inflammatory, antioxidant, and antineoplastic properties [Lobo et al., J Pharm Pharmacol 2009;61:13–21]. We report a case of a patient undergoing Liposorber® therapy for treatment of hyperLp(a)lipidemia who had three episodes of anaphylactoid-like reactions after starting therapy with the spice turmeric.

Lipid apheresis, indications, and principles

“…Recently, a similar reaction has been described in patients undergoing LDL‐A and using the spice turmeric as herbal therapy [24]. While the spice does not have ACE inhibitory effects, it does demonstrate vasodilator properties and the symptoms produced in the reported patient were similar to those seen in patients taking ACE inhibitors.…”

“…While the spice does not have ACE inhibitory effects, it does demonstrate vasodilator properties and the symptoms produced in the reported patient were similar to those seen in patients taking ACE inhibitors. The exception was that the onset of symptoms occurred after 2–3 L of blood had been processed [24]. Typically with ACE inhibitors; the onset of symptoms is shortly after plasma begins to return to the patient.…”

Low‐Density Lipoprotein Apheresis: Principles and Indications

“…A similar reaction has been described in patients undergoing LDL‐A using turmeric as herbal therapy (20). While the spice does not have ACEi effects, it does demonstrate vasodilator properties and the symptoms produced were similar to those seen in patients taking ACEi except that the onset occurred after 2–3 l of blood had been processed (20).…”

A case of ‘anaphylactic‐like’ reaction during LDL apheresis: a pathophysiological hypothesis on white wine containing metabisulphite

“…During LDL apheresis, a case of reaction secondary to herbal remedy was described (Adamski et al, 2010), but 'anaphylactic-like' reaction, that may be linked to metabisulphite, has not been previously linked with LDL apheresis. Nowadays, the increasing production of wine at home may lead to an increased risk of interactions between drugs or therapeutic procedures (as LDL apheresis) with potentially serious consequences, and is an example of an interaction with a medical therapy with over-the-counter medications or herbal products and food additives.…”