ChEMBL

HAE is a rare genetic disease and is caused by low levels of C1-esterase inhibitor (C1-INH), the major endogenous inhibitor and regulator of the protease plasma kallikrein and the key regulator of the Factor XII/kallikrein cascade. One component this cascade is the production of bradykinin by plasma kallikrein. During HAE attacks, disregulated activity of plasma kallikrein leads to excessive bradykinin production; bradykinin is a potent vasodilator, which s thought to be responsible for the characteristic HAE symptoms of localised swelling, inflammation and pain.

Icatibant treats the clinical symptoms of HAE attack by selective- and competitively binding, as an antagonist, to the B2 bradykinin receptor (B2R) (Uniprot: P30411; ChEMBL ID: CHEMBL3157; PFAM: PF00001), with similar affinity to bradykinin (1-10 nM for the B2R, while affinity for the B1R is 100-fold lower). Icatibant is the first in class agent against this target. The -tibant stem covers bradykinin antagonists.


B2R is a Rhodopsin-like receptor, 391 amino acid long, which belongs to the G protein-coupled receptor (GPCR) A3 family and is encoded by the BDKRB2 gene in humans. The amino acid sequence of B2R is:

>B2R 
MFSPWKISMFLSVREDSVPTTASFSADMLNVTLQGPTLNGTFAQSKCPQVEWLGWLNTIQ
PPFLWVLFVLATLENIFVLSVFCLHKSSCTVAEIYLGNLAAADLILACGLPFWAITISNN
FDWLFGETLCRVVNAIISMNLYSSICFLMLVSIDRYLALVKTMSMGRMRGVRWAKLYSLV
IWGCTLLLSSPMLVFRTMKEYSDEGHNVTACVISYPSLIWEVFTNMLLNVVGFLLPLSVI
TFCTMQIMQVLRNNEMQKFKEIQTERRATVLVLVVLLLFIICWLPFQISTFLDTLHRLGI
LSSCQDERIIDVITQIASFMAYSNSCLNPLVYVIVGKRFRKKSWEVYQGVCQKGGCRSEP
IQMENSMGTLRTSISVERQIHKLQDWAGSRQ

There are no known experimental structures of B2R, however there are several relevant homologous structures of other members of the rhodopsin-like GPCR family (see here for a current list).

Icatibant is the third drug approved in the US to treat HAE attacks. Previous drugs include Ecallantide (approved in December 2009 under the trade name Kalbitor), which is a potent, selective, reversible inhibitor of plasma kallikrein, and C1-INH (approved in October 2009 under the trade name Berinert), which is a freeze-dried human C1-esterase inhibitor concentrate.

Icatibant (IUPAC: (2S)-2-[[(3aS,7aS)-1-[2-[(2S)-2-[[(2S)-2-[[2-[[(4R)-1-[1-[2-[[(2R)-2-amino-5-(diaminomethylideneamino)pentanoyl]amino]-5-(diaminomethylideneamino)pentanoyl]pyrrolidine-2-carbonyl]-4-hydroxypyrrolidine-2-carbonyl]amino]acetyl]amino]-3-thiophen-2-ylpropanoyl]amino]-3-hydroxypropanoyl]-3,4-dihydro-1H-isoquinoline-3-carbonyl]-2,3,3a,4,5,6,7,7a-octahydroindole-2-carbonyl]amino]-5-(diaminomethylideneamino)pentanoic acid; ChEMBL ID: CHEMBL375218; PubChem: 71364; ChemSpider: 5293384) is a synthetic decapeptide that differs from bradykinin (a nonapeptide with an amino acid sequence RPPGFSPFR) at the amino acids' positions 3, 5, 7 and 8, which have been replaced by four non-natural amino acids, and also in one additional amino acid (a D-arginine) at the N-terminus of the bradykinin arginine at position 1. Thus, Icatibant amino acid sequence is D-Arg-Arg-Pro-Hyp-Gly-Thi-Ser-D-Tic-Oic-Arg. These modifications prevent Icatibant from being metabolised by major bradykinin-metabolizing enzymes, which makes it more stable that bradykinin. Icatibant has a molecular weight of 1304.5 Da.

Icatibant can be self-administrated through an injection in the abdominal area, thus providing a new option for the treatment of acute HAE attacks. The recommended dose is 30 mg administrated subcutaneously. In the case of inadequate response or recurrence of symptoms, additional dose may be administrated at intervals of at least 6 hours, with no more than 3 doses administrated in any 24-hour period (recommended daily dose equivalent 69.0 umol). 

The full prescribing information can be found here.


Icatibant is marketed by Shire Human Genetic Therapies Inc. and the product website is www.firazyr.com (Since 2008, Icatibant has been approved for use in the European Union; the european SPC can be found here).