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Davin L, Marechal P, Lancellotti P, Martinez C, Pierard L, Radermecker R. Angioedema: a rare and sometimes delayed side effect of angiotensin-converting enzyme inhibitors. Acta Cardiol 2019; 74:277-281. [PMID: 30328786 DOI: 10.1080/00015385.2018.1507477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The effects of angiotensin converting enzyme (ACE) inhibitors result from the inhibition of the ACE (kininase II) to ultimately influence both the renin-angiotensin system and the degradation of the bradykinin (BK) metabolism. ACE inhibitors block the degradation of BK and substance P by ACE. In addition, an active metabolite of BK (Des-Arg9-BK) is catalysed by kininase I and its degradation is controlled in part by the conversion enzyme. These molecules have been associated with increased plasma extravasation associated with ACE inhibitors. ACE inhibitors are the leading cause of drug-induced Angioedema (AE). Symptoms of AE mainly occur after the first month of treatment by ACE. However, very late onset cases, sometimes after several years of stable therapy, are also described in the literature. It has been observed that patients previously stable under ACE inhibitor will most likely develop AE soon after the addition of another medication, including the combination of aspirin or non-steroid anti-inflammatory drugs with ACE inhibitor which has proved to be the most common cause, accounting for close to 50% of all AE cases related to ACE inhibitors. This side effect of ACE inhibitors, sometimes very late and rare, deserves to be recalled.
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Affiliation(s)
- Laurent Davin
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
- GIGA Cardiovascular Sciences University Hospital of Liege
| | - Patrick Marechal
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
| | - Patrizio Lancellotti
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
- GIGA Cardiovascular Sciences University Hospital of Liege
| | - Christophe Martinez
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
| | - Luc Pierard
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
- GIGA Cardiovascular Sciences University Hospital of Liege
| | - Regis Radermecker
- Diabetes, Nutrition and Metabolic disorders Unit CHU Liege; Clinical Pharmacology, Liege University, Belgium
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52
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Jeon J, Lee YJ, Lee S. Effect of icatibant on angiotensin‐converting enzyme inhibitor‐induced angioedema: A meta‐analysis of randomized controlled trials. J Clin Pharm Ther 2019; 44:685-692. [DOI: 10.1111/jcpt.12997] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/20/2019] [Accepted: 05/28/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Jinyoung Jeon
- School of Pharmacy Sungkyunkwan University Suwon Korea
- Department of Pharmacy National Cancer Center Hospital Goyang Korea
| | - Yun Jeong Lee
- College of Pharmacy Dankook University Cheonan Korea
| | - Seok‐Yong Lee
- School of Pharmacy Sungkyunkwan University Suwon Korea
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53
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Long BJ, Koyfman A, Gottlieb M. Evaluation and Management of Angioedema in the Emergency Department. West J Emerg Med 2019; 20:587-600. [PMID: 31316698 PMCID: PMC6625683 DOI: 10.5811/westjem.2019.5.42650] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 01/14/2023] Open
Abstract
Angioedema is defined by non-dependent, non-pitting edema that affects several different sites and is potentially life-threatening due to laryngeal edema. This narrative review provides emergency physicians with a focused overview of the evaluation and management of angioedema. Two primary forms include histamine-mediated and bradykinin-mediated angioedema. Histamine-mediated forms present similarly to anaphylaxis, while bradykinin-mediated angioedema presents with greater face and oropharyngeal involvement and higher risk of progression. Initial evaluation and management should focus on evaluation of the airway, followed by obtaining relevant historical features, including family history, medications, and prior episodes. Histamine-mediated angioedema should be treated with epinephrine intramuscularly, antihistaminergic medications, and steroids. These medications are not effective for bradykinin-mediated forms. Other medications include C1-INH protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists. Evidence is controversial concerning the efficacy of these medications in an acute episode, and airway management is the most important intervention when indicated. Airway intervention may require fiberoptic or video laryngoscopy, with preparation for cricothyrotomy. Disposition is dependent on patient's airway and respiratory status, as well as the sites involved.
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Affiliation(s)
- Brit Jeffrey Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Abstract
Incidence of angioedema associated with angiotensin-converting enzyme inhibitors (ACE-I) has been estimated at 0.1%-2.2% of patients receiving treatment. Despite the potential severity of this disease state, standardized treatment is lacking. Traditional pharmacotherapy options include medications that target inflammatory mediators and the angiotensin pathway. However, because ACE-I-induced angioedema is caused by accumulation of bradykinin, these medications fail to target the underlying pathophysiology. Recently, novel therapies that target the kallikrein-bradykinin pathway have been studied. These include icatibant, ecallantide, C1 esterase inhibitors, and fresh-frozen plasma. Recent randomized controlled trials exhibit contradictory results with the use of icatibant. This is a focused review on traditional and novel treatment strategies for ACE-I-induced angioedema.
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Ducote C, Kesterke MJ, Bhattacharjee R, Read-Fuller A, Reddy LV. Macroglossia secondary to lisinopril-induced acute angioedema. Proc (Bayl Univ Med Cent) 2019; 32:70-72. [PMID: 30956587 DOI: 10.1080/08998280.2018.1540736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/16/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022] Open
Abstract
Presented here are two cases of acute acquired macroglossia in adults caused by angioedema resulting from a reaction to angiotensin-converting enzyme inhibitors (ACEIs). Angioedema can be caused by a variety of factors, but ACEIs are the most common precipitating factor. Symptoms such as swelling of the lips, face, tongue, and throat can lead to life-threatening airway compromise. Early management of acute angioedema and macroglossia includes antihistamines, steroids, and occasionally epinephrine, yet a small percentage of patients progress toward airway obstruction and will require intubation. Edema within the lips, face, and throat usually subsides within a week, but the tongue can remain edematous for prolonged periods if biting trauma occurs. If the patient's macroglossia does not resolve in a reasonable amount of time, a partial glossectomy may be indicated.
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Affiliation(s)
- Colten Ducote
- Department of Oral and Maxillofacial Surgery, Baylor University Medical Center at DallasDallasTexas.,Department of Oral and Maxillofacial Surgery, Texas A&M University College of DentistryDallasTexas
| | - Matthew J Kesterke
- Department of Biomedical Sciences, Texas A&M University College of DentistryDallasTexas
| | - Ritesh Bhattacharjee
- Department of Oral and Maxillofacial Surgery, Texas A&M University College of DentistryDallasTexas.,Department of Biomedical Sciences, Texas A&M University College of DentistryDallasTexas
| | - Andrew Read-Fuller
- Department of Oral and Maxillofacial Surgery, Baylor University Medical Center at DallasDallasTexas.,Department of Oral and Maxillofacial Surgery, Texas A&M University College of DentistryDallasTexas
| | - Likith V Reddy
- Department of Oral and Maxillofacial Surgery, Baylor University Medical Center at DallasDallasTexas.,Department of Oral and Maxillofacial Surgery, Texas A&M University College of DentistryDallasTexas
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56
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Mawhirt SL, Fonacier L, Aquino M. Utilization of high-fidelity simulation for medical student and resident education of allergic-immunologic emergencies. Ann Allergy Asthma Immunol 2019; 122:513-521. [PMID: 30802501 DOI: 10.1016/j.anai.2019.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/07/2019] [Accepted: 02/17/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The advantages of clinical simulation used in medical education include the acquisition of clinical skills in a controlled setting, promoting a multidisciplinary approach to patient care, and a high degree of learner satisfaction. OBJECTIVE We aimed to identify knowledge gaps among Internal Medicine residents and students in the diagnosis and treatment of anaphylaxis and angiotensin-converting enzyme (ACE)-inhibitor-induced angioedema through their participation in a simulation course. METHODS We conducted a cohort study involving clinical simulations with a high-fidelity, patient-simulator. The cases (antibiotic-induced anaphylaxis and ACE-inhibitor-induced angioedema) were standardized and algorithmic. Participants completed a pre- and post- simulation knowledge assessment and course evaluation. A follow-up knowledge survey was sent out 6 to 12 months after the course completion. RESULTS Twelve groups comprising 45 medical students and residents completed the anaphylaxis course. All groups diagnosed anaphylaxis after more than 2-organ-system involvement had manifested, and half of the groups made the diagnosis after the patient-simulator was in anaphylactic shock. Half gave an incorrect dose of epinephrine, and most of the participants were inexperienced in epinephrine auto-injector (EAI) administration. Eight groups comprising 27 participants completed the ACE-inhibitor-angioedema course. Six of the groups correctly diagnosed the patient-simulator, but multiple incorrect treatments were given, and only 1 group successfully intubated the patient-simulator. Knowledge improved immediately after the simulation, and knowledge specific to EAI treatment seemed to be retained long-term. All participants agreed that the simulation was practical to their education. CONCLUSION Clinical simulation improves knowledge on the diagnosis and treatment of anaphylaxis and ACE-inhibitor-induced angioedema. We advocate that clinical simulation be incorporated at institutions with appropriate capabilities.
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Affiliation(s)
- Stephanie L Mawhirt
- NYU-Winthrop Hospital, Division of Allergy and Immunology, Mineola, New York.
| | - Luz Fonacier
- NYU-Winthrop Hospital, Division of Allergy and Immunology, Mineola, New York
| | - Marcella Aquino
- Hasbro Children's Hospital, Department of Pediatrics, Allergy & Immunology Section, Providence, Rhode Island
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Patel H, Kant S, Chow R. A rare presentation of angioedema with isolated retropharyngeal and supraglottic involvement. J Community Hosp Intern Med Perspect 2019; 9:36-39. [PMID: 30788074 PMCID: PMC6374935 DOI: 10.1080/20009666.2018.1562855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/18/2018] [Indexed: 11/07/2022] Open
Abstract
Angiotensin converting-enzyme (ACE) inhibitors are commonly prescribed drugs with multiple indications including congestive heart failure, hypertension, and diabetic nephropathy. ACE inhibitor induced angioedema is commonly seen across emergency departments and clinics, with transient swelling of lips, tongue, and other facial structures being the common presentation. Isolated airway obstruction as a result of pharyngeal and laryngeal swelling without facial swelling is a rare presentation. We present a case of a patient on lisinopril therapy for one year who experienced severe airway compromise without the classic symptoms of ACE inhibitor induced angioedema. He required emergent cricothyroidotomy to secure his airway, as fiberoptic laryngoscopy showed 90% obstruction and inability to visualize true vocal cords. His ACE inhibitor therapy was discontinued, and he was discharged home within a few days with no residual symptoms.
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Affiliation(s)
- H Patel
- Department of Medicine, American University of Antigua, New York, USA
| | - S Kant
- Department of Nephrology/Internal Medicine, University of Maryland, Maryland, USA
| | - R Chow
- Department of Nephrology/Internal Medicine, University of Maryland, Maryland, USA
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58
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Rathbun KM. Angioedema after thrombolysis with tissue plasminogen activator: an airway emergency. Oxf Med Case Reports 2019; 2019:omy112. [PMID: 30697429 PMCID: PMC6345090 DOI: 10.1093/omcr/omy112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 09/10/2018] [Accepted: 10/12/2018] [Indexed: 01/26/2023] Open
Abstract
Recombinant tissue plasminogen activator (rtPA), an enzyme that catalyzes the conversion of plasminogen to plasmin resulting in fibrinolysis, is used for the treatment of acute ischemic strokes. The use of this medication is not without complication. One complication of this therapy is angioedema. This complication can be life-threatening if not recognized quickly. However, the potential for the development of angioedema after rtPA administration is not widely known. This is a case of a 60-year-old man who suffered an acute ischemic stroke and was given rtPA. The patient subsequently developed rapidly progressing angioedema leading to airway compromise. The patient was intubated with some difficulty and the angioedema improved and the patient was able to be extubated the next day. Angioedema secondary to administration of rtPA is thought to be bradykinin mediated, but the exact mechanism is unknown. Treatment with FFP, Icatibant, Ecallantide or a C1-esterase inhibitor can be considered.
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Affiliation(s)
- Kimberly M Rathbun
- Department of Emergency Medicine, The Brody School of Medicine at East Carolina University, Greenville, NC, USA
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59
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Dhopeshwarkar N, Sheikh A, Doan R, Topaz M, Bates DW, Blumenthal KG, Zhou L. Drug-Induced Anaphylaxis Documented in Electronic Health Records. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:103-111. [PMID: 29969686 PMCID: PMC6311439 DOI: 10.1016/j.jaip.2018.06.010] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 06/15/2018] [Accepted: 06/19/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although drugs represent a common cause of anaphylaxis, few large studies of drug-induced anaphylaxis have been performed. OBJECTIVE To describe the epidemiology and validity of reported drug-induced anaphylaxis in the electronic health records (EHRs) of a large United States health care system. METHODS Using EHR drug allergy data from 1995 to 2013, we determined the population prevalence of anaphylaxis including anaphylaxis prevalence over time, and the most commonly implicated drugs/drug classes reported to cause anaphylaxis. Patient risk factors for drug-induced anaphylaxis were assessed using a logistic regression model. Serum tryptase and allergist visits were used to assess the validity and follow-up of EHR-reported anaphylaxis. RESULTS Among 1,756,481 patients, 19,836 (1.1%) reported drug-induced anaphylaxis; penicillins (45.9 per 10,000), sulfonamide antibiotics (15.1 per 10,000), and nonsteroidal anti-inflammatory drugs (NSAIDs) (13.0 per 10,000) were most commonly implicated. Patients with white race (odds ratio [OR] 2.38, 95% CI 2.27-2.49), female sex (OR 2.20, 95% CI 2.13-2.28), systemic mastocytosis (OR 4.60, 95% CI 2.66-7.94), Sjögren's syndrome (OR 1.94, 95% CI 1.47-2.56), and asthma (OR 1.50, 95% CI 1.43-1.59) had an increased odds of drug-induced anaphylaxis. Serum tryptase was performed in 135 (<1%) anaphylaxis cases and 1,587 patients (8.0%) saw an allergist for follow-up. CONCLUSIONS EHR-reported anaphylaxis occurred in approximately 1% of patients, most commonly from penicillins, sulfonamide antibiotics, and NSAIDs. Females, whites, and patients with mastocytosis, Sjögren's syndrome, and asthma had increased odds of reporting drug-induced anaphylaxis. The low observed frequency of tryptase testing and specialist evaluation emphasize the importance of educating providers on anaphylaxis management.
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Affiliation(s)
- Neil Dhopeshwarkar
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; College of Pharmacy and Health Sciences, St. John's University, Queens, NY
| | - Aziz Sheikh
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Raymond Doan
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; School of Pharmacy, MCPHS University, Boston, Mass
| | - Maxim Topaz
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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60
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Wong A, Seger DL, Lai KH, Goss FR, Blumenthal KG, Zhou L. Drug Hypersensitivity Reactions Documented in Electronic Health Records within a Large Health System. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1253-1260.e3. [PMID: 30513361 DOI: 10.1016/j.jaip.2018.11.023] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/13/2018] [Accepted: 11/19/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hypersensitivity reactions (HSRs) are immunologic responses to drugs. Identification of HSRs documented in the electronic health record (EHR) is important for patient safety. OBJECTIVE To examine HSR epidemiology using longitudinal EHR data from a large United States health care system. METHODS Patient demographic information and drug allergy data were obtained from the Partners Enterprise-wide Allergy Repository for 2 large tertiary care hospitals from 2000 to 2013. Drug-induced HSRs were categorized into immediate and delayed HSRs based on typical phenotypes. Causative drugs and drug groups were assessed. The prevalence of HSRs was determined, and sex and racial differences were analyzed. RESULTS Among 2.7 million patients, 377,474 (13.8%) reported drug-induced HSRs, of whom 70.3% were female and 77.5% were white. A total of 580,456 HSRs were reported, of which 53.1% were immediate reaction phenotypes. Common immediate HSRs included hives (48.8%), itching (15.0%), and angioedema (14.1%). Delayed HSR phenotypes (46.9%) were largely rash (99.0%). Penicillins were associated with the most immediate (33.0%) and delayed (39.0%) HSRs. Although most HSRs were more prevalent in females and white patients, notable differences were identified for certain rare HSRs including acute interstitial nephritis, which appeared more commonly in males (0.02% vs 0.01%, P < .001). Asian patients had more fixed drug eruptions (0.007% vs 0.002%, P = .021) and severe cutaneous adverse reactions (0.05% vs 0.04%, P < .001). CONCLUSIONS Drug HSRs were reported in 13.8% of patients. Almost one-half of reported immediate HSR phenotypes were hives, and almost all reported delayed HSR phenotypes were rash. HSRs largely affected female and white patients, but differences were identified for specific rare HSRs.
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Affiliation(s)
- Adrian Wong
- Department of Pharmacy Practice, MCPHS University, Boston, Mass; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass
| | - Diane L Seger
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass; Clinical and Quality Analysis, Partners HealthCare, Somerville, Mass
| | - Kenneth H Lai
- Clinical and Quality Analysis, Partners HealthCare, Somerville, Mass; Department of Computer Science, Brandeis University, Waltham, Mass
| | - Foster R Goss
- Department of Emergency Medicine, University of Colorado, Aurora, Colo
| | - Kimberly G Blumenthal
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
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Intérêt de l’acide tranexamique en traitement d’urgence de première intention des crises d’angiœdème bradykinique sous IEC. Rev Med Interne 2018; 39:772-776. [DOI: 10.1016/j.revmed.2018.04.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 04/11/2018] [Accepted: 04/15/2018] [Indexed: 11/22/2022]
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Abstract
Drug allergy is commonly encountered in clinical practice. It is an immunological response to a pharmaceutical agent. The clinical presentation can vary from mild cutaneous reactions to life-threatening conditions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Diagnosis is most often clinical, but investigations such as measurement of immunoglobulin E, patch testing, and skin biopsy may be required. In patients with a known drug allergy, the offending drug should be avoided. [Pediatr Ann. 2018;47(10):e419-e425.].
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63
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Hahn J, Bock B, Muth CM, Pfaue A, Friedrich D, Hoffmann TK, Greve J. [The ulm emergency algorithm for the acute treatment of drug-induced, bradykinin-mediated angioedema]. Med Klin Intensivmed Notfmed 2018; 114:708-716. [PMID: 30232503 DOI: 10.1007/s00063-018-0483-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/16/2018] [Accepted: 08/05/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Bradykinin-mediated, drug-induced edema like ACE-inhibitor-induced angioedema (ACEi AE) is almost exclusively located in the head and neck region and is potentially life threatening. To date, there are no guidelines or officially-approved treatments available for this pathology. OBJECTIVES We sought to provide a structured therapeutic algorithm for the acute treatment of drug-induced bradykinin-mediated angioedema. MATERIALS AND METHODS We analyzed data (especially the course of disease and therapy) of all patients with acute angioedema, who presented to the Department of Otorhinolaryngology, Head and Neck Surgery at the University of Ulm (2010-2015). We also conducted a literature review on PubMed with the terms "acute angioedema", "angioedema emergency", "ACE angioedema", "bradykinin angioedema" and "angioedema therapy". Other fundamental references were the recent German guidelines "hereditary angioedema", "anaphylaxis" and "airway management". RESULTS An emergency algorithm was generated as a flowchart for the acute therapy of bradykinin-mediated drug-induced angioedema was generated. We focused on the decision criteria for intubation/airway management and pharmacological therapy: antihistamines and glucocorticoids versus anti-bradykinin treatment. Furthermore, recommendations for inpatient monitoring have been derived. CONCLUSION/DISCUSSION To date, therapy of drug-induced bradykinin-mediated angioedema is performed according to an "off-label" use and without officially-approved guidelines. The presented emergency algorithm provides a first approach for a structured therapeutic concept for a potentially life-threatening pathology.
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Affiliation(s)
- J Hahn
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Frauensteige 12, 89075, Ulm, Deutschland.
| | - B Bock
- Klinik für Anästhesiologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - C-M Muth
- Klinik für Anästhesiologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - A Pfaue
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - D Friedrich
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - T K Hoffmann
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - J Greve
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Frauensteige 12, 89075, Ulm, Deutschland
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Kostis WJ, Shetty M, Chowdhury YS, Kostis JB. ACE Inhibitor-Induced Angioedema: a Review. Curr Hypertens Rep 2018; 20:55. [PMID: 29884969 DOI: 10.1007/s11906-018-0859-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW This study aims to examine current knowledge on the occurrence, pathophysiology, and treatment of angioedema among patients who receive angiotensin-converting enzyme inhibitors. RECENT FINDINGS Angiotensin-converting enzyme inhibitors (ACE-I), a medication class used by an estimated 40 million people worldwide, are associated with angioedema that occurs with incidence ranging from 0.1 to 0.7%. The widespread use of ACE-I resulted in one third of all emergency department visits for angioedema. Angioedema occurs more frequently in African Americans, smokers, women, older individuals, and those with a history of drug rash, seasonal allergies, and use of immunosuppressive therapy. The pathophysiology of ACE-I-induced angioedema involves inhibition of bradykinin and substance P degradation by ACE (kininase II) leading to vasodilator and plasma extravasation. Treatment modalities include antihistamines, steroids, and epinephrine, as well as endotracheal intubation in cases of airway compromise. Patients with a history of ACE-I-induced angioedema should not be re-challenged with this class of agents, as there is a relatively high risk of recurrence. CONCLUSION ACE-I are frequently used therapeutic agents that are associated with angioedema. Their use should be avoided in high-risk individuals and early diagnosis, tracheal intubation in cases of airway compromise, and absolute avoidance of re-challenge are important.
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Affiliation(s)
- William J Kostis
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute, 125 Paterson Street, CAB-4100, New Brunswick, NJ, 08901, USA.
| | - Mrinali Shetty
- Saint Peter's University Hospital, New Brunswick, NJ, USA
| | | | - John B Kostis
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute, 125 Paterson Street, CAB-4100, New Brunswick, NJ, 08901, USA
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Small bowel angioedema from angiotensin-converting enzyme: Changes on computed tomography. Radiol Case Rep 2018; 13:55-57. [PMID: 29552243 PMCID: PMC5851310 DOI: 10.1016/j.radcr.2017.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/11/2017] [Accepted: 09/11/2017] [Indexed: 11/20/2022] Open
Abstract
Intestinal angioedema is a rare side effect of angiotensin-converting enzyme inhibitors. We present a 41-year-old woman with sporadic right lower quadrant abdominal pain and diarrhea with multiple computed tomography scans demonstrating enteritis. Suspicion turned to angiotensin-converting enzyme inhibitor use as the cause for the patient's illness after an extensive negative evaluation including labs, stool studies, endoscopies, and capsule endoscopy. Weeks after stopping the medication, the patient's symptoms improved and repeat computed tomography showed a resolution of the previously seen findings of enteritis. This case illustrates the importance of a good medication review to make appropriate clinical decisions and diagnoses.
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Kuperstock JE, Pritchard N, Horný M, Xiao CC, Brook CD, Platt MP. Inhalant allergen sensitization is an independent risk factor for the development of angioedema. Am J Otolaryngol 2018; 39:111-115. [PMID: 29310846 DOI: 10.1016/j.amjoto.2017.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVE The etiology and risk factors for angioedema remain poorly understood with causative triggers often going undiagnosed despite repeated reactions. The purpose of this study was to determine the relationship between inhalant allergen sensitization and angioedema. METHODS A retrospective review of patients who had in vitro inhalant allergy testing from 2006 to 2010 was performed. Patients with a diagnosis of angioedema who underwent inhalant allergy testing were identified. Analyses for co-morbidities, class of sensitization, seasonal timing of angioedema, and concurrent use of known hypertensive medications that can cause angioedema were performed. RESULTS There were 1000 patients who underwent inhalant allergy testing and qualified for the study. 37/1000 had at least one episode of angioedema and of these patients, 34 had positive inhalant sensitization testing results. Multivariate regression models showed overall sensitization status, seasonal allergen and epidermal/mite sensitization as independent risk factors (p<0.001, p=0.005, p=0.025 respectively) when controlling for ACE inhibitor use and other covariates. Tree, and epidermal/mite sensitizations were independent risk factors for angioedema in mono-sensitized subject analysis (p=0.028, p=0.029, respectively). CONCLUSION Both seasonal and perennial allergen sensitizations are independent risk factors for the development of angioedema. In patients with angioedema and an unknown trigger, inhalant allergen sensitization should be considered as a potential contributing factor to the development of angioedema.
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67
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Ticagrelor-Induced Angioedema: A Rare and Unexpected Phenomenon. Case Rep Cardiol 2018; 2017:7612713. [PMID: 29391955 PMCID: PMC5748116 DOI: 10.1155/2017/7612713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 11/23/2017] [Indexed: 11/18/2022] Open
Abstract
Angioedema can cause potentially life-threatening airway obstruction. This case report describes an exceedingly rare episode of ticagrelor-induced hypersensitivity reaction, manifesting as angioedema with periorbital and likely respiratory involvement. The heart team should be vigilant for this precarious condition which may require emergent airway management. Desensitization protocols and alternative regimens (e.g., clopidogrel, prasugrel, and addition of an adjunctive anticoagulant) should be considered when there is an absolute indication for antiplatelet therapy.
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68
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Yancey R. Anesthetic Management of the Hypertensive Patient: Part I. Anesth Prog 2018; 65:131-138. [PMID: 29952638 PMCID: PMC6022786 DOI: 10.2344/anpr-65-02-12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 04/30/2018] [Indexed: 12/20/2022] Open
Abstract
Hypertension is an important health challenge that affects millions of people across the world and is a major risk factor for cardiovascular disease. It is critical that anesthesia providers have a working knowledge of the systemic implications of hypertension. This review article will discuss the medical definitions of hypertension, the physiology of maintaining blood pressure, outpatient treatment of hypertension, anesthetic implications, and the common medications used by anesthesia providers in the treatment of hypertension. Part I will provide an overview of hypertension and blood pressure regulation. In addition, drugs affecting predominantly renal control of hypertension, such as diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and renin-inhibiting agents, will be discussed. In part II, the remaining major antihypertensive medications will be reviewed as well as anesthetic implications of managing patients with hypertension.
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Affiliation(s)
- Russell Yancey
- PGY-2 Resident, New York University–Langone Hospital Dental Anesthesiology Service, Brooklyn, New York
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69
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Björkqvist J, Sala-Cunill A, Renné T. Hereditary angioedema: a bradykinin-mediated swelling disorder. Thromb Haemost 2017; 109:368-74. [DOI: 10.1160/th12-08-0549] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 11/08/2012] [Indexed: 11/05/2022]
Abstract
SummaryEdema is tissue swelling and is a common symptom in a variety of diseases. Edema form due to accumulation of fluids, either through reduced drainage or increased vascular permeability. There are multiple vascular signalling pathways that regulate vessel permeability. An important mediator that increases vascular leak is the peptide hormone bradykinin, which is the principal agent in the swelling disorder hereditary angioedema. The disease is autosomal dominant inherited and presents clinically with recurrent episodes of acute swelling that can be life-threatening involving the skin, the oropharyngeal, laryngeal, and gastrointestinal mucosa. Three different types of hereditary angiodema exist in patients. The review summarises current knowledge on the pathophysiology of hereditary angiodema and focuses on recent experimental and pharmacological findings that have led to a better understanding and new treatments for the disease.
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Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor–Induced Upper Airway Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1402-1409.e3. [DOI: 10.1016/j.jaip.2017.03.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/02/2017] [Accepted: 03/08/2017] [Indexed: 01/14/2023]
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71
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Geenen JW, Baranova EV, Asselbergs FW, de Boer A, Vreman RA, Palmer CNA, Maitland-van der Zee AH, Hövels AM. Early health technology assessments in pharmacogenomics: a case example in cardiovascular drugs. Pharmacogenomics 2017; 18:1143-1153. [DOI: 10.2217/pgs-2017-0063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To assess the required characteristics (cost, sensitivity and specificity) of a pharmacogenomic test for being a cost-effective prevention of angiotensin-converting enzyme inhibitors induced angioedema. Furthermore, we assessed the influence of only testing high-risk populations. Materials & methods: A decision tree was used. Results: With a willingness-to-pay threshold of €20,000 and €80,000 per quality adjusted life year, a 100% sensitive and specific test may have a maximum cost of €1.30 and €1.95, respectively. When only genotyping high-risk populations, the maximum test price would be €5.03 and €7.55, respectively. Conclusion: This theoretical pharmacogenomic test is only cost-effective at high specificity, high sensitivity and a low price. Only testing high-risk populations yields more realistic maximum test prices for cost–effectiveness of the intervention.
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Affiliation(s)
- Joost W Geenen
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
| | - Ekaterina V Baranova
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart & Lungs, UMC Utrecht, 3508 GA Utrecht, The Netherlands
- Durrer Center for Cardiovascular Research, Netherlands Heart Institute, 3501 DG Utrecht, The Netherlands
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, WC1E 6BT London, UK
| | - Anthonius de Boer
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
| | - Rick A Vreman
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
| | - Colin NA Palmer
- Population Pharmacogenetics Group, Biomedical Research Centre, University of Dundee, Ninewells Hospital & Medical School, DD2 1GZ Dundee, UK
| | - Anke H Maitland-van der Zee
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
- Department of Respiratory Disease, Academic Medical Center, PO Box 22660,1100 DD, Amsterdam, The Netherlands
| | - Anke M Hövels
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
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72
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Hahn J, K. Hoffmann T, Bock B, Nordmann-Kleiner M, Trainotti S, Greve J. Angioedema. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:489-496. [PMID: 28818177 PMCID: PMC5569554 DOI: 10.3238/arztebl.2017.0489] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 12/13/2016] [Accepted: 04/24/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute angioedema of the upper airways can be life-threatening. An important distinction is drawn between mast-cell-mediated angioedema and bradykinin-mediated angioedema; the treatment of these two entities is fundamentally different. METHODS This review is based on pertinent articles retrieved by a selective search in PubMed and on guidelines concerning the treatment of angioedema. The authors draw on their own clinical experience in their assessment of the literature. RESULTS In the emergency clinical situation, the most important information comes from accompanying manifestations such as itching and urticaria and from the patient's drug history and family history. When angioedema affects the head and neck, securing the upper airways is the highest priority. Angioedema is most commonly caused by mast-cell mediators, such as histamine. This type of angioedema is sometimes accompanied by urticaria and can be effectively treated with antihistamines or glucocorticoids. In case of a severe allergic reaction or anaphylaxis, epinephrine is given intramuscularly in a dose that is adapted to the patient's weight (150 μg for body weight >10 kg, 300 μg for body weight >30 kg). Bradykinin-mediated angioedema may arise as either a hereditary or an acquired tendency. Acquired angioedema can be caused by angiotensin converting enzyme (ACE) inhibitors and by angiotensin II receptor blockers. Bradykinin-mediated angioedema should be treated specifically with C1-esterase inhibitor concentrates or bradykinin-2 receptor antagonists. CONCLUSION Angioedema of the upper airways requires a well-coordinated diagnostic and therapeutic approach. Steroids and antihistamines are very effective against mast-cell-mediated angioedema, but nearly useless against bradykinin-mediated angioedema. For angioedema induced by ACE inhibitors, no causally directed treatment has yet been approved.
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Affiliation(s)
- Janina Hahn
- Department of Otorhinolaryngology, Ulm University Hospital
| | | | - Bastian Bock
- Department of Anaesthesiology, Ulm University Hospital
| | | | | | - Jens Greve
- Department of Otorhinolaryngology, Ulm University Hospital
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73
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Reichman ME, Wernecke M, Graham DJ, Liao J, Yap J, Chillarige Y, Southworth MR, Keeton S, Goulding MR, Mott K, Kelman JA. Antihypertensive drug associated angioedema: effect modification by race/ethnicity. Pharmacoepidemiol Drug Saf 2017; 26:1190-1196. [DOI: 10.1002/pds.4260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 06/12/2017] [Accepted: 06/19/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Marsha E. Reichman
- Office of Surveillance and Epidemiology; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | | | - David J. Graham
- Office of Surveillance and Epidemiology; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | | | - John Yap
- Office of Biostatistics; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | | | - Mary Ross Southworth
- Office of New Drugs; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | - Stephine Keeton
- Office of Biostatistics; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | - Margie R. Goulding
- Office of Surveillance and Epidemiology; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | - Katrina Mott
- Office of Surveillance and Epidemiology; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
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74
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Bonner N, Panter C, Kimura A, Sinert R, Moellman J, Bernstein JA. Development and validation of the angiotensin-converting enzyme inhibitor (ACEI) induced angioedema investigator rating scale and proposed discharge criteria. BMC Health Serv Res 2017; 17:366. [PMID: 28532495 PMCID: PMC5440910 DOI: 10.1186/s12913-017-2274-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 04/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of angiotensin-converting enzyme inhibitors (ACEI) has been associated with the development of bradykinin-mediated angioedema. With ever-widening indications for ACEI in diseases including hypertension, congestive heart failure and diabetic nephropathy, a concomitant increase in ACEI-Angioedema (ACEI-A) has been reported. At present there is no validated severity scoring or discharge criteria for ACEI-A. We sought to develop and validate an investigator rating scale with corresponding discharge criteria using clinicians experienced in treating ACEI-A. METHODS In-depth, 60-min qualitative telephone interviews were conducted with 12 US-based emergency physicians. Beforehand, clinicians were sent four case studies describing patients experiencing different severities of angioedema attacks. Clinicians were initially asked open-ended questions about their experience of patients' symptoms, treatment and discharge decisions. Clinicians then rated each patient case study and discussed patient diagnoses, ratings of symptom severity and discharge evaluation. The ratings were used to assess inter-rater reliability of the scale using the intra-class correlation coefficient (ICC) using IBM SPSS analysis Version 19 software. RESULTS The findings provide support focusing on four key symptoms of airway compromise scored on a 0-4 scale: 1) Difficulty Breathing, 2) Difficulty Swallowing, 3) Voice Changes and 4) Tongue Swelling and the corresponding discharge criteria of a score of 0 or 'No symptoms' for Difficulty Breathing and Difficulty Swallowing and a score of 0 or 1 indicating mild or absence of symptoms for Voice Change and Tongue Swelling. Eleven clinicians agreed the absence of standardized discharge criteria supported the use of this scale. All physicians concurred with the recommended discharge criteria. The clinician ratings provided evidence of strong inter-rater reliability for the rating scale (ICC > 0.80). CONCLUSION The investigator rating scale and discharge criteria are clinically valid, relevant and reliable. Moreover, both address the current unmet need for standardized ED discharge criteria.
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Affiliation(s)
- Nicola Bonner
- Adelphi Values, Adelphi Mill, Grimshaw Lane, Bollington, Cheshire, SK10 5JB, UK.
| | - Charlotte Panter
- Adelphi Values, Adelphi Mill, Grimshaw Lane, Bollington, Cheshire, SK10 5JB, UK
| | - Alan Kimura
- Shire, 300 Shire Way, Lexington, MA, 02421, USA
| | - Rich Sinert
- Department of Emergency Medicine, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, USA
| | - Joseph Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan A Bernstein
- Clinical Research, Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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75
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Bernstein JA, Cremonesi P, Hoffmann TK, Hollingsworth J. Angioedema in the emergency department: a practical guide to differential diagnosis and management. Int J Emerg Med 2017; 10:15. [PMID: 28405953 PMCID: PMC5389952 DOI: 10.1186/s12245-017-0141-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 03/28/2017] [Indexed: 11/23/2022] Open
Abstract
Background Angioedema is a common presentation in the emergency department (ED). Airway angioedema can be fatal; therefore, prompt diagnosis and correct treatment are vital. Objective of the review Based on the findings of two expert panels attended by international experts in angioedema and emergency medicine, this review aims to provide practical guidance on the diagnosis, differentiation, and management of histamine- and bradykinin-mediated angioedema in the ED. Review The most common pathophysiology underlying angioedema is mediated by histamine; however, ED staff must be alert for the less common bradykinin-mediated forms of angioedema. Crucially, bradykinin-mediated angioedema does not respond to the same treatment as histamine-mediated angioedema. Bradykinin-mediated angioedema can result from many causes, including hereditary defects in C1 esterase inhibitor (C1-INH), side effects of angiotensin-converting enzyme inhibitors (ACEis), or acquired deficiency in C1-INH. The increased use of ACEis in recent decades has resulted in more frequent encounters with ACEi-induced angioedema in the ED; however, surveys have shown that many ED staff may not know how to recognize or manage bradykinin-mediated angioedema, and hospitals may not have specific medications or protocols in place. Conclusion ED physicians must be aware of the different pathophysiologic pathways that lead to angioedema in order to efficiently and effectively manage these potentially fatal conditions.
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Affiliation(s)
- Jonathan A Bernstein
- Division of Immunology/Allergy, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
| | - Paolo Cremonesi
- Department of Emergency Medicine, E. O. Galliera Hospital, Genoa, Italy
| | - Thomas K Hoffmann
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - John Hollingsworth
- Department of Emergency Medicine, University Hospital, Aintree, Liverpool, UK
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76
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Epidemiology of ACE Inhibitor Angioedema Utilizing a Large Electronic Health Record. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:744-749. [PMID: 28377081 DOI: 10.1016/j.jaip.2017.02.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 02/08/2017] [Accepted: 02/20/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEIs) are a common cause of drug-induced angioedema in the United States. Most epidemiologic ACEI angioedema data are from large multicenter clinical trials. OBJECTIVE The objective of this study was to identify the incidence of and risk factors for ACEI angioedema using a large integrated electronic health record (EHR). METHODS We conducted a retrospective cohort study of all ACEI prescriptions in the outpatient setting of a large academic center between January 1, 2000, and September 30, 2008. We determined frequency, timing, and risk factors for ACEI angioedema within 5 years of prescription. All data were derived from EHR sources, with angioedema defined by EHR reactions of angioedema, swelling, edema, or lip, eye, face, tongue, throat or mouth swelling. RESULTS Among 134,945 patients prescribed an ACEI, 0.7% (n = 888) developed angioedema during the subsequent 5 years. Sex was similar but patients who developed ACEI angioedema were younger (61.5 vs 62.7 years, P = .007). Patients with ACEI angioedema were more likely to have a history of nonsteroidal anti-inflammatory drug allergy compared with patients who did not develop angioedema (7.1% vs 4.2%, P < .001). We identified a 0.07% incidence of ACEI angioedema within 1 month of prescription and a 0.23% incidence during the first year. Incidence of angioedema was relatively constant annually over the subsequent 4 years (0.10% to 0.12%). CONCLUSIONS The incidence of ACEI angioedema within a large EHR is consistent with large clinical trial data. We observed a persistent and relatively constant annual risk; however, angioedema risk factors and underlying genetic and pathophysiological mechanisms require further study.
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77
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Abstract
The purpose of this article is to review the current available material pertaining to atopic dermatitis, contact dermatitis, urticaria, and angioedema. This article focuses on each disease process's clinical presentation, diagnosis, and management. Although atopic dermatitis and contact dermatitis are similar, their development is different and can affect a patient's quality of life. Urticaria and angioedema are also similar, but the differentiation of the two processes is crucial in that they have significant morbidity and mortality, each with a different prognosis.
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Affiliation(s)
- Van Nguyen
- Department of Family Medicine, Loma Linda University, 25455 Barton Road, Suite 209B, Loma Linda, CA 92354, USA.
| | - Lauren Simon
- Department of Family Medicine, Loma Linda University, 25455 Barton Road, Suite 209B, Loma Linda, CA 92354, USA
| | - Ecler Jaqua
- Department of Family Medicine, Loma Linda University, 25455 Barton Road, Suite 209B, Loma Linda, CA 92354, USA
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78
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Savino MR, Mittal PK, Miller FH. MR imaging of intestinal angioedema related to angiotensin-converting enzyme inhibitors: Report of three cases and review of literature. Clin Imaging 2017; 43:122-126. [PMID: 28292712 DOI: 10.1016/j.clinimag.2017.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/09/2017] [Accepted: 03/06/2017] [Indexed: 11/20/2022]
Abstract
Angioedema is a condition in which an increase in vascular permeability leads to the swelling of body tissues. There are both hereditary and acquired forms of the disease, with the latter often associated with the administration of angiotensin-converting enzyme inhibitor medication. Involvement of the intestinal tract is a rare manifestation of angioedema, and can present with abdominal pain, nausea, and vomiting. It is critical for radiologists to be aware of this entity, as they may have the only opportunity to make the diagnosis. We present three cases of intestinal angioedema diagnosed on MRI with discussion of the imaging findings.
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Affiliation(s)
- Michael R Savino
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair St., Suite 800, Chicago, IL 60611, United States
| | - Pardeep K Mittal
- Department of Radiology, Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322, United States
| | - Frank H Miller
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair St., Suite 800, Chicago, IL 60611, United States.
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79
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Icatibant Compared to Steroids and Antihistamines for ACE-Inhibitor-Induced Angioedema. CAN J EMERG MED 2017; 19:159-162. [DOI: 10.1017/cem.2016.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Article chosenBas M, Greve J, Stelter K, et al. A Randomized Trial of Icatibant in ACE-Inhibitor-Induced Angioedema. N Engl J Med 2015;372:418-25. doi:10.1056/NEJMoa1312524.
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Abstract
Small bowel angioedema induced by angiotensin-converting enzyme (ACE) inhibitors is a rare clinicopathologic entity. It frequently poses a diagnostic challenge and is often not recognized before surgical exploration. The present study illustrates that clinical awareness for this condition and adequate use of radiologic investigations can help make the correct diagnosis of ACE inhibitor-associated angioedema, thus avoiding the cost and morbidity associated with unnecessary interventions.
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Affiliation(s)
- Faisal Inayat
- Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical College, New York City, NY, USA
| | - Abu Hurairah
- Division of Gastroenterology, Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
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81
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Angioedema Due to ACE Inhibitors. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0099-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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82
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Hahn J, Bas M, Hoffmann TK, Greve J. [Bradykinin-induced angioedema: Definition, pathogenesis, clinical presentation, diagnosis and therapy]. HNO 2016; 63:885-93; quiz 894-5. [PMID: 26597136 DOI: 10.1007/s00106-015-0084-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The incidence of bradykinin-induced angioedema is considerably lower than that of histamine-induced forms; however, the same is true for the clinician's knowledge of this condition. Bradykinin-induced angioedemas include hereditary angioedema (HAE), as well as acquired forms induced by drugs or antibody formation, e.g., during the course of oncologic disease. Drug-induced forms affect almost exclusively the head and neck region, and are thus important for the otorhinolaryngologist. Clear differentiation between histamine-induced angioedema (e. g., connected to allergy/urticaria) and bradykinin-induced angioedema is essential for selection of the specific treatment and may be lifesaving. Antihistamines and cortisone derivatives have no relevant effect in bradykinin induced-angioedema, whereas blood-derived C1 esterase inhibitor and bradykinin receptor 2 antagonists represent effective therapeutic options--both for acute and prophylactic treatment.
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Affiliation(s)
- J Hahn
- Universitätsklinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Frauensteige 12, 89070, Ulm, Deutschland.
| | - M Bas
- Hals-Nasen-Ohren-Klinik und Poliklinik, Technische Universität München, München, Deutschland
| | - T K Hoffmann
- Universitätsklinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Frauensteige 12, 89070, Ulm, Deutschland
| | - J Greve
- Universitätsklinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Frauensteige 12, 89070, Ulm, Deutschland
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83
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Erickson DL, Coop CA. Angiotensin-converting enzyme inhibitor-associated angioedema treated with c1-esterase inhibitor: A case report and review of the literature. ALLERGY & RHINOLOGY 2016; 7:168-171. [PMID: 27502825 PMCID: PMC5244275 DOI: 10.2500/ar.2016.7.0166] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Case Report: A 59-year old man currently on >5 years of angiotensin-converting enzyme inhibitor (ACEI) therapy presented to the emergency department with angioedema of the tongue and difficulty swallowing. After receiving conventional therapy of antihistamine, steroids, and epinephrine, the patient's condition continued to deteriorate, with imminent intubation. The patient was treated with a C1-esterase inhibitor (C1-INH) and experienced rapid resolution of symptoms, which avoided airway complications. Discussion: Although no therapy has been approved for the treatment of ACEI–associated angioedema (AAE), the conventional therapy (antihistamine, steroids, and epinephrine) often proves ineffective in this bradykinin-mediated angioedema. There are drugs approved and used for hereditary angioedema that may be effective in the acute phase of ACEI-AAE that may prevent the need for further interventions, such as intubation and tracheotomy. These drugs include icatibant, ecallantide, fresh frozen plasma, and C1-INH. Conclusion: The literature and clinical evidence indicate C1-INH can be effectively used in the treatment of ACEI-AAE to halt the progression of the condition, prevent airway compromise and the need for intervention, and lead to rapid resolution of symptoms.
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Affiliation(s)
- Davis Lynn Erickson
- From the Allergy and Immunology Department, San Antonio Military Medical Center, San Antonio, Texas
| | - Christopher Albert Coop
- From the Allergy and Immunology Department, San Antonio Military Medical Center, San Antonio, Texas
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84
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Angiœdème bradykinique et médecine d’urgence : vers une optimisation des stratégies de prise en charge. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1209-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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85
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Scalese MJ, Reinaker TS. Pharmacologic management of angioedema induced by angiotensin-converting enzyme inhibitors. Am J Health Syst Pharm 2016; 73:873-9. [DOI: 10.2146/ajhp150482] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Abstract
Purpose
The published evidence on pharmacologic approaches to the management of angiotensin-converting enzyme inhibitor (ACEI)–induced angioedema is reviewed.
Summary
Angioedema is a serious, potentially life-threatening adverse effect of ACEI use. Although the underlying mechanism is not fully understood, excess bradykinin produced through a complex interplay between the kallikrein-kinin and renin-angiotensin-aldosterone systems is thought to play a major role. The nonallergic nature of the reaction renders traditional therapies (corticosteroids and antihistamines) ineffective because those agents do not modify the proposed pathophysiology. Fresh frozen plasma (FFP) provides kinase II, a protein that breaks down bradykinin. Case reports support FFP as a treatment for ACEI-induced angioedema, but no formal evaluations have been completed to date. Both ecallantide and complement 1 esterase (C1) inhibitor concentrate reduce bradykinin production through upstream inhibition of kallikrein. C1 inhibitor concentrate has been used successfully to manage ACEI-induced angioedema in a few reported cases, but robust supportive studies are lacking. Conversely, ecallantide has been evaluated in multiple randomized trials but has not been shown to offer advantages over traditional therapies. The use of icatibant, a direct antagonist of bradykinin B2 receptors, was reported to be beneficial in several case reports and in a small Phase II study, safely and rapidly reducing symptoms of ACEI-induced angioedema. An ongoing Phase III trial (NCT01919801) will better define the role of icatibant in the management of ACEI-induced angioedema.
Conclusion
FFP, C1 inhibitor, and icatibant appear to be safe and effective therapeutic options for the management of ACEI-induced angioedema, whereas it appears ecallantide should be avoided.
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Affiliation(s)
- Michael J. Scalese
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Mobile, AL
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86
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87
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Curtis RM, Felder S, Borici-Mazi R, Ball I. ACE-I Angioedema: Accurate Clinical Diagnosis May Prevent Epinephrine-Induced Harm. West J Emerg Med 2016; 17:283-9. [PMID: 27330660 PMCID: PMC4899059 DOI: 10.5811/westjem.2016.2.29224] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/17/2016] [Accepted: 02/08/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction Upper airway angioedema is a life-threatening emergency department (ED) presentation with increasing incidence. Angiotensin-converting enzyme inhibitor induced angioedema (AAE) is a non-mast cell mediated etiology of angioedema. Accurate diagnosis by clinical examination can optimize patient management and reduce morbidity from inappropriate treatment with epinephrine. The aim of this study is to describe the incidence of angioedema subtypes and the management of AAE. We evaluate the appropriateness of treatments and highlight preventable iatrogenic morbidity. Methods We conducted a retrospective chart review of consecutive angioedema patients presenting to two tertiary care EDs between July 2007 and March 2012. Results Of 1,702 medical records screened, 527 were included. The cause of angioedema was identified in 48.8% (n=257) of cases. The most common identifiable etiology was AAE (33.1%, n=85), with a 60.0% male predominance. The most common AAE management strategies included diphenhydramine (63.5%, n=54), corticosteroids (50.6%, n=43) and ranitidine (31.8%, n=27). Epinephrine was administered in 21.2% (n=18) of AAE patients, five of whom received repeated doses. Four AAE patients required admission (4.7%) and one required endotracheal intubation. Epinephrine induced morbidity in two patients, causing myocardial ischemia or dysrhythmia shortly after administration. Conclusion AAE is the most common identifiable etiology of angioedema and can be accurately diagnosed by physical examination. It is easily confused with anaphylaxis and mismanaged with antihistamines, corticosteroids and epinephrine. There is little physiologic rationale for epinephrine use in AAE and much risk. Improved clinical differentiation of mast cell and non-mast cell mediated angioedema can optimize patient management.
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Affiliation(s)
- R Mason Curtis
- Queen's University, Departments of Emergency Medicine and Biomedical and Molecular Sciences, Kingston, Ontario, Canada; Western University, Division of Emergency Medicine, Department of Medicine, London, Ontario, Canada
| | - Sarah Felder
- Queen's University, Division of Allergy and Immunology, Kingston, Ontario, Canada
| | - Rozita Borici-Mazi
- Queen's University, Division of Allergy and Immunology, Kingston, Ontario, Canada
| | - Ian Ball
- Queen's University, Departments of Emergency Medicine and Biomedical and Molecular Sciences, Kingston, Ontario, Canada; Queen's University, Program in Critical Care Medicine, Kingston, Ontario, Canada; Western University, Division of Critical Care of Medicine, Department of Medicine, London, Ontario, Canada
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88
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Complements Are Not Always a Good Thing. Adv Emerg Nurs J 2016; 38:93-108. [DOI: 10.1097/tme.0000000000000097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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89
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Sussman G, Gonçalo M, Sánchez-Borges M. Treatment dilemmas in chronic urticaria. J Eur Acad Dermatol Venereol 2016; 29 Suppl 3:33-7. [PMID: 26053293 DOI: 10.1111/jdv.13199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/14/2015] [Indexed: 11/29/2022]
Abstract
The European Academy of Allergy and Clinical Immunology (EAACI)/Global Allergy and Asthma European Network (GA(2) LEN)/European Dermatology Forum (EDF)/World Allergy Organization (WAO) recently published updated recommendations for the classification, diagnosis and management of chronic urticaria (CU). This article discusses several case histories that provide examples of how these recommendations can be implemented in the treatment of CU in a variety of real-life patients.
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Affiliation(s)
- G Sussman
- Division of Allergy and Clinical Immunology, St. Michael's Hospital and University of Toronto, Toronto, ON, Canada
| | - M Gonçalo
- Clinic of Dermatology, University Hospital and Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - M Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico-Docente La Trinidad, Caracas, Venezuela
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90
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Abstract
Infectious and inflammatory conditions of the head and neck may present with impaired airways. An understanding of the pathophysiology will allow for accurate diagnosis and prompt intervention. Preintervention discussion and planning by members of the airway team are crucial in developing a primary and backup plans for safely securing the airway.
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Affiliation(s)
- Gary Linkov
- Temple University Hospital, Philadelphia, PA 19140, USA
| | - Ahmed M S Soliman
- Department of Otolaryngology-Head & Neck Surgery, Voice, Airway & Swallowing Center, Temple University School of Medicine, 3440 North Broad Street Kresge West 312, Philadelphia, PA 19140, USA.
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91
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Linkov G, Cracchiolo JR, Chan NJ, Healy M, Jamal N, Soliman AMS. The role of serial physical examinations in the management of angioedema involving the head and neck: A prospective observational study. World J Otorhinolaryngol Head Neck Surg 2016; 2:7-12. [PMID: 29204542 PMCID: PMC5698507 DOI: 10.1016/j.wjorl.2016.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 12/31/2015] [Accepted: 01/05/2016] [Indexed: 11/28/2022] Open
Abstract
Objective To elucidate the progression of angioedema of the head and neck with routine management and to assess the utility of serial physical exams and fiberoptic laryngoscopy in its management. Methods This study was a prospective observational research. From 2013 to 2014, a prospective observational study was conducted at a tertiary referral center. Forty patient were approached, 7 refused, 33 (18–90 years old) were enrolled. Patients presented with angioedema involving the head and neck over a 12 month period were asked to participate in the study. Physical examination and fiberoptic laryngoscopy were performed at presentation and then repeated at least 1 h later. Results Thirty-three patients with head and neck angioedema from any cause were enrolled (mean age 58, range 23–89 years). The upper lip was the most commonly involved site (58%). On reevaluation, 82% of patients reported subjective improvement in symptoms. The association between subjective improvement and the physical exam, including fiberoptic laryngoscopy findings, was statistically significant (P < 0.001). Conclusion In stable patients with angioedema of any head and neck subsite, self-reported symptoms are associated with clinical stability or improvement as assessed by physical signs and fiberoptic laryngoscopy. Patients' symptoms may be an appropriate surrogate to monitor clinical status without the need for routine serial physical examinations or fiberoptic laryngoscopy, though further study is needed.
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Affiliation(s)
- Gary Linkov
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Jennifer R Cracchiolo
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Norman J Chan
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Megan Healy
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Nausheen Jamal
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Ahmed M S Soliman
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
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92
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Angioedema Triggered by Medication Blocking the Renin/Angiotensin System: Retrospective Study Using the French National Pharmacovigilance Database. J Clin Immunol 2015; 36:95-102. [PMID: 26707788 DOI: 10.1007/s10875-015-0228-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 12/14/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Bradykinin-mediated angioedema (AE) is a rare side effect of some medications, including angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB). In France, side-effects to treatments are reported to the national pharmacovigilance database. METHODS The national MedDRA database was searched using the term "angioedema". Patients were included if they met the clinical criteria corresponding to bradykinin-mediated AE, if their C1-inhibitor levels were normal, and if they were treated with an ACEi or an ARB. RESULTS 7998 cases of AE were reported between 1994 and 2013. Among these, 112 met the criteria for bradykinin-mediated AE with normal C1-inhibitor levels. On the 112 drug-AE, patients were treated with an ARB in 21% of cases (24 patients), or an ACEi in 77% of cases (88 patients), in combination with another treatment in 17 cases (mTORi for 3 patients, iDPP-4 for 1 patient, hormonal treatment for 7 patients). ENT involvement was reported in 90% of cases (tongue: 48.2%, larynx: 23.2%). The median duration of treatment before the first attack was 720 days, and the mean duration of attacks was 36.6 h. Forty-one percent (19/46) of patients relapsed after discontinuing treatment. CONCLUSION Angioedema triggered by medication blocking the renin/angiotensin system is rare but potentially severe, with a high risk of recurrence despite cessation of the causative drug.
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93
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Wagner JG, Bench EM, Plantmason L. An Unusual Case of Angiotensin-Converting-Enzyme Inhibitor-Related Penile Angioedema with Evolution to the Oropharynx. West J Emerg Med 2015; 16:1185-7. [PMID: 26759679 PMCID: PMC4703164 DOI: 10.5811/westjem.2015.8.28061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 08/19/2015] [Indexed: 11/21/2022] Open
Abstract
A 52-year-old African American male with a long history of poorly controlled hypertension presented to the emergency department (ED) with two days of genital edema and pain. During ED work-up, the patient developed sudden onset of non-pitting, non-pruritic, and non-urticarial upper lip edema. Review of his antihypertensive medication list revealed that he normally took benazepril, highly suggestive of a diagnosis of angiotensin-converting-enzyme inhibitor-related angioedema (ACEI-RA). We present the first reported case of penile ACEI-RA that progressed to involve the oropharynx. The ED management of the condition and some of the newer treatment options available for ACEI-RA is also briefly discussed.
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Affiliation(s)
- Jonathan G Wagner
- Keck School of Medicine of the University of Southern California, Los Angeles County + University of Southern California (LAC+USC), Department of Emergency Medicine, Los Angeles, California
| | - Elias M Bench
- Keck School of Medicine of the University of Southern California, Los Angeles County + University of Southern California (LAC+USC), Department of Emergency Medicine, Los Angeles, California
| | - Lee Plantmason
- Keck School of Medicine of the University of Southern California, Los Angeles County + University of Southern California (LAC+USC), Department of Emergency Medicine, Los Angeles, California
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94
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Mahajan H, Thynne T, Gabb GM, Poh EW. Drug safety in Aboriginal Australians: three cases of angiotensin-converting enzyme inhibitor angioedema. Intern Med J 2015; 45:231-3. [PMID: 25650541 DOI: 10.1111/imj.12659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 08/19/2014] [Indexed: 11/27/2022]
Affiliation(s)
- H Mahajan
- Medicine, University of Adelaide, Adelaide, South Australia, Australia
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95
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Javaud N, Achamlal J, Reuter PG, Lapostolle F, Lekouara A, Youssef M, Hamza L, Karami A, Adnet F, Fain O. Angioedema Related to Angiotensin-Converting Enzyme Inhibitors: Attack Severity, Treatment, and Hospital Admission in a Prospective Multicenter Study. Medicine (Baltimore) 2015; 94:e1939. [PMID: 26559262 PMCID: PMC4912256 DOI: 10.1097/md.0000000000001939] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The number of cases of acquired angioedema related to angiotensin converting enzyme inhibitors induced (ACEI-AAE) is on the increase, with a potential concomitant increase in life-threatening attacks of laryngeal edema. Our objective was to determine the main characteristics of ACEI-AAE attacks and, in doing so, the factors associated with likelihood of hospital admission from the emergency department (ED) after a visit for an attack.A prospective, multicenter, observational study (April 2012-December 2014) was conducted in EDs of 4 French hospitals in collaboration with emergency services (SAMU 93) and a reference center for bradykinin-mediated angioedema. For each patient presenting with an attack, emergency physicians collected demographic and clinical presentation data, treatments, and clinical course. They recorded time intervals from symptom onset to ED arrival and to treatment decision, from ED arrival to specific treatment with plasma-derived C1-inhibitor (C1-INH) or icatibant, and from specific treatment to onset of symptom relief. Attacks requiring hospital admission were compared with those not requiring admission.Sixty-two eligible patients with ACEI-AAE (56% men, median age 63 years) were included. Symptom relief occurred significantly earlier in patients receiving specific treatment than in untreated patients (0.5 [0.5-1.0] versus 3.9 [2.5-7.0] hours; P < 0.0001). Even though icatibant was injected more promptly than plasma-derived C1-INH, there, however, was no significant difference in median time to onset of symptom relief between the 2 drugs (0.5 [0.5-1.3] versus 0.5 [0.4-1.0] hours for C1-INH and icatibant, respectively, P = 0.49). Of the 62 patients, 27 (44%) were admitted to hospital from the ED. In multivariate analysis, laryngeal involvement and progressive swelling at ED arrival were independently associated with admission (Odds ratio [95% confidence interval] = 6.2 [1.3-28.2] and 5.9 [1.3-26.5], respectively). A favorable course was observed in all patients. Three patients (5%) experienced a recurrence after angiotensin-converting enzyme inhibitor discontinuation after a median follow-up of 18 (11-30) months.Two severity criteria-laryngeal edema and the progression of the edema-were independent factors associated with likelihood of hospital admission. Appropriate specific treatments (plasma-derived C1-INH or icatibant) should be available in EDs to prevent possibly life-threatening complications.
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Affiliation(s)
- Nicolas Javaud
- Service des Urgences, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Université Paris 7, 92 700 Colombes (NJ, JA); Urgences et (P-GR, FL, LH, FA); SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000 Bobigny (P-GR, FL, FA); Urgences, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Université Paris 13, 93 140 Bondy (AL, AK); Urgences, Hôpital d'Eaubonne, 95 600 Eaubonne (AL); Urgences, Hôpital de Gonesse, 95 500 Gonesse (MY); Service de Médecine Interne, DHUi2B, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, Université Paris 6, 75 012 Paris, France (OF)
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96
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Ostenfeld S, Bygum A, Rasmussen ER. Life-threatening ACE inhibitor-induced angio-oedema successfully treated with icatibant: a bradykinin receptor antagonist. BMJ Case Rep 2015; 2015:bcr-2015-212891. [PMID: 26498671 DOI: 10.1136/bcr-2015-212891] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of a 75-year-old woman treated with an ACE inhibitor, who presented with angio-oedema of the tongue and had difficulty speaking. No symptoms of anaphylaxis or urticaria were present. The patient was treated intravenously with antihistamine and glucocorticoid in combination with adrenaline inhalations. After 6 h in the hospital the swelling progressed, and the patient was admitted to the intensive care unit and treated with one injection of icatibant-a bradykinin receptor antagonist. The patient reported subjective relief after 20-30 min and the swelling resolved within 2 h. Although the angio-oedema was potentially life threatening, the patient avoided intubation and mechanical ventilation. ACE inhibitor-induced angio-oedema is most likely caused by an accumulation of bradykinin and substance P. Consequently, a bradykinin receptor antagonist is the rational treatment of choice instead of antiallergic medications, which have no proven efficacy in this condition.
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Affiliation(s)
- Sarah Ostenfeld
- Department of Anaesthesiology and Intensive Care, Roskilde University Hospital, Roskilde, Denmark
| | - Anette Bygum
- Dermatology and Allergy Center, University Hospital of Odense, Odense, Denmark
| | - Eva Rye Rasmussen
- Department of Otorhinolaryngology Head and Neck Surgery, Koege Hospital, Koege, Denmark
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97
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Bas M, Greve J, Strassen U, Khosravani F, Hoffmann TK, Kojda G. Angioedema induced by cardiovascular drugs: new players join old friends. Allergy 2015; 70:1196-200. [PMID: 26119220 DOI: 10.1111/all.12680] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2015] [Indexed: 12/11/2022]
Abstract
During the last years, two new cardiovascular drug classes, namely inhibitors of DPP IV or neprilysin, have been developed. In both cases, there is clinical evidence for their potential to induce angioedema as known already from blockers of the renin-angiotensin-aldosterone system (RAAS). The majority of angioedema induced by DPP IV inhibitors occurs during concomitant treatment with ACEi and is therefore likely mediated by overactivation of bradykinin type 2 receptors (B2). In striking contrast, the molecular pathways causing angioedema induced by neprilysin inhibitors, that is, sacubitril, are unclear, although a contribution of bradykinin appears likely. Nevertheless, there is no clinical evidence suggesting that inhibition of B2 might relieve the symptoms and/or prevent invasive treatment including coniotomy or tracheotomy in angioedema caused by these drugs. Therefore, the risk of angioedema should always be considered, especially in ambulatory care situations where patients have no rapid access to intensive care.
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Affiliation(s)
- M. Bas
- Otorhinolaryngology Department; University Hospital Rechts der Isar; Munich Technical University; Munich Germany
| | - J. Greve
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery; Ulm University Medical Center; Ulm Germany
| | - U. Strassen
- Otorhinolaryngology Department; University Hospital Rechts der Isar; Munich Technical University; Munich Germany
| | - F. Khosravani
- Institute of Pharmacology and Clinical Pharmacology; Heinrich Heine University; Düsseldorf Germany
| | - T. K. Hoffmann
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery; Ulm University Medical Center; Ulm Germany
| | - G. Kojda
- Institute of Pharmacology and Clinical Pharmacology; Heinrich Heine University; Düsseldorf Germany
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98
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Angiotensin-converting enzyme inhibitor induced angioedema: predictors of mechanical ventilation and treatment approaches. Intensive Care Med 2015; 41:2233-4. [DOI: 10.1007/s00134-015-4065-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2015] [Indexed: 10/23/2022]
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99
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Egan M, Wang J. Icatibant Use in Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2015; 3:824-825. [PMID: 26613106 DOI: 10.1016/j.jaip.2015.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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100
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Fok JS, Katelaris CH, Brown AF, Smith WB. Icatibant in angiotensin-converting enzyme (ACE) inhibitor-associated angioedema. Intern Med J 2015; 45:821-7. [DOI: 10.1111/imj.12799] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 04/30/2015] [Indexed: 11/29/2022]
Affiliation(s)
- J. S. Fok
- Department of Clinical Immunology and Allergy; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - C. H. Katelaris
- Department of Clinical Immunology and Allergy; Campbelltown Hospital; Sydney New South Wales Australia
- University of Western Sydney; Sydney New South Wales Australia
| | - A. F. Brown
- School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Emergency Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - W. B. Smith
- Department of Clinical Immunology and Allergy; Royal Adelaide Hospital; Adelaide South Australia Australia
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