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Lochbaum R, Hoffmann TK, Greve J, Hahn J. Concomitant medication in patients with bradykinin-mediated angioedema - there's more than ACE inhibitors. J Dtsch Dermatol Ges 2023; 21:1283-1289. [PMID: 37483139 DOI: 10.1111/ddg.15154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 05/20/2023] [Indexed: 07/25/2023]
Abstract
Bradykinin-mediated angioedema is a rare, non-allergic, potentially life-threatening disease. ACE inhibitor-induced angioedema and hereditary angioedema (HAE) are the two most common presentations. Therapeutic options, pathophysiology and diagnosis continue to be investigated, with considerable progress in HAE over the last few decades. For all patients with bradykinin-mediated angioedema, there are several medications that should be avoided or administered with caution. Some of the triggering medications are well known, while others are suspected or of unknown significance. A common denominator is that there is no approved therapy for bradykinin-mediated angioedema as a drug side effect. Some medications, such as tissue plasminogen activator, have a higher incidence of angioedema with potential airway compromise than ACE inhibitors, although this fact is widely underappreciated. In this review, we aim to summarize what is currently known and recommended about concomitant medication in HAE patients and the interaction of other bradykinin-influencing drugs.
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Affiliation(s)
- Robin Lochbaum
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Thomas K Hoffmann
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Jens Greve
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Janina Hahn
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
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Lochbaum R, Hoffmann TK, Greve J, Hahn J. Medikamente als Auslöser Bradykinin-vermittelter Angioödeme - mehr als ACE-Hemmer. J Dtsch Dermatol Ges 2023; 21:1283-1290. [PMID: 37946655 DOI: 10.1111/ddg.15154_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 05/20/2023] [Indexed: 11/12/2023]
Abstract
ZusammenfassungBradykinin‐vermittelte Angioödeme sind seltene, nichtallergische und potenziell lebensbedrohliche Krankheiten. Die beiden bekanntesten Formen sind das ACE‐Hemmer‐induzierte Angioödem und das hereditäre Angioödem (HAE). Die therapeutischen Möglichkeiten, die Pathophysiologie und die Diagnostik werden weiter erforscht, wobei beim HAE in den letzten Jahrzehnten erhebliche Fortschritte erzielt wurden. Für alle Patienten mit Bradykinin‐vermittelten Angioödemen gibt es Medikamente, die vermieden oder mit Vorsicht verabreicht werden sollten. Einige dieser auslösenden Medikamente sind gut bekannt, bei anderen wird ein Zusammenhang vermutet oder ihre Bedeutung ist unbekannt. Ein gemeinsamer Nenner ist, dass es keine zugelassene Therapie für das Bradykinin‐vermittelte Angioödem als Arzneimittelnebenwirkung gibt. Bei einigen Medikamenten, wie dem gewebespezifischen Plasminogenaktivator, ist die Inzidenz von Angioödemen mit möglicher Beeinträchtigung der Atemwege höher als bei ACE‐Hemmern, wobei diese Tatsache weitgehend unterschätzt wird. In dieser Übersichtsarbeit fassen wir zusammen, was derzeit über die Begleitmedikation bei HAE‐Patienten und die Interaktion mit anderen Bradykinin‐beeinflussenden Medikamenten bekannt ist und empfohlen wird.
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Affiliation(s)
- Robin Lochbaum
- Abteilung für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm
| | - Thomas K Hoffmann
- Abteilung für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm
| | - Jens Greve
- Abteilung für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm
| | - Janina Hahn
- Abteilung für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm
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Baccino D, Merlo G, Cozzani E, Rosa GM, Tini G, Burlando M, Parodi A. Cutaneous effects of antihypertensive drugs. GIORN ITAL DERMAT V 2020; 155:202-211. [DOI: 10.23736/s0392-0488.19.06360-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Pfaue A, Schuler PJ, Mayer B, Hoffmann TK, Greve J, Hahn J. Clinical features of angioedema induced by renin-angiotensin-aldosterone system inhibition: a retrospective analysis of 84 patients. J Community Hosp Intern Med Perspect 2019; 9:453-459. [PMID: 32002148 PMCID: PMC6968333 DOI: 10.1080/20009666.2019.1698259] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/08/2019] [Indexed: 01/09/2023] Open
Abstract
Background and objectives: Bradykinin-mediated angioedema (AE) induced by antihypertensive drugs primarily affect the head and neck region and may occur even after several years of uneventful treatment. Many facts about the clinical course remain unknown. Diagnosis is not easy, as the clinical appearance resembles allergic AE. No specific diagnostic markers are known and no officially approved treatment is currently available. Methods: All patients who presented to the ORL department between 2010 and 2016 with acute AE were included. Those with a history of renin-angiotensin-aldosterone system (RAAS) blocker intake were defined as RAE and their pathophysiological characteristics and clinical course of the disease were analyzed. Results: A total of 84 patients (median age of 71 years) with RAE was identified. The majority (80%) was on ACE inhibition. The oral cavity was most often affected. Nearly 60% were medicated for more than 1 year before AE occurred. RAE occurred more often during the morning hours. The necessity for emergency intubation and/or tracheostomy was nine times higher in patients with acute RAE compared to patients with AE due to other reasons. Conclusions: Event-free, long-term therapy with an RAAS blocker before the first development of edema does not exclude RAE. RAE is associated with an increased risk for emergency airway management. Abbreviations ACE: Angiotensin Converting Enzyme; ACEi AE: ACE inhibitor-induced angioedema; AE: Angioedema; ARB: Angiotensin II receptor 1 blocker; C1 INH: C1 Inhibitor; CI: Confidence Interval; CRP: C-reactive protein; DPP IV: Dipeptidyl peptidase IV; ENT: Ear, Nose and Throat; HAE: Hereditary Angioedema; ICD 10: International Statistical Classification of Diseases and Related Health Problems, 10th Edition; OR: Odds Ratio; ORL: Otorhinolaryngology; RAAS: Renin-Angiotensin-Aldosterone System; RAE: RAAS-blocker-induced angioedema
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Affiliation(s)
- Anja Pfaue
- Department for Otorhinolaryngology, Head and Neck Surgery, Ulm University Hospital, Ulm, Germany
| | - Patrick J Schuler
- Department for Otorhinolaryngology, Head and Neck Surgery, Ulm University Hospital, Ulm, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Thomas K Hoffmann
- Department for Otorhinolaryngology, Head and Neck Surgery, Ulm University Hospital, Ulm, Germany
| | - Jens Greve
- Department for Otorhinolaryngology, Head and Neck Surgery, Ulm University Hospital, Ulm, Germany
| | - Janina Hahn
- Department for Otorhinolaryngology, Head and Neck Surgery, Ulm University Hospital, Ulm, Germany
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Affiliation(s)
- N Javaud
- AP-HP, Urgences, Centre de référence sur les angiœdèmes à kinines (CRéAk), Hôpital Louis Mourier, Université Paris 7, Colombes, France
| | - O Fain
- AP-HP, Médecine Interne, DHUi2B, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Hôpital Saint-Antoine, Université Paris 6, Paris, France
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Alhowary AA, Odat H, Alali O, Al-Omari A. Intraoperative angioedema induced by angiotensin II receptor blocker: a case report. Patient Saf Surg 2018; 12:27. [PMID: 30250510 PMCID: PMC6146661 DOI: 10.1186/s13037-018-0174-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/13/2018] [Indexed: 01/18/2023] Open
Abstract
Background Angiotensin II receptor blockers are a class of antihypertensive agent that is developed to exclude the adverse effects of angiotensin converting enzyme inhibitors. However, as angiotensin II receptor blockers have begun to be more widely prescribed, cases of angiotensin II receptor blocker-induced angioedema have been reported. Rare cases of angioedema following surgery in patients using angiotensin converting enzyme inhibitors have been published. Case presentation A 38-year-old man with past history of hypertension was admitted for an elective lumbosacral spine surgery. He had been taking Valsartan 160 mg a day for the past 4 years.At the end of the surgical procedure and turning the patient into supine position, we noticed severe swelling in the neck and the face with.an edematous tongue, floor of the mouth, glottis, and supraglottic areas. A diagnosis of drug induced angioedema was made and intravenous dexamethasone, diphenhydramine and ranitidine were given. The patient remained intubated and was transferred to the intensive care unit. The valsartan was suspected to be the precipitating factor for the angioedema and was therefore discontinued.The swelling started to regress after 2 h, and resolved completely by the third day. Conclusion The precise mechanism of angiotensin II receptor blocker-induced angioedema is still unknown and should be thoroughly investigated. This report demonstrates a unique case of intraoperative angiotensin II receptor blocker-induced angioedema. Potential differential diagnoses of postoperative facial edema are discussed in detail, including the prolonged prone positioning for posterior spine surgery. Anesthesiologists should be aware of such rare, but potentially dangerous, perioperative adverse reaction that can occur with angiotensin II receptor blockers use.
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Affiliation(s)
- Ala A Alhowary
- 1Department of Anesthesiology and critical care, King Abdullah University Hospital, Ar Ramtha, Jordan.,2Faculty of Medicine, Jordan University of Science and Technology, P.O.Box: 953, Irbid, 21110 Jordan
| | - Haitham Odat
- 2Faculty of Medicine, Jordan University of Science and Technology, P.O.Box: 953, Irbid, 21110 Jordan.,3Division of Otolaryngology, Department of Special Surgery, King Abdullah University Hospital, Ar Ramtha, Jordan
| | - Obada Alali
- 1Department of Anesthesiology and critical care, King Abdullah University Hospital, Ar Ramtha, Jordan.,2Faculty of Medicine, Jordan University of Science and Technology, P.O.Box: 953, Irbid, 21110 Jordan
| | - Ali Al-Omari
- 2Faculty of Medicine, Jordan University of Science and Technology, P.O.Box: 953, Irbid, 21110 Jordan.,4Division of orthopedics, Department of Special Surgery, King Abdullah University Hospital, Ar Ramtha, Jordan
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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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Joshua J, Scholten E, Schaerer D, Mafee MF, Alexander TH, Crotty Alexander LE. Otolaryngology in Critical Care. Ann Am Thorac Soc 2018; 15:643-654. [PMID: 29565639 PMCID: PMC6207134 DOI: 10.1513/annalsats.201708-695fr] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 03/22/2018] [Indexed: 01/02/2023] Open
Abstract
Diseases affecting the ear, nose, and throat are prevalent in intensive care settings and often require combined medical and surgical management. Upper airway occlusion can occur as a result of malignant tumor growth, allergic reactions, and bleeding events and may require close monitoring and interventions by intensivists, sometimes necessitating surgical management. With the increased prevalence of immunocompromised patients, aggressive infections of the head and neck likewise require prompt recognition and treatment. In addition, procedure-specific complications of major otolaryngologic procedures can be highly morbid, necessitating vigilant postoperative monitoring. For optimal outcomes, intensivists need a broad understanding of the pathophysiology and management of life-threatening otolaryngologic disease.
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Affiliation(s)
- Jisha Joshua
- Pulmonary and Critical Care Section, Department of Medicine, Veterans Affairs San Diego Healthcare System, San Diego, California; and
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine
| | - Eric Scholten
- Pulmonary and Critical Care Section, Department of Medicine, Veterans Affairs San Diego Healthcare System, San Diego, California; and
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine
| | | | - Mahmood F. Mafee
- Division of Neuroradiology, Department of Radiology, University of California–San Diego, San Diego, California
| | | | - Laura E. Crotty Alexander
- Pulmonary and Critical Care Section, Department of Medicine, Veterans Affairs San Diego Healthcare System, San Diego, California; and
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine
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A score for the differential diagnosis of bradykinin- and histamine-induced head and neck swellings. Eur Arch Otorhinolaryngol 2018; 275:1767-1773. [DOI: 10.1007/s00405-018-4989-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/27/2018] [Indexed: 02/02/2023]
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Cardiovascular and Diabetic Medications That Cause Bradykinin-Mediated Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:610-615. [PMID: 28483314 DOI: 10.1016/j.jaip.2017.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 02/18/2017] [Accepted: 03/21/2017] [Indexed: 01/14/2023]
Abstract
Medication-induced angioedema is a bradykinin-mediated process that results from increased production or decreased degradation of bradykinin. These reactions are documented for several cardiac medications including blockers of the renin-angiotensin-aldosterone system (RAAS). Other cardiovascular and diabetes medications further increase the risk of medication-induced angioedema, particularly with concomitant use of RAAS inhibitors. Dipeptidyl peptidase IV inhibitors are a class of oral diabetic agents that affect bradykinin and substance P degradation and therefore can lead to angioedema. Neprilysin inhibitors are a separate class of cardiac medications, which includes sacubitril, and can lead to drug-induced angioedema especially when used in combination with RAAS inhibitors. This article discusses the proposed mechanisms by which these medications cause angioedema and how medication-induced angioedema differs from mast cell-mediated angioedema. It also details how to recognize medication-induced angioedema and the treatment options available.
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Hahn J, Trainotti S, Hoffmann TK, Greve J. Drug-Induced Inhibition of Angiotensin Converting Enzyme and Dipeptidyl Peptidase 4 Results in Nearly Therapy Resistant Bradykinin Induced Angioedema: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:576-579. [PMID: 28539578 PMCID: PMC5453401 DOI: 10.12659/ajcr.901960] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bradykinin is an underestimated mediator of angioedema. One subgroup of bradykinin induced angioedema is angioedema triggered by treatment with angiotensin converting enzyme (ACE) inhibitors. Due to its localization in the head and neck region and its unpredictable course, it is a possibly life-threatening condition. There is not an officially approved treatment for ACE inhibitor induced angioedema. CASE REPORT We present a case of an 83-year-old woman, who presented to our ENT department because of acute swelling of the tongue. On admission, there was no pharyngeal or laryngeal edema and no dyspnea. Treatment with glucocorticoids and antihistamines had no response. The patient had ramipril as regular medication, so we assumed ACE inhibitor induced angioedema and treated consequently with C1-inhibitor (human) 1,500 IU. Nevertheless, swelling was progressive and required intubation. Even after the second specific treatment with icatibant, her angioedema subsided extremely slowly. The patient also had regular treatment with saxagliptin, a dipeptidyl peptidase 4 inhibitor, so we assumed that the simultaneous inhibition of two bradykinin degrading enzymes led to a treatment-refractory course of angioedema. CONCLUSIONS General awareness for bradykinin induced angioedema due to regular medication is limited. Our case demonstrated the importance of improving awareness and knowledge about this side effect. We need a better understanding of the pathomechanism to aid in more precise clinical diagnosis. Securing the patient's airway as well as administration of an officially approved therapy is of utmost importance. As the number of patients simultaneously treated with antihypertensive and antidiabetic drugs is likely to increase, the incidence of bradykinin mediated drug induced angioedema is likely to increase as well.
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Affiliation(s)
- Janina Hahn
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm-Michelsberg, Germany
| | - Susanne Trainotti
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm-Michelsberg, Germany
| | - Thomas K Hoffmann
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm-Michelsberg, Germany
| | - Jens Greve
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm-Michelsberg, Germany
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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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Pahs L, Droege C, Kneale H, Pancioli A. A Novel Approach to the Treatment of Orolingual Angioedema After Tissue Plasminogen Activator Administration. Ann Emerg Med 2016; 68:345-8. [DOI: 10.1016/j.annemergmed.2016.02.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Indexed: 10/21/2022]
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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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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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Nielsen EW, Lappegård KT, Johansen HT. Re: Ny og bedre medisin mot hjertesvikt. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015. [DOI: 10.4045/tidsskr.15.0486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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