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Rubin S, Tomaszewski M. Prediction and prevention of ACE-inhibitor-induced angioedema-an unmet clinical need in management of hypertension. Hypertens Res 2024; 47:257-260. [PMID: 37945891 DOI: 10.1038/s41440-023-01491-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Sébastien Rubin
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
- Renal Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK.
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK.
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Dabek RJ, Pina NA, Sheber BA, Axentiev A, Scott MC. A Case Report of Delayed Post-operative Angioedema Associated With Angiotensin-Converting Enzyme Inhibitor Use. Cureus 2021; 13:e18800. [PMID: 34692263 PMCID: PMC8523184 DOI: 10.7759/cureus.18800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 11/05/2022] Open
Abstract
Angiotensin-converting enzyme inhibitors are known to precipitate angioedema. Drug-induced angioedema is rare in the perioperative setting. Even fewer cases described hours following a minor procedure. In this case report, we present a 45-year-old female who developed drug-induced angioedema hours following an obstetric procedure.
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Affiliation(s)
- Robert J Dabek
- General Surgery, Ascension St. Agnes Hospital, Baltimore, USA
| | - Nancy A Pina
- General Surgery, Ross University School of Medicine, Bridgetown, BRB
| | | | - Anna Axentiev
- General Surgery, Ascension St. Agnes Hospital, Baltimore, USA
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Mohanty S, Bangaari A, Gnanasekaran K. Case Report: Compromised Airway Following Anesthesia and Its Correlation With the Use of ACE Inhibitors-An Unexpected Clinical Event and Review of Literature. Front Surg 2021; 8:631456. [PMID: 33829036 PMCID: PMC8021017 DOI: 10.3389/fsurg.2021.631456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/08/2021] [Indexed: 11/24/2022] Open
Abstract
Angiotensin-converting enzyme inhibitors associated angioedema involving the upper aerodigestive tract is indisputably a hazardous airway condition which is clinically poorly recognized and frequently underestimated. We describe and present case of a 70-year old man on ramipril who developed massive tongue swelling post-operatively after unremarkable laryngeal mask anaesthesia which was fortuitously managed conservatively. High index of suspicion, timely recognition and knowledge of pathophysiology and the clinical course should guide airway and further supportive management in these patients.
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Affiliation(s)
| | - Ashish Bangaari
- Department of Anaesthesia, MIOT International, Chennai, India
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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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[Postoperative angioedema induced by angiotensin-converting enzyme inhibitor: case report]. Rev Bras Anestesiol 2019; 69:521-526. [PMID: 31526514 DOI: 10.1016/j.bjan.2019.01.005] [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: 12/08/2018] [Revised: 01/06/2019] [Accepted: 01/14/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Angioedema is a potentially fatal condition that may occur at any time in the perioperative period. It may result from histamine release, hypersensitivity reaction to drugs, or be triggered by bradykinin, in non-allergic reactions of hereditary or acquired etiology. The aim of this report is to report a case of angioedema in the early postoperative period in a patient on antihypertensive medication involving angiotensin-converting enzyme inhibitors. CASE REPORT A 67-year-old male, Afro-descendant, hypertensive, and taken enalapril maleate underwent orthopedic shoulder surgery under general anesthesia combined with brachial plexus block. The procedure lasted 3hours uneventfully. After discharge from the post-anesthesia care unit, the patient presented with angioedema and severe airway impairment. Tracheal intubation was attempted but it was impossible due to edema affecting the lips, tongue, and oropharyngeal region Emergency cricothyroidotomy was performed. The onset of angioedema had no causal relationship with the administration of any medication; there were no cutaneous manifestations and also not response to therapy for hypersensitivity reaction to drugs, such as antihistamines, corticoid, and adrenaline. It was considered to be mediated by bradykinin, as the patient had already had two similar episodes and was on regular medication (enalapril). The evolution was satisfactory. CONCLUSION Angioedema is a potentially fatal condition when it affects the airway, and should be recognized by anesthesiologists and physicians working in the emergency departments.
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Bisinotto FMB, Seabra BC, Lóes FBP, Martins LB, Silveira LAMD. Postoperative angioedema induced by angiotensin-converting enzyme inhibitor: case report. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31526514 PMCID: PMC9391843 DOI: 10.1016/j.bjane.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ebo DG, Clarke RC, Mertes PM, Platt PR, Sabato V, Sadleir PH. Molecular mechanisms and pathophysiology of perioperative hypersensitivity and anaphylaxis: a narrative review. Br J Anaesth 2019; 123:e38-e49. [DOI: 10.1016/j.bja.2019.01.031] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/25/2018] [Accepted: 01/15/2019] [Indexed: 12/19/2022] Open
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Alharbi FA, Alharthi AA, Alsaadi FN. Perindopril-induced angioedema of the lips and tongue: a case report. J Med Case Rep 2018; 12:359. [PMID: 30514395 PMCID: PMC6280524 DOI: 10.1186/s13256-018-1910-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 10/31/2018] [Indexed: 11/28/2022] Open
Abstract
Background Ace inhibitor-induced angioedema, characterized by sudden-onset swelling of the mucous membrane, skin, or both, is a rare occurrence in the Kingdom of Saudi Arabia. Because of its safety and efficacy, perindopril is a commonly prescribed angiotensin-converting enzyme inhibitor. Here we describe the clinical manifestations, management, and outcome of perindopril-induced angioedema of the lips and tongue in a 65-year-old Saudi man. Case presentation A 65-year-old Saudi Arab man presented to an emergency department with lip and tongue swelling and dysphagia. There were no systemic symptoms and no past history of a similar event. He had been consuming perindopril 5 mg and amlodipine 5 mg for the last 3 weeks: brand name, Coveram, from the company Servier (Ireland) Industries Ltd.; one tablet of Coveram contains 3.395 mg perindopril corresponding to 5 mg perindopril arginine and 6.935 mg amlodipine besilate corresponding to 5 mg amlodipine. A physical examination revealed considerable swelling of his lips and tongue. Examinations of other systems, including his cardiovascular and respiratory systems, revealed unremarkable findings. All laboratory parameters were also normal. Electrocardiography demonstrated sinus rhythm, a normal P axis, and V-rate of 50–99. A clinical diagnosis of perindopril-induced angioedema was made, and perindopril was discontinued. The angioedema resolved completely after the administration of antihistamines and corticosteroids. Conclusions Angioedema caused by angiotensin-converting enzyme inhibitors is an uncommon occurrence in Saudi Arabia. The findings from this case are expected to raise awareness about this condition among clinicians in this country.
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Affiliation(s)
- Fawaz Abdullah Alharbi
- Drug Information and Poison Center, Alansar Hospital, Al Madinah, Al Munawarah, Saudi Arabia.
| | | | - Faisal Nuefa Alsaadi
- Pharmaceutical Care Department, Alansar Hospital, Al Madinah, Al Munawarah, Saudi Arabia
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9
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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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10
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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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Okumu M, Ochola F, Bodo C, Apuoyo K, Odhiambo N, Ng'ong'a A. Enalapril-Induced Angioedema: Two Case Reports in a Rural Health Facility in Kenya. Cureus 2018; 10:e2572. [PMID: 29974027 PMCID: PMC6029729 DOI: 10.7759/cureus.2572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Tolerability, a good safety profile, affordability, and a preponderance to afford cardio-renal protection in patients with diabetes make enalapril one of the most commonly prescribed angiotensin-converting enzyme (ACE) inhibitors. However, there is low awareness of enalapril/ACE inhibitor-induced angioedema among medical personnel. This is because the diagnosis presents an ongoing challenge, particularly when the presentation is delayed following long-term therapy with ACE inhibitors. Here, we present two cases: a 58-year-old female and a 55-year-old male who presented to the outpatient department of Nyakach County Hospital, Pap Onditi village, Kenya, with progressive swelling of the face and upper and lower lips and stridor of 11 and 10 hours, respectively, after their usual dose of enalapril. Case 1 resolved following the administration of stat doses of intravenous (IV) hydrocortisone 200 mg and IV chlorpheniramine 20 mg as well as thrice daily peroral doses of chlorpheniramine 8 mg, and tapered peroral doses of prednisolone: 40 mg thrice daily for five days, 20 mg thrice daily for five days, 10 mg thrice daily for five days, and 5 mg thrice daily for five days. Case 2 resolved following the administration of a stat dose of IV dexamethasone, a twice daily peroral dose of cetrizine 10 mg, and tapered peroral doses of prednisolone: 20 mg thrice daily for five days, 10 mg thrice daily for five days, and 5 mg thrice daily for five days.
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Affiliation(s)
- Mitchel Okumu
- Department of Pharmacy, Jaramogi Oginga Odinga Teaching and Referral Hospital
| | - Francis Ochola
- Department of Pharmacology and Toxicology, Moi University School of Medicine
| | - Calvin Bodo
- Department of Clinical Medicine, Nyakach County Hospital
| | - Kevin Apuoyo
- Department of Clinical Medicine, Nyakach County Hospital
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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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Change in prescription pattern as a potential marker for adverse drug reactions of angiotensin converting enzyme inhibitors. Int J Clin Pharm 2015; 37:1095-103. [PMID: 26159317 PMCID: PMC4619457 DOI: 10.1007/s11096-015-0159-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 06/29/2015] [Indexed: 11/13/2022]
Abstract
Background Angiotensin converting enzyme inhibitors (ACEIs) are among the most frequently prescribed groups of medications. ACEI-induced adverse drug reactions (ADRs) are the main reason to discontinue or switch ACEI treatment. ADRs information is not available in prescription databases. Objective To identify a proxy for ACEI-induced ADRs in prescription databases. Setting The Rotterdam Study is an ongoing prospective cohort study that started in 1990 in the Netherlands and has included 14,926 subjects aged 45 years or older. Methods All ACEI starters from 2000 to 2011 were identified using prescription data within the Rotterdam Study. Participants were classified into 4 mutually exclusive groups: continuing, discontinuing, switching to angiotensin receptor blockers (ARBs), and switching to other antihypertensives. For categorization, the maximum time-interval between two prescription periods was set at 3 and 6 months. Subsequently, primary care physician files were searched and clinical events were classified as definite ADRs, probable ADRs, possible ADRs and definite non-ADRs. Finally the accuracy of different prescription patterns as indicators of ADRs was evaluated. Main outcome measure Positive predictive values (PPVs), negative predictive values (NPVs), sensitivity and specificity of the prescription patterns of the 4 groups were calculated. Results Totally, 1132 ACEI starters were included. The PPV for a definite ADR was 56.1 % for switchers to ARB, while the PPVs for switchers to other antihypertensives, and discontinuation were 39.5 and 19.5 %, respectively. After including probable ADRs and possible ADRs, PPVs for switchers to ARB increased to 68.3 and 90.5 %. A 6-month interval gave slightly higher PPVs compared to a 3-month interval (maximum 6.1 % higher). The differences in NPVs between 3 and 6-months interval groups were approximately 1.0 %. Conclusions Switching ACEIs to ARBs is the best marker for ACEI-induced ADRs in prescription databases.
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Lipski SM, Casimir G, Vanlommel M, Jeanmaire M, Dolhen P. Angiotensin-converting enzyme inhibitors-induced angioedema treated by C1 esterase inhibitor concentrate (Berinert®): about one case and review of the therapeutic arsenal. Clin Case Rep 2014; 3:126-30. [PMID: 25767713 PMCID: PMC4352369 DOI: 10.1002/ccr3.171] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/06/2014] [Accepted: 09/24/2014] [Indexed: 12/17/2022] Open
Abstract
C1 esterase inhibitor (Berinert®) is generally used to treat severe attack of hereditary angioedema. We describe here the case of a patient who presented with a severe angioedema induced by angiotensin-converting enzyme inhibitors (ACEIs) endangering her life. It could be successfully treated with that medicine.
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Affiliation(s)
- Samuel Michael Lipski
- Ear-Nose-Throat Department, Tivoli University Hospital, Free University of Brussels Brussels, Belgium
| | - Georges Casimir
- Pulmonology and Allergology Unit, University Children's Hospital Queen Fabiola, Free University of Brussels Brussels, Belgium
| | - Martine Vanlommel
- Ear-Nose-Throat Department, Tivoli University Hospital, Free University of Brussels Brussels, Belgium
| | - Mathieu Jeanmaire
- Emergency Department, Tivoli University Hospital, Free University of Brussels Brussels, Belgium
| | - Pierre Dolhen
- Ear-Nose-Throat Department, Tivoli University Hospital, Free University of Brussels Brussels, Belgium
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Postanesthetic Severe Oral Angioedema in Patient's Taking Angiotensin-Converting Enzyme Inhibitor. Case Rep Anesthesiol 2014; 2014:693191. [PMID: 25431681 PMCID: PMC4241279 DOI: 10.1155/2014/693191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 10/17/2014] [Indexed: 01/08/2023] Open
Abstract
Angiotensin-converting enzyme (ACE) inhibitors are the leading cause of a drug-induced angioedema. This occurrence is frequently underdiagnosed, but its relapse can be life-threatening. The authors' intention in reporting this clinical case is to sound a warning about reviewing attitudes and surveillance to try to improve patient perioperative safety.
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Affiliation(s)
- Madhu Gupta
- Department of Anaesthesia, ESI PGIMSR and Associated Hospital, Basaidarapur, New Delhi, India
| | - Shalini Subramanian
- Department of Anaesthesia, ESI PGIMSR and Associated Hospital, Basaidarapur, New Delhi, India
| | - Anil Kumar
- Department of Anaesthesia, ESI PGIMSR and Associated Hospital, Basaidarapur, New Delhi, India
| | - Divya Sethi
- Department of Anaesthesia, ESI PGIMSR and Associated Hospital, Basaidarapur, New Delhi, India
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Loftus PA, Tan M, Patel G, Lin J, Helman S, Badhey A, Du E, Smith RV, Fried MP, Ow TJ. Risk factors associated with severe and recurrent angioedema: an epidemic linked to ACE-inhibitors. Laryngoscope 2014; 124:2502-7. [PMID: 24938823 DOI: 10.1002/lary.24777] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/27/2014] [Accepted: 05/20/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the etiology and risk factors for severe manifestation and recurrent episodes of angioedema; to evaluate efficacy of short-term and long-term management strategies for angioedema among a high-risk population. STUDY DESIGN Institutional review board-approved retrospective review of a large, urban population. METHODS Data from 875 adult patients treated from January 2008 to December 2013 with the diagnosis of angioedema were obtained using the Clinical Looking Glass utility and review of medical records. Demographic and clinicopathologic risk factors were recorded. The major outcomes evaluated were hospital admission, need for airway intervention, and recurrent episodes of angioedema following the first presentation. Initial treatment strategy and follow-up recommendations were also recorded. RESULTS The most common cause of angioedema was angiotensin converting enzyme inhibitor (ACEi)-induced (496 [56.6%]). Significant risk factors for severe cases of angioedema included older age, Hispanic race, ACEi-induced angioedema type, American Society of Anesthesiologists class III or above, coexistent cardiopulmonary disease, and a positive smoking history. A total of 17.2% of patients experienced recurrent attacks of angioedema; of those patients, 25.9% were still taking an ACEi at subsequent presentation. Risk factors for recurrent episodes included older age, idiopathic angioedema type, and coexistent cardiopulmonary disease. Only 54.1% of patients who experienced ACEi-induced angioedema had electronic medical record documentation of these allergies. CONCLUSIONS Knowledge of risk factors for severe and recurrent episodes of angioedema and improved education for both healthcare providers and patients, specifically related to ACEi use and allergy documentation, may significantly decrease the burden and morbidity of angioedema among high risk populations. LEVEL OF EVIDENCE 2b.
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Affiliation(s)
- Patricia A Loftus
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
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Sher J, Davis-Lorton M. Angioedema with normal laboratory values: the next step. Curr Allergy Asthma Rep 2014; 13:563-70. [PMID: 23979825 DOI: 10.1007/s11882-013-0383-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
When faced with a patient with recurrent swelling, a thorough laboratory evaluation to determine the underlying etiology ensues. When the laboratory work-up is unrevealing, health care practitioners are frequently left in a quandary. This review will attempt to provide up-to-date information on how to approach the diagnosis and management of angioedema in a patient with normal laboratory values. The subtypes that will be reviewed in detail include: hereditary angioedema with normal C1 inhibitor (HAE with normal C1INH), drug-induced angioedema, and idiopathic angioedema. We present literature to aid the physician in the diagnosis and treatment of these disorders.
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Affiliation(s)
- Janelle Sher
- Rheumatology, Allergy & Immunology, Winthrop University, 120 Mineola Blvd., Suite 410, Mineola, NY, 11501, USA,
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Wood A, Choromanski D, Orlewicz M. Intubation of patients with angioedema: A retrospective study of different methods over three year period. Int J Crit Illn Inj Sci 2013; 3:108-12. [PMID: 23961454 PMCID: PMC3743334 DOI: 10.4103/2229-5151.114267] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Angioedema (AE) is edema of the skin, subcutaneous tissue and/or submucosal tissues, resulting from extravasation of intravascular fluid. Swelling of the supraglottic mucosa can lead to airway obstruction with consequent hypoxia, brain damage and death. To date, fiberoptic bronchoscope (FOB) intubation of the spontaneously breathing patient is the preferred method for an anticipated difficult intubation. However, other alternative devices can be utilized to intubate angioedema successfully. Materials and Methods: A retrospective chart review was performed over a three-year period (2008-2010) of all patients with angioedema that required airway intervention. We hypothesized that fiberoptic intubation would have a higher success rate for intubation attempts; however, would take longer to perform when compared to videolaryngoscopic (VL) intubation. Outcomes for FOB versus VL intubations were reviewed, along with alternative miscellaneous methods of tracheal intubation in the setting of angioedema. Results: Thirty-three patients were grouped, according to the chosen method of intubation into FOB (n=12), VL (n=11), and miscellaneous (n=10) groups. No significant difference was found in first intubation attempts or number of intubation attempts between the three groups. Duration of time to perform successful intubation revealed a significantly shorter intubation time (P<0.05) in the VL group (6.9±0.9 min) and miscellaneous group (9.1±2.0 min) than that of the FOB group (10.4±0.7 min). Conclusion: This retrospective review of intubation methods showed that VL could be performed faster than FOB without an increase in adverse events.
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Affiliation(s)
- Aaron Wood
- Department of Anesthesiology, WSU/DMC Harper Hospital, 3990 John R Road, Box 162 Detroit, MI 48201, USA
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Mahmoudpour SH, Leusink M, van der Putten L, Terreehorst I, Asselbergs FW, de Boer A, Maitland-van der Zee AH. Pharmacogenetics of ACE inhibitor-induced angioedema and cough: a systematic review and meta-analysis. Pharmacogenomics 2013; 14:249-60. [PMID: 23394388 DOI: 10.2217/pgs.12.206] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIM Angioedema and cough are the two most important adverse effects of ACE inhibitors (ACEIs). Evidence exists that ACEI-related angioedema/cough is partly genetically determined and several genes have been identified to play a role in the development of ACEI-related adverse effects. MATERIALS & METHODS This study was performed in order to evaluate the evidence of these genetic associations and ACEIs' adverse effects. After removing duplicates and critical appraisal, 19 studies were considered to be eligible to review; 14 articles about cough and five articles about angioedema. A separate meta-analysis was performed for the most studied ACE insertion/deletion polymorphism (rs4646994) and its association with cough. RESULTS & CONCLUSION One gene region (XPNPEP2) was associated with ACEI-induced angioedema in three studies. In our meta-analysis we did not find a significant association between the ACE insertion/deletion polymorphism and ACEI cough.
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Affiliation(s)
- Seyed Hamidreza Mahmoudpour
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
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Barbara DW, Ronan KP, Maddox DE, Warner MA. Perioperative angioedema: background, diagnosis, and management. J Clin Anesth 2013; 25:335-43. [DOI: 10.1016/j.jclinane.2012.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 07/11/2012] [Accepted: 07/21/2012] [Indexed: 11/26/2022]
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Hassen GW, Kalantari H, Parraga M, Chirurgi R, Meletiche C, Chan C, Ciarlo J, Gazi F, Lobaito C, Tadayon S, Yemane S, Velez C. Fresh Frozen Plasma for Progressive and Refractory Angiotensin-Converting Enzyme Inhibitor-induced Angioedema. J Emerg Med 2013; 44:764-72. [DOI: 10.1016/j.jemermed.2012.07.055] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 03/12/2012] [Accepted: 07/01/2012] [Indexed: 01/13/2023]
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Abstract
Angioedema is the end result of deep dermal, subcutaneous and/or mucosal swelling, and is potentially a life-threatening condition in cases where the pharynx or larynx is involved. Drug-induced angioedema has been reported to occur in response to a wide range of drugs and vaccines. Drug-induced angioedema, like other cutaneous drug reactions, has been reported to be most frequently elicited by beta-lactam antibiotics and non-steroidal anti-inflammatory drugs, although reliable data from epidemiologic studies are scarce. Recent reports suggested an increasing role of angiotensin-converting enzyme inhibitors (ACEIs) in the causation of life-threatening angioedema. ACEI-related angioedema is never accompanied by urticaria and occurs via a kinin-dependent mechanism. ACEI-related angioedema not only can start years after beginning the treatment, but it can then recur irregularly while under that treatment. Furthermore, allergy tests are unreliable for the diagnosis of ACEI-related angioedema, and so the relationship between angioedema and ACEIs is often missed and consequently quite underestimated. Accordingly, better understanding of the kinin-dependent mechanism, which is particular to angioedema, is necessary for the appropriate management of drug-induced angioedema.
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Affiliation(s)
- Naoko Inomata
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan. −cu.ac.jp
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Abstract
PURPOSE OF REVIEW Angioedema is a serious complication of renin-angiotensin system inhibitor therapy. The incidence is 0.1-0.7%. It consists of nonpitting edema and involves the face and lips. In severe cases, it extends to pharyngeal and laryngeal structures. RECENT FINDINGS Decreased degradation of bradykinin and its metabolites is thought to be a culprit. When the angiotensin-converting enzyme is inhibited, bradykinin metabolism is dependent on degradation by neutral endopeptidase, dipeptidyl peptidase IV, and aminopeptidase P. When these enzymes are inhibited, as in treatment of diabetes or in transplant recipients, the incidence of angioedema increases significantly. African-Americans, people over 65, women, and those with a history of smoking are especially at risk. A fiberoptic laryngeal examination should be performed in all patients. Patients with rapid progression of symptoms are at risk for airway compromise. Supportive treatment with steroids and antihistamines is not very effective. Recently, icatibant, a bradykinin receptor antagonist, has been used to successfully shorten the resolution of edema. SUMMARY Trauma of the airway, especially during difficult intubation, may precipitate severe angioedema. In cases with laryngeal involvement, fiberoptic intubation may be necessary. After the episode of angioedema, lifetime discontinuation of all renin-angiotensin inhibitors may be warranted.
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Farhat HA. Angiotensin-converting enzyme inhibitor-induced angioedema may not be a class-related event. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2012. [DOI: 10.5339/jemtac.2012.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Hassan A. Farhat
- Beth Israel Medical Center, Kings Highway Division, 3201 Kings Highway, Brooklyn, NY 1134, USA
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Sánchez-Borges M, González-Aveledo LA. Angiotensin-converting enzyme inhibitors and angioedema. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2010; 2:195-8. [PMID: 20592919 PMCID: PMC2892052 DOI: 10.4168/aair.2010.2.3.195] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 03/26/2010] [Indexed: 12/21/2022]
Abstract
Purpose To investigate the incidence and clinical characteristics of angioedema associated with the use of angiotensin-converting enzyme inhibitors (ACEIs) in an outpatient allergy department. Methods A retrospective review of medical records of new patients seen in an allergy clinic. Demographic and clinical data of patients with ACEI-induced angioedema were analyzed. Results Nine (0.37%) out of 2,421 new patients attending the allergy clinic developed ACEI-associated angioedema. Enalapril was the drug most frequently incriminated. The onset of the angioedema was as early as after the first dose or as late as 2 years after beginning treatment. Six patients experienced life-threatening angioedema involving the tongue, oropharynx, or larynx, and two patients required transfer to the intensive care unit. One patient required a tracheostomy. Conclusions Angiotensin-converting enzyme inhibitor treatment is often responsible for angioedema, especially involving the upper airways. Due to the high proportion of the population exposed to ACEIs and to the severity of this adverse effect, it is important that physicians consider ACEIs as possible inducers when evaluating patients with acute or recurrent angioedema.
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Affiliation(s)
- Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico-Docente La Trinidad, Caracas, Venezuela
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Tiemensma M, Burger EH, Dempers JJ, Wadee SA. Fatal angioedema induced by angiotensin conversion enzyme (ACE) inhibitors. S Afr Fam Pract (2004) 2010. [DOI: 10.1080/20786204.2010.10873974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Hoover T, Lippmann M, Grouzmann E, Marceau F, Herscu P. Angiotensin converting enzyme inhibitor induced angio-oedema: a review of the pathophysiology and risk factors. Clin Exp Allergy 2009; 40:50-61. [PMID: 19659669 DOI: 10.1111/j.1365-2222.2009.03323.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Angio-oedema (AE) is a known adverse effect of angiotensin converting enzyme inhibitor (ACE-I) therapy. Over the past several decades, evidence of failure to diagnose this important and potentially fatal reaction is commonly found in the literature. Because this reaction is often seen first in the primary care setting, a review was undertaken to analyse and document the keys to both diagnostic criteria as well as to investigate potential risk factors for ACE-I AE occurrence. A general review of published literature was conducted through Medline, EMBASE, and the Cochrane Database, targeting ACE-I-related AE pathomechanism, diagnosis, epidemiology, risk factors, and clinical decision making and treatment. The incidence and severity of AE appears to be on the rise and there is evidence of considerable delay in diagnosis contributing to significant morbidity and mortality for patients. The mechanism of AE due to ACE-I drugs is not fully understood, but some genomic and metabolomic information has been correlated. Additional epidemiologic data and clinical treatment outcome predictors have been evaluated, creating a basis for future work on the development of clinical prediction tools to aid in risk identification and diagnostic differentiation. Accurate recognition of AE by the primary care provider is essential to limit the rising morbidity associated with ACE-I treatment-related AE. Research findings on the phenotypic indicators relevant to this group of patients as well as basic research into the pathomechanism of AE are available, and should be used in the construction of better risk analysis and clinical diagnostic tools for ACE-I AE.
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Affiliation(s)
- T Hoover
- Herscu Laboratory, Clinical Research Division, Amherst, MA 01002, USA.
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ACE-I induced angioedema: a case report and review of literature. CASES JOURNAL 2009; 2:7181. [PMID: 19829931 PMCID: PMC2740143 DOI: 10.4076/1757-1626-2-7181] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 05/23/2009] [Indexed: 11/18/2022]
Abstract
Introduction Although rare, angioedema has been documented to occur following the administration of angiotensin-Converting Enzyme Inhibitors. Angiotensin-converting enzyme inhibitors are the leading cause of drug induced angioedema. Angiotensin-converting enzyme inhibitors induced angioedema is a class effect that can affect between 0.1% and 0.5% of patients taking the drug. It is rarely documented in Nigeria. Lisinopril is a commonly prescribed angiotensin-converting enzyme inhibitors-I which is considered to be generally safe and well tolerated. We report a case of angioedema following the use of lisinopril. Case presentation A 52-year-old man, known hypertensive, presented with severe breathlessness on exertion, paroxysmal nocturnal dyspnoea and bilateral pedal swelling of six weeks duration. There was no history of allergy or atopy. He was managed with lisinopril 5 mg o.d, frusemide 40 mg daily, aspirin 150 mg daily and digoxin 0.25 mg daily. He re-presented at the medical emergency unit of the hospital two days later with swellings involving the lips and the lower face of 10 hours duration. There was associated difficulty in swallowing but no stridor or hoarseness of voice. He did not have skin rashes or pruritus. There was no history of previous similar episodes. Physical examination revealed a middle aged man with swollen lips and lower part of the face. The pharynx was oedematous. The respiratory and cardiovascular system examinations revealed features of hypertensive heart disease in biventricular failure. Clinical assessment of hypertensive heart disease in failure with Lisinopril induced Angioedema was made. The Naranjo probability scale indicated that this adverse drug event was probable. Lisinopril was discontinued. After administration of corticosteroid and antihistamine, a complete resolution of the patient's symptoms was achieved. He was discharged to the medical outpatient unit of the hospital having recovered fully. Conclusion This case is presented for the purposes of documentation since it is a rare occurrence among Nigerians.
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Libert N, Schérier S, Dubost C, Franck L, Rouquette I, Tortosa JC, Rousseau JM. Prise en charge anesthésique d’un accouchement chez une patiente atteinte d’un déficit en inhibiteur de C1 estérase. ACTA ACUST UNITED AC 2009; 28:375-80. [DOI: 10.1016/j.annfar.2009.02.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 02/25/2009] [Indexed: 10/20/2022]
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Flattery MP, Sica DA. Angiotensin-converting enzyme inhibitor-related angioedema: recognition and treatment. ACTA ACUST UNITED AC 2007; 22:47-51. [PMID: 17342008 DOI: 10.1111/j.0889-7204.2007.06493.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Maureen P Flattery
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, VA 23298, USA.
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Adachi YU, Iwakiri S, Katoh T. Angioedema, angiotensin converting enzyme inhibitors, and angiotensin receptor blocking drugs. Can J Anaesth 2007; 54:155-7; author reply 157. [PMID: 17272257 DOI: 10.1007/bf03022016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Kapoor A, Jefferson P, Ball DR. Airway management in angiotensin converting enzyme inhibitor related angioedema. Can J Anaesth 2007; 54:242; author reply 242-3. [PMID: 17331937 DOI: 10.1007/bf03022646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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