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Sridharan K, Sivaramakrishnan G. A pharmacovigilance study assessing risk of angioedema with angiotensin receptor blockers using the US FDA Adverse Event Reporting System. Expert Opin Drug Saf 2024:1-8. [PMID: 39140622 DOI: 10.1080/14740338.2024.2393279] [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: 06/14/2024] [Revised: 07/23/2024] [Accepted: 07/29/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Angiotensin receptor blockers (ARBs) are widely used for treating hypertension and heart failure. Angioedema has been reported as a controversial adverse effect of ARBs and the evidence on individual ARB risks is limited. This study aimed to assess signals of angioedema with different ARBs using the US FDA Adverse Event Reporting System (AERS) database. RESEARCH DESIGN AND METHODS Reports of angioedema from 2004 to 2024 in AERS with an ARB as the primary suspect were extracted using Medical Dictionary for Regulatory Activities queries. Disproportionality analyses including reporting odds ratio, proportional reporting ratio, Bayesian confidence propagation neural network and multi-item gamma Poisson shrinker were conducted to identify safety signals for individual ARBs. RESULTS A total of 3,683 unique reports met the selection criteria. Irbesartan and losartan generated signals in all statistical measures, followed by telmisartan and candesartan in some measures. Valsartan had the highest report count. Most reports reported hospitalization, prolonged hospitalization or life-threatening outcomes consequent to angioedema. CONCLUSION This pharmacovigilance study using AERS highlights potential higher risks of angioedema with losartan and irbesartan compared to other ARBs, warranting validation through prospective epidemiological studies to characterize individual ARB safety profiles.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
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Wira CR, Kearns T, Fleming-Nouri A, Tyrrell JD, Wira CM, Aydin A. Considering Adverse Effects of Common Antihypertensive Medications in the ED. Curr Hypertens Rep 2024; 26:355-368. [PMID: 38687403 DOI: 10.1007/s11906-024-01304-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE OF REVIEW To evaluate the adverse effects of common antihypertensive agents utilized or encountered in the Emergency Department. RECENT FINDINGS All categories of antihypertensive agents may manifest adverse effects, inclusive of adverse drug reactions (ADRs), drug-to-drug interactions, or accidental overdose. Adverse effects, and specifically ADRs, may be stratified into the organ systems affected, might require specific time-sensitive interventions, could pose particular risks to vulnerable populations, and may result in significant morbidity, and potential mortality. Adverse effects of common antihypertensive agents may be encountered in the ED, necessitating that ED systems of care are poised to prevent, recognize, and intervene when adverse effects arise.
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Affiliation(s)
- Charles R Wira
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Suite 260, New Haven, CT, 06519, USA.
- Yale Acute Stroke Program, Section of Vascular Neurology, Department of Neurology, New Haven, CT, USA.
| | - Thomas Kearns
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Suite 260, New Haven, CT, 06519, USA
| | - Alex Fleming-Nouri
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Suite 260, New Haven, CT, 06519, USA
| | - John D Tyrrell
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Suite 260, New Haven, CT, 06519, USA
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | | | - Ani Aydin
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Suite 260, New Haven, CT, 06519, USA
- Section of Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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3
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Reshef A, Buttgereit T, Betschel SD, Caballero T, Farkas H, Grumach AS, Hide M, Jindal AK, Longhurst H, Peter J, Riedl MA, Zhi Y, Aberer W, Abuzakouk M, Al Farsi T, Al Sukaiti N, Al-Ahmad M, Altrichter S, Aygören-Pürsün E, Baeza ML, Bara NA, Bauer A, Bernstein JA, Boccon-Gibod I, Bonnekoh H, Bouillet L, Brzoza Z, Bygum A, Calderon O, de Albuquerque Campos R, Campos Romero FH, Cancian M, Chong-Neto HJ, Christoff G, Cimbollek S, Cohn DM, Craig T, Danilycheva I, Darlenski R, Du-Thanh A, Ensina LF, Fomina D, Fonacier L, Fukunaga A, Gelincik A, Giavina-Bianchi P, Godse K, Gompels M, Goncalo M, Gotua M, Guidos-Fogelbach G, Guilarte M, Kasperska-Zajac A, Katelaris CH, Kinaciyan T, Kolkhir P, Kulthanan K, Kurowski M, Latysheva E, Lauerma A, Launay D, Lleonart R, Lumry W, Malbran A, Ali RM, Nasr I, Nieto-Martinez S, Parisi C, Pawankar R, Piñero-Saavedra M, Popov TA, Porebski G, Prieto Garcia A, Pyatilova P, Rudenko M, Sekerel BE, Serpa FS, Sheikh F, Siebenhaar F, Soria A, Staevska M, Staubach P, Stobiecki M, Thomsen SF, Triggiani M, Valerieva A, Valle S, Van Dinh N, Vera Ayala CE, Zalewska-Janowska A, Zanichelli A, Magerl M, Maurer M. Definition, acronyms, nomenclature, and classification of angioedema (DANCE): AAAAI, ACAAI, ACARE, and APAAACI DANCE consensus. J Allergy Clin Immunol 2024; 154:398-411.e1. [PMID: 38670233 DOI: 10.1016/j.jaci.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/24/2024] [Accepted: 03/04/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Angioedema (AE) manifests with intermittent, localized, self-limiting swelling of the subcutaneous and/or submucosal tissue. AE is heterogeneous, can be hereditary or acquired, may occur only once or be recurrent, may exhibit wheals or not, and may be due to mast cell mediators, bradykinin, or other mechanisms. Several different taxonomic systems are currently used, making it difficult to compare the results of studies, develop multicenter collaboration, and harmonize AE treatment. OBJECTIVE We developed a consensus on the definition, acronyms, nomenclature, and classification of AE (DANCE). METHODS The initiative involved 91 experts from 35 countries and was endorsed by 53 scientific and medical societies, and patient organizations. A consensus was reached by online discussion and voting using the Delphi process over a period of 16 months (June 2021 to November 2022). RESULTS The DANCE initiative resulted in an international consensus on the definition, classification, and terminology of AE. The new consensus classification features 5 types and endotypes of AE and a harmonized vocabulary of abbreviations/acronyms. CONCLUSION The DANCE classification complements current clinical guidelines and expert consensus recommendations on the diagnostic assessment and treatment of AE. DANCE does not replace current clinical guidelines, and expert consensus algorithms and should not be misconstrued in a way that affects reimbursement of medicines prescribed by physicians using sound clinical judgment. We anticipate that this new AE taxonomy and nomenclature will harmonize and facilitate AE research and clinical studies, thereby improving patient care.
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Affiliation(s)
- Avner Reshef
- Angioedema Research Center, Barzilai University Medical Center, Ashkelon, Israel.
| | - Thomas Buttgereit
- Angioedema Center of Reference and Excellence (ACARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine, and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Stephen D Betschel
- Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Teresa Caballero
- Department of Allergy, La Paz University Hospital, Hospital La Paz Institute for Health Research (IdiPAZ-Group 44), Biomedical Research Network on Rare Diseases (CIBERER U754), Madrid, Spain; NRC Institute of Immunology FMBA of Russia, Moscow, Russia
| | - Henriette Farkas
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Anete S Grumach
- Department of Clinical Immunology, University Center Faculdade de Medicina do ABC, Santo André, Brazil
| | - Michihiro Hide
- Department of Dermatology, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ankur K Jindal
- Department of Pediatrics, Allergy Immunology Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Hilary Longhurst
- Department of Medicine, University of Auckland and Department of Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Jonathan Peter
- Department of Medicine, Division of Allergy and Clinical Immunology, University of Cape Town, and the Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Marc A Riedl
- Division of Rheumatology, Allergy, and Immunology, University of California San Diego, La Jolla, Calif
| | - Yuxiang Zhi
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Werner Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Mohamed Abuzakouk
- Allergy and Immunology, Respiratory Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Tariq Al Farsi
- Department of Pediatric Allergy and Clinical Immunology, The Royal Hospital, Muscat, Oman
| | - Nashat Al Sukaiti
- Department of Pediatric Allergy and Clinical Immunology, The Royal Hospital, Muscat, Oman
| | - Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Sabine Altrichter
- Klinik für Dermatologie und Venerologie, Kepler Uniklinikum, Linz, Austria
| | - Emel Aygören-Pürsün
- Department of Pediatrics, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Maria Luisa Baeza
- Allergy Department, Hospital General Universitario Gregorio Marañón, Biomedical Research Network on Rare Diseases-U761, Gregorio Marañón Health Research Institute (IiSGM), Gregorio Marañón, Madrid, Spain
| | - Noemi Anna Bara
- Romanian Hereditary Angioedema Expertise Centre, Centrul Clinic Mediquest, Sângeorgiu de Mure, Romania
| | - Andrea Bauer
- Department of Dermatology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Jonathan A Bernstein
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Cincinnati, Ohio
| | | | - Hanna Bonnekoh
- Angioedema Center of Reference and Excellence (ACARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine, and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Laurence Bouillet
- National Reference Center of Angioedema CREAK, Grenoble, France; Internal medicine department, Grenoble University Hospital, Grenoble, France
| | - Zenon Brzoza
- Department of Internal Diseases with Division of Allergology, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Anette Bygum
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark; Clinical Institute, University of Southern Denmark, Odense, Denmark
| | | | | | - Freya Helena Campos Romero
- Department of Allergy and Clinical Immunology, Hospital Central Sur Alta Especialidad, Mexico City, Mexico City, Mexico
| | - Mauro Cancian
- Departmental Unit of Allergology, University Hospital of Padua, Padua, Italy
| | - Herberto Jose Chong-Neto
- Serviço de Alergia e Imunologia, Complexo Hospital de Clinicas, Universidade Federal do Paraná, Curitiba, Brazil
| | - George Christoff
- Excelsior Medical Centre, Sofia, Bulgaria; Medical University-Sofia, Sofia, Bulgaria
| | | | - Danny M Cohn
- Department of Vascular Medicine, Amsterdam UMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Timothy Craig
- Department of Pediatrics, Pennsylvania State University, Hershey, Pa
| | | | - Razvigor Darlenski
- Department of Dermatovenereology, Trakia University, Stara Zagora, Bulgaria
| | - Aurélie Du-Thanh
- Département de dermatologie, ACARE, Centre Hospitalier Universitaire de Montpellier Montpellier, France
| | | | - Daria Fomina
- Moscow City Research and Practical Center of Allergoloy and Immunology, Clinical Hospital No. 52, Moscow Healthcare Department, Moscow, Russia
| | - Luz Fonacier
- New York University-Long Island School of Medicine, Mineola, NY
| | - Atsushi Fukunaga
- Department of Dermatology, Division of Medicine for Function and Morphology of Sensory Organs, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Asli Gelincik
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Pedro Giavina-Bianchi
- Division of Clinical lmmunology and Allergy, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Kiran Godse
- Dr D. Y. Patil Medical College and Hospital, Navi Mumbai, Maharashtra, India
| | - Mark Gompels
- Department of Immunology, ACARE, North Bristol NHS Trust, Bristol, United Kingdom
| | - Margarida Goncalo
- Department of Dermatology, Coimbra Hospital and University Center, and Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Maia Gotua
- Center of Allergy and Immunology and David Tvildiani Medical University, Tbilisi, Georgia
| | | | - Mar Guilarte
- Allergy Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Alicja Kasperska-Zajac
- European Center for Diagnosis and Treatment of Urticaria and Angioedema and Department of Clinical Allergology and Urticaria, Medical University of Silesia in Katowice, Katowice, Poland
| | | | - Tamar Kinaciyan
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Pavel Kolkhir
- Angioedema Center of Reference and Excellence (ACARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine, and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Kanokvalai Kulthanan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Marcin Kurowski
- Department of Immunology and Allergy, Medical University of Lodz, Lodz, Poland
| | - Elena Latysheva
- NRC Institute of Immunology FMBA of Russia, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
| | - Antti Lauerma
- Department of Dermatology, Skin and Allergy Hospital, Helsinki University Hospital, Helsinki, Finland
| | - David Launay
- University Lille, Inserm, CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de Référence des Angioedemes à Kinine (CREAK), U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Ramon Lleonart
- Allergology Department, Hospital Universitari Bellvitge, IDIBILL Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Alejandro Malbran
- Unidad de Alergia, Asma e Inmunología Clínica, Buenos Aires, Argentina
| | - Ramzy Mohammed Ali
- Department of Medicine, Allergy and Immunology Division, Hamad Medical Corporation, Doha, Qatar
| | - Iman Nasr
- Immunology and Allergy Department, The Royal Hospital, Muscat, Oman
| | - Sandra Nieto-Martinez
- Unidad de Genética de la Nutrición, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - Claudio Parisi
- Pediatric and Adult Allergy sections of the Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | | | | | | | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Alicia Prieto Garcia
- Department of Allergy, Gregorio Marañón Health Research Institute (IiSGM), Gregorio Marañón University Hospital, Madrid, Spain
| | - Polina Pyatilova
- Angioedema Center of Reference and Excellence (ACARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine, and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Michael Rudenko
- The London Allergy and Immunology Centre, London, United Kingdom
| | | | - Faradiba Sarquis Serpa
- Angioedema and Urticaria Reference Center, Hospital Santa Casa de Misericórdia de Vitória, Vitória, Espirito Santo, Brazil
| | | | - Frank Siebenhaar
- Angioedema Center of Reference and Excellence (ACARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine, and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Angèle Soria
- Médecine Sorbonne Université, Service de Dermatologie et Allergologie, hôpital Tenon, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Maria Staevska
- Department of Allergology, Medical University of Sofia, Clinic of Allergology, University Hospital "Alexandrovska" Sofia, Bulgaria
| | - Petra Staubach
- Department of Dermatology, ACARE, University Medical Center Mainz, Mainz, Germany
| | - Marcin Stobiecki
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Anna Valerieva
- Department of Allergology, Medical University of Sofia, Clinic of Allergology, University Hospital "Alexandrovska" Sofia, Bulgaria
| | - Solange Valle
- Department of Internal Medicine, Immunology Service, Hospital Universitario Clementino Fraga Filho, Rio De Janiero, Brazil
| | - Nguyen Van Dinh
- Department of General Internal Medicine, Respiratory-Allergy and Clinical Immunology Unit, Vinmec Healthcare System, Hanoi, Vietnam
| | - Carolina Elisa Vera Ayala
- Angioedema Center of Reference and Excellence (ACARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine, and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | | | - Andrea Zanichelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy; Operative Unit of Medicine, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Markus Magerl
- Angioedema Center of Reference and Excellence (ACARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine, and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Marcus Maurer
- Angioedema Center of Reference and Excellence (ACARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine, and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
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Bogart J, Otteson T. Substance Use Disorder as Risk Factor for Intubation in Angioedema: A Nationwide Cohort Study. Laryngoscope 2024. [PMID: 39007365 DOI: 10.1002/lary.31644] [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: 01/25/2024] [Revised: 05/24/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVES Individuals with angioedema (AE) are at high risk for airway compromise and often require endotracheal intubation. Patient factors predisposing one to airway compromise are not well described. The objective of this study is to examine whether substance use disorder (SUD) in patients with AE is associated with need for airway intervention. METHODS This population-based retrospective cohort study compared AE patients with SUD versus propensity-matched control groups. Outcomes were hospitalization, intubation, and tracheotomy. Using the TriNetX National Database, this study included 28,931 patients with SUD and 117,509 patients without SUD who presented with AE. RESULTS Among patients with AE, those with each subtype of SUD (alcohol, cannabis, cocaine, tobacco, and opioids) were found to have higher risk of severe AE compared to propensity-matched non-SUD cohorts. Rate of hospitalization after cohort matching ranged from 20.4% for tobacco use disorder to 30.4% for cocaine use disorder, all significantly higher than the 8.0% in a population without SUD. Each SUD subtype was associated with a higher rate of intubation compared with matched non-SUD groups, with cannabis use disorder having the highest relative risk (RR) of 3.67 (95% CI: 2.69-5.02). Tobacco (RR = 2.45, 95% CI: 1.79-3.34) and alcohol (RR = 2.82, 95% CI: 1.73-4.58) use disorders were both associated with significantly higher risk of tracheotomy. CONCLUSION These data suggest that patients with SUD, regardless of subtype, and after propensity matching for demographics and comorbidities are at higher risk for adverse outcomes when presenting with AE. This study highlights clinically relevant predictors of airway compromise. LEVEL OF EVIDENCE Level 3 Laryngoscope, 2024.
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Affiliation(s)
- Joseph Bogart
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
| | - Todd Otteson
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
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Poddar S, Chandra S, Podder I. Vildagliptin-Induced Tongue Angioedema: An Uncommon Occurrence. Indian Dermatol Online J 2024; 15:685-686. [PMID: 39050061 PMCID: PMC11265730 DOI: 10.4103/idoj.idoj_534_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/14/2023] [Accepted: 12/17/2023] [Indexed: 07/27/2024] Open
Affiliation(s)
- Shreya Poddar
- Department of Dermatology, Asansol District Hospital, Asansol, West Bengal, India
| | | | - Indrashis Podder
- Department of Dermatology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
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Szabó AÁ, Enyedi EE, Altorjay IT, Hajnal P, Pintér TB, Mányiné IS, Váradi C, Bányai E, Tóth A, Papp Z, Fagyas M. Get reliable laboratory findings - how to recognize the deceptive effects of angiotensin-converting enzyme inhibitor therapy in the laboratory diagnostics of sarcoidosis? Clin Chem Lab Med 2024; 62:1393-1401. [PMID: 38205624 DOI: 10.1515/cclm-2023-1288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVES Serum angiotensin-converting enzyme (ACE) is the only biomarker routinely used in the laboratory diagnostics of sarcoidosis, and ACE inhibitor (ACEi) drugs are among the most prescribed drugs worldwide. Taking ACEi can mislead medical teams by lowering ACE activity, delaying diagnosis and giving a false impression of disease activity of sarcoidosis. We aimed to develop a simple method to detect the presence of ACEi drugs in samples, to investigate the ACEi medication-caused interference and consequences in a retrospective study. METHODS ACE activity and the level of ACE inhibition were determined for 1823 patients with suspected sarcoidosis. These values were compared with the therapeutic information at the first and follow-up visits. RESULTS A total of 302 patients had biochemical evidence of an ACEi drug effect during diagnostic ACE activity testing. In their case, ACE activity was significantly lower (median(IQR): 4.41 U/L(2.93-6.72)) than in patients not taking ACEi (11.32 U/L(8.79-13.92), p<0.01). In 62 sarcoidosis patients, the ACEi reduced ACE activity to the reference range or below. Only in 40 % of the cases was the medication list recorded in the outpatient chart and only in 3 cases was low ACE activity associated with ACEi use. 67 % of the repeated ACE activity measurements were also performed during ACEi therapy. CONCLUSIONS Our study revealed that the use of ACEi is common in patients with suspected sarcoidosis. The ACE activity lowering effect of ACEi drugs may escape the attention of medical teams which can lead to diagnostic errors and unnecessary tests. Nevertheless, these pitfalls can be avoided by using a method suggested by our team.
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Affiliation(s)
- Attila Ádám Szabó
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Enikő Edit Enyedi
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - István Tibor Altorjay
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Hajnal
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Tamás Bence Pintér
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ivetta Siket Mányiné
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Csongor Váradi
- Department of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Emese Bányai
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Attila Tóth
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklós Fagyas
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Gil-Serrano J, Labrador-Horrillo M, Galvan-Blasco P, Sala-Cunill A, Bigas P, Pereira-González J, Luengo O, Cardona V, Guilarte M. Systemic inflammation biomarkers during angioedema attacks in hereditary angioedema. Front Immunol 2024; 15:1400526. [PMID: 38953032 PMCID: PMC11215006 DOI: 10.3389/fimmu.2024.1400526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/27/2024] [Indexed: 07/03/2024] Open
Abstract
Background Hereditary angioedema (HAE) is a rare disease characterized by localized and self-limited angioedema (AE) attacks. A local increase of bradykinin (BK) mediates AE attacks in HAE, however the role of inflammation in HAE has been poorly explored We aim to analyze the role of inflammatory mediators in HAE patients during AE attacks. Methods Patients with a confirmed HAE diagnosis due to C1 inhibitor deficiency (HAE-C1INH) or patients F12 gene mutations (HAE-FXII) attending to our outpatient clinic between November-2019 and May-2022 were included. Demographic and clinical characteristics were analyzed. Blood samples were collected both during symptom-free periods (baseline) and during HAE attacks, and acute phase reactants (APR), such as serum amyloid A (SAA), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), D-Dimer and white blood cells were measured. Results Seventy-eight patients were enrolled in the study, with a predominant representation of women (76%, n=59), and a mean age of 47.8 years (range 6-88). Among them, 67% (n=52) of patients had HAE-C1INH (46 classified as type 1 and 6 as type 2) while 33% (n=26) had HAE-FXII. During attack-free periods, the majority of patients exhibited normal levels of SAA, ESR, D-dimer, ACE and WCC. However, in a subset of patients (16% for SAA, 18% for ESR, and 14.5% for D-dimer), elevations were noted at baseline. Importantly, during HAE attacks, significant increases were observed in SAA in 88% of patients (p< 0.0001 vs. baseline), in ESR in 65% (p= 0.003 vs. baseline) and D-dimer in 71% (p=0.001 vs. baseline) of the patients. A comparison between baseline and acute attack levels in 17 patients revealed significant differences in SAA AA (p<0. 0001), ESR (p<0.0001) and D-dimer (p= 0.004). No significant differences were observed in CRP (p=0.7), ACE (p=0.67) and WCC (p=0.54). These findings remained consistent regardless of HAE type, disease activity or location of angioedema. Conclusion The systemic increase in APR observed during HAE attacks suggests that inflammation extends beyond the localized edematous area. This finding underscores the potential involvement of inflammatory pathways in HAE and highlights the need for further investigation into their role in the pathophysiology of HAE.
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Affiliation(s)
- Johana Gil-Serrano
- Department of Allergy, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Allergy Research Unit, Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Moisés Labrador-Horrillo
- Department of Allergy, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Allergy Research Unit, Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Paula Galvan-Blasco
- Department of Allergy, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Allergy Research Unit, Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
| | - Anna Sala-Cunill
- Department of Allergy, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Allergy Research Unit, Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Patricia Bigas
- Department of Allergy, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Allergy Research Unit, Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
| | - Javier Pereira-González
- Department of Allergy, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Allergy Research Unit, Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
| | - Olga Luengo
- Department of Allergy, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Allergy Research Unit, Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victoria Cardona
- Department of Allergy, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Allergy Research Unit, Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
| | - Mar Guilarte
- Department of Allergy, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Allergy Research Unit, Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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8
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Rabinovich-Nikitin I, Liu S, Kirshenbaum LA. Sex-specific considerations in cardiovascular drug therapy. Can J Physiol Pharmacol 2024. [PMID: 38781601 DOI: 10.1139/cjpp-2024-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Despite major advances in cardiac research over the past three decades, cardiovascular disease (CVD) still remains the leading cause of morbidity and mortality in women and men worldwide. However, a major challenge for health care providers is that the current guidelines for cardiovascular drug therapies do not consider the impact of sex in the development of treatment plan for optimizing therapies for women. Clinical research in recent years suggests significant pharmacological and pharmacokinetic differences between females and males, which have been attributed in part to differences in body composition, plasma protein binding capacity, drug metabolism, and excretion. Herein, we provide a comprehensive review regarding sex-specific differences and drugs commonly used for CVDs in women and men. Understanding how sex-related differences influence drug efficacy and CVD outcomes is crucial for not only optimizing treatment strategies for women and men but also to encourage the implementation of specific guidelines that address sex difference as a consideration for the treatment of CVDs.
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Affiliation(s)
- Inna Rabinovich-Nikitin
- The Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Shuangbo Liu
- Section of Cardiology, Department of Medicine, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Lorrie A Kirshenbaum
- The Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- The Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Pharmacology and Therapeutics, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, MB, Canada
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9
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Bresler RM, Whelan J. Angiotensin-Converting Enzyme (ACE) Inhibitor-Induced Angioedema in an African American Male With Coronavirus Disease 2019 (COVID-19). Cureus 2024; 16:e60852. [PMID: 38910667 PMCID: PMC11191406 DOI: 10.7759/cureus.60852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/25/2024] Open
Abstract
Angioedema is a condition characterized by non-pitting swelling of the subcutaneous or submucosal tissues in particular the face, lips, and oral cavity. Angiotensin-converting enzyme (ACE) inhibitors are known to contribute to the development of angioedema by increasing the levels of bradykinin and its active metabolites. Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is hypothesized to contribute to the development of angioedema by modifying ACE II levels and further increasing the level of bradykinin in patients taking ACE inhibitors. African Americans may be at particular risk of developing angioedema with concomitant SARS-CoV-2 infection and ACE inhibitor use. This case involves a 31-year-old African American male diagnosed with coronavirus disease 2019 (COVID-19) who developed angioedema while taking an ACE inhibitor.
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Affiliation(s)
- Richard M Bresler
- Internal Medicine, Baptist Memorial Hospital North Mississippi, Oxford, USA
| | - Jacob Whelan
- Internal Medicine, Baptist Memorial Hospital North Mississippi, Oxford, USA
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10
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Zeng G, Li Y. Gastrointestinal: Small intestinal angioedema induced by angiotensin-converting enzyme inhibitors. J Gastroenterol Hepatol 2024. [PMID: 38644669 DOI: 10.1111/jgh.16583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/01/2024] [Indexed: 04/23/2024]
Affiliation(s)
- G Zeng
- Department of Gastroenterology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Y Li
- Department of Gastroenterology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
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11
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Mathey CM, Maj C, Eriksson N, Krebs K, Westmeier J, David FS, Koromina M, Scheer AB, Szabo N, Wedi B, Wieczorek D, Amann PM, Löffler H, Koch L, Schöffl C, Dickel H, Ganjuur N, Hornung T, Buhl T, Greve J, Wurpts G, Aygören-Pürsün E, Steffens M, Herms S, Heilmann-Heimbach S, Hoffmann P, Schmidt B, Mavarani L, Andresen T, Sørensen SB, Andersen V, Vogel U, Landén M, Bulik CM, Bygum A, Magnusson PKE, von Buchwald C, Hallberg P, Rye Ostrowski S, Sørensen E, Pedersen OB, Ullum H, Erikstrup C, Bundgaard H, Milani L, Rasmussen ER, Wadelius M, Ghouse J, Sachs B, Nöthen MM, Forstner AJ. Meta-analysis of ACE inhibitor-induced angioedema identifies novel risk locus. J Allergy Clin Immunol 2024; 153:1073-1082. [PMID: 38300190 DOI: 10.1016/j.jaci.2023.11.921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/20/2023] [Accepted: 11/13/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Angioedema is a rare but potentially life-threatening adverse drug reaction in patients receiving angiotensin-converting enzyme inhibitors (ACEis). Research suggests that susceptibility to ACEi-induced angioedema (ACEi-AE) involves both genetic and nongenetic risk factors. Genome- and exome-wide studies of ACEi-AE have identified the first genetic risk loci. However, understanding of the underlying pathophysiology remains limited. OBJECTIVE We sought to identify further genetic factors of ACEi-AE to eventually gain a deeper understanding of its pathophysiology. METHODS By combining data from 8 cohorts, a genome-wide association study meta-analysis was performed in more than 1000 European patients with ACEi-AE. Secondary bioinformatic analyses were conducted to fine-map associated loci, identify relevant genes and pathways, and assess the genetic overlap between ACEi-AE and other traits. Finally, an exploratory cross-ancestry analysis was performed to assess shared genetic factors in European and African-American patients with ACEi-AE. RESULTS Three genome-wide significant risk loci were identified. One of these, located on chromosome 20q11.22, has not been implicated previously in ACEi-AE. Integrative secondary analyses highlighted previously reported genes (BDKRB2 [bradykinin receptor B2] and F5 [coagulation factor 5]) as well as biologically plausible novel candidate genes (PROCR [protein C receptor] and EDEM2 [endoplasmic reticulum degradation enhancing alpha-mannosidase like protein 2]). Lead variants at the risk loci were found with similar effect sizes and directions in an African-American cohort. CONCLUSIONS The present results contributed to a deeper understanding of the pathophysiology of ACEi-AE by (1) providing further evidence for the involvement of bradykinin signaling and coagulation pathways and (2) suggesting, for the first time, the involvement of the fibrinolysis pathway in this adverse drug reaction. An exploratory cross-ancestry comparison implicated the relevance of the associated risk loci across diverse ancestries.
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Affiliation(s)
- Carina M Mathey
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany
| | - Carlo Maj
- Institute for Genomic Statistics and Bioinformatics, University Hospital Bonn, Bonn, Germany; Centre for Human Genetics, University of Marburg, Marburg, Germany
| | - Niclas Eriksson
- Uppsala Clinical Research Center, Uppsala, Sweden; Department of Medical Sciences, Clinical Pharmacogenomics and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Kristi Krebs
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Julia Westmeier
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany
| | - Friederike S David
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany
| | | | - Annika B Scheer
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany
| | - Nora Szabo
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany
| | - Bettina Wedi
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Hannover Medical School, Hannover, Germany
| | - Dorothea Wieczorek
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Hannover Medical School, Hannover, Germany
| | - Philipp M Amann
- Department of Medicine, Faculty of Medicine and Dentistry, Danube Private University, Krems, Austria
| | - Harald Löffler
- Department of Dermatology, SLK Hospital Heilbronn, Heilbronn, Germany
| | - Lukas Koch
- Department of Dermatology and Venereology, Medical University Graz, Graz, Austria
| | - Clemens Schöffl
- Department of Dermatology and Venereology, Medical University Graz, Graz, Austria
| | - Heinrich Dickel
- Department of Dermatology, Venereology and Allergology, St Josef Hospital, University Medical Center, Ruhr University Bochum, Bochum, Germany
| | - Nomun Ganjuur
- Department of Dermatology, Venereology and Allergology, St Josef Hospital, University Medical Center, Ruhr University Bochum, Bochum, Germany; Institute of Health Care Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Hornung
- Department of Dermatology and Allergy, University Hospital of Bonn, Bonn, Germany
| | - Timo Buhl
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Greve
- Department of Otorhinolaryngology-Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Gerda Wurpts
- Department of Dermatology and Allergy, Aachen Comprehensive Allergy Center, University Hospital RWTH Aachen, Aachen, Germany
| | - Emel Aygören-Pürsün
- Department for Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Michael Steffens
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Stefan Herms
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany
| | - Stefanie Heilmann-Heimbach
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany
| | - Per Hoffmann
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Laven Mavarani
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Trine Andresen
- Molecular Diagnostics and Clinical Research Unit, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Signe Bek Sørensen
- Molecular Diagnostics and Clinical Research Unit, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Vibeke Andersen
- Molecular Diagnostics and Clinical Research Unit, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark; Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark; OPEN, University of Southern Denmark, Odense, Denmark
| | - Ulla Vogel
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Mikael Landén
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Cynthia M Bulik
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anette Bygum
- Department of Clinical Institute, University of Southern Denmark, Odense, Denmark; Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Patrik K E Magnusson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Christian von Buchwald
- Department of Otorhinolaryngology-Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacogenomics and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Sisse Rye Ostrowski
- Department of Clinical Immunology, Copenhagen Hospital Biobank Unit, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Erik Sørensen
- Department of Clinical Immunology, Copenhagen Hospital Biobank Unit, Rigshospitalet, Copenhagen, Denmark
| | - Ole B Pedersen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Christian Erikstrup
- Departments of Clinical Immunology, Aarhus University, Aarhus, Denmark; Departments of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Henning Bundgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lili Milani
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Eva Rye Rasmussen
- Department of Otorhinolaryngology-Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Departments of Private Practice Ølsemaglevej, Køge, Denmark
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacogenomics and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Jonas Ghouse
- Laboratory for Molecular Cardiology, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Laboratory for Molecular Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bernhardt Sachs
- Department of Dermatology and Allergy, Aachen Comprehensive Allergy Center, University Hospital RWTH Aachen, Aachen, Germany; Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Markus M Nöthen
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany
| | - Andreas J Forstner
- Institute of Human Genetics, University of Bonn, School of Medicine and University Hospital Bonn, Bonn, Germany; Institute of Neuroscience and Medicine (INM-1), Research Center Jülich, Jülich, Germany.
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12
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Pathak GN, Truong TM, Chakraborty A, Rao B, Monteleone C. Tranexamic acid for angiotensin-converting enzyme inhibitor-induced angioedema. Clin Exp Emerg Med 2024; 11:94-99. [PMID: 37525579 PMCID: PMC11009700 DOI: 10.15441/ceem.23.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 08/02/2023] Open
Abstract
Approximately 0.7% of patients taking angiotensin-converting enzyme inhibitors (ACEIs) develop ACEI-induced angioedema (ACEI-IA). With no approved treatments for ACEI-IA, the risk of complications is concerning. Tranexamic acid (TXA) has the potential to prevent intubations and resolve ACEI-IA by inhibiting the downstream production of bradykinin. In this review, we aim to evaluate the safety and efficacy of TXA use in ACEI-IA. We queried the PubMed database for studies involving TXA for ACEI-IA from January 2003 to January 2023. Seven studies met the study inclusion criteria. Our results demonstrate that TXA may improve angioedema symptoms and prevent intubation. In addition, its availability, low cost, and safety profile support its use for improving the symptoms and complications of ACEI-IA in an emergency setting.
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Affiliation(s)
| | | | | | - Babar Rao
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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13
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Wu CL, Ni ZF, Kuang XY, Li MF, Zong MH, Fan XD, Lou WY. Novel Multitarget ACE Inhibitory Peptides from Bovine Colostrum Immunoglobulin G: Cellular Transport, Efficacy in Regulating Endothelial Dysfunction, and Network Pharmacology Studies. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2024; 72:4155-4169. [PMID: 38366990 DOI: 10.1021/acs.jafc.3c08795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
In this study, we used traditional laboratory methods, bioinformatics, and cellular models to screen novel ACE inhibitory (ACEI) peptides with strong ACEI activity, moderate absorption rates, and multiple targets from bovine colostrum immunoglobulin G (IgG). The purified fraction of the compound proteinase hydrolysate of IgG showed good ACEI activity. After nano-UPLC-MS/MS identification and in silico analysis, eight peptides were synthesized and verified. Among them, SFYPDY, TSFYPDY, FSWF, WYQQVPGSGL, and GVHTFP were identified as ACEI peptides, as they exhibited strong ACEI activity (with IC50 values of 104.7, 80.0, 121.2, 39.8, and 86.3 μM, respectively). They displayed good stability in an in vitro simulated gastrointestinal digestion assay. In a Caco-2 monolayer model, SFYPDY, FSWF, and WYQQVPGSGL exhibited better absorption rates and lower IC50 values than the other peptides and were thereby identified as novel ACEI peptides. Subsequently, in a H2O2-induced endothelial dysfunction (ED) model based on HUVECs, SFYPDY, FSWF, and WYQQVPGSGL regulated ED by reducing apoptosis and ROS accumulation while upregulating NOS3 mRNA expression. Network pharmacology analysis and RT-qPCR confirmed that they regulated multiple targets. Overall, our results suggest that SFYPDY, FSWF, and WYQQVPGSGL can serve as novel multitarget ACEI peptides.
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Affiliation(s)
- Chu-Li Wu
- Laboratory of Applied Biocatalysis, School of Food Science and Engineering, South China University of Technology, 381 Wushan Road, Guangzhou 510640, Guangdong China
| | - Zi-Fu Ni
- Laboratory of Applied Biocatalysis, School of Food Science and Engineering, South China University of Technology, 381 Wushan Road, Guangzhou 510640, Guangdong China
| | - Xiao-Yan Kuang
- Laboratory of Applied Biocatalysis, School of Food Science and Engineering, South China University of Technology, 381 Wushan Road, Guangzhou 510640, Guangdong China
| | - Meng-Fan Li
- Laboratory of Applied Biocatalysis, School of Food Science and Engineering, South China University of Technology, 381 Wushan Road, Guangzhou 510640, Guangdong China
| | - Min-Hua Zong
- Laboratory of Applied Biocatalysis, School of Food Science and Engineering, South China University of Technology, 381 Wushan Road, Guangzhou 510640, Guangdong China
| | - Xiao-Dan Fan
- Laboratory of Applied Biocatalysis, School of Food Science and Engineering, South China University of Technology, 381 Wushan Road, Guangzhou 510640, Guangdong China
| | - Wen-Yong Lou
- Laboratory of Applied Biocatalysis, School of Food Science and Engineering, South China University of Technology, 381 Wushan Road, Guangzhou 510640, Guangdong China
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14
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Liaghatdar A, Mazaheri-Tehrani S, Fakhrolmobasheri M. Management of Hypertension in Patients With Polycystic Ovarian Syndrome: A Mini-Review. Cardiol Rev 2024:00045415-990000000-00199. [PMID: 38305409 DOI: 10.1097/crd.0000000000000635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Polycystic ovarian syndrome (PCOS) is a common problem among young women. It is characterized mainly by hyperandrogenism features, such as hirsutism, menstrual problems, and anovulation. Diagnosis is based on the existence of 2 items out of, oligo-ovulation, hyperandrogenism features, and ultrasounds findings. Cardiovascular complications such as hypertension are a prevalent serious condition in these patients which is mainly predisposed by the high levels of androgens, and insulin resistance. High blood pressure should be controlled well to prevent the progression of other serious conditions. Various antihypertensive drugs could be prescribed. However, in selecting an antihypertensive medication, other therapeutic properties of the drug should also be considered. Up to now, many clinicians do not differ between PCOS patients with hypertension and other hypertensive patients. However, being aware of the potential effects of each hypertension drug could help to choose better options for the patient. Here is a brief review of how each antihypertensive drug could affect PCOS women and if they cause any improvement in the disorder progression.
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Affiliation(s)
- Amin Liaghatdar
- From the Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sadegh Mazaheri-Tehrani
- From the Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
- Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Fakhrolmobasheri
- From the Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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15
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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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16
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Beaini H, Bjorkman C, Johnson K, Araj FG. Sirolimus potentiated angioedema: A case report and review of the literature. Open Med (Wars) 2024; 19:20230884. [PMID: 38205154 PMCID: PMC10775924 DOI: 10.1515/med-2023-0884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024] Open
Abstract
Introduction In the realm of organ transplantation, particularly heart transplantation, angioedema presents a significant challenge. This clinical condition ranges from minor facial edema to life-threatening swelling of vital structures. Its multifactorial etiology involves various factors and mechanisms, including C1 esterase inhibitor deficiency, food allergen hypersensitivity, and adverse drug reactions, notably involving angiotensin-converting enzyme (ACE) inhibitors and mechanistic target of rapamycin inhibitors (mTOR-Is). We present a rare case of sirolimus potentiated angioedema in a patient with long-standing ACE inhibitor therapy. Case A 52-year-old male with a history of heart transplant developed severe upper and lower lip edema. The patient had been on Lisinopril without any adverse events. However, sirolimus was recently added to his drug regimen. Sirolimus potentiated angioedema was suspected. Intervention Intravenous methylprednisolone, famotidine, and diphenhydramine were initiated, and both lisinopril and sirolimus were discontinued. The patient showed improvement and was discharged with oral antihistamines. Lessons Transplant physicians should be aware of the life-threatening interaction between ACE inhibitors and mTOR-Is like sirolimus. Consideration should be given to switching from an ACE inhibitor to an angiotensin-receptor blocker when initiating patients on mTOR-Is.
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Affiliation(s)
- Hadi Beaini
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, United States
| | - Carol Bjorkman
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, United States
| | - Kelly Johnson
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, United States
| | - Faris G. Araj
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Professional Office Bldg. 2 Suite 600, 5939 Harry Hines Blvd.Dallas, TX, 75390-9252, United States
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17
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Ringwald M, Moi L, Wetzel A, Comte D, Muller YD, Ribi C. Risk factors for allergy documentation in electronic health record: A retrospective study in a tertiary health center in Switzerland. Allergol Int 2024; 73:143-150. [PMID: 37455165 DOI: 10.1016/j.alit.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/27/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Most hospitals use electronic health records (EHR) to warn health care professionals of drug hypersensitivity (DH) and other allergies. Indiscriminate recording of patient self-reported allergies may bloat the alert system, leading to unjustified avoidances and increases in health costs. The aim of our study was to analyze hypersensitivities documented in EHR of patients at Lausanne University Hospital (CHUV). METHODS We conducted a retrospective study on patients admitted at least 24 h to CHUV between 2011 and 2021. After ethical clearance, we obtained anonymized data. Because culprit allergen could be either manually recorded or selected through a list, data was harmonized using a reference allergy database before undergoing statistical analysis. RESULTS Of 192,444 patients, 16% had at least one allergy referenced. DH constituted 60% of all allergy alerts, mainly beta-lactam antibiotics (BLA) (30%), NSAID (11%) and iodinated contrast media (ICM) (7%). Median age at first hospitalization and hospitalization length were higher in the allergy group. Female to male ratio was 2:1 in the allergic group. Reactions were limited to the skin in half of patients, and consistent with anaphylaxis in 6%. In those deemed allergic to BLA, culprit drug was specified in 19%, 'allergy to penicillin' otherwise. It was impossible to distinguish DH based on history alone or resulting from specialized work-up. CONCLUSIONS Older age, longer hospital stays, and female sex increase the odds of in-patient allergy documentation. Regarding DH, BLA were referenced in 4% of inpatient records. Specific delabeling programs should be implemented to increase data reliability and patient safety.
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Affiliation(s)
- Maxime Ringwald
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland.
| | - Laura Moi
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Alexandre Wetzel
- Data Science & Research, Direction of Informatics Systems, Department of Infrastructures, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Denis Comte
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Yannick D Muller
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Camillo Ribi
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
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18
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Rice B, Mbatidde L, Oluleye O, Onwuanyi A, Adedinsewo D. Managing hypertension in African Americans with heart failure: A guide for the primary care clinician. J Natl Med Assoc 2023:S0027-9684(23)00144-X. [PMID: 38135590 DOI: 10.1016/j.jnma.2023.11.004] [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: 10/11/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
Hypertension is the predominant risk factor for cardiovascular disease related morbidity and mortality among Black adults in the United States. It contributes significantly to the development of heart failure and increases the risk of death following heart failure diagnosis. It is also a leading predisposing factor for hypertensive disorders of pregnancy and peripartum cardiomyopathy in Black women. As such, all stakeholders including health care providers, particularly primary care clinicians (including physicians and advanced practice providers), patients, and communities must be aware of the consequences of uncontrolled hypertension among Black adults. Appropriate treatment strategies should be identified and implemented to ensure timely and effective blood pressure management among Black individuals, particularly those with, and at risk for heart failure.
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Affiliation(s)
- Bria Rice
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Lydia Mbatidde
- Department of Family Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - Anekwe Onwuanyi
- Department of Cardiovascular Medicine, Morehouse School of Medicine, Atlanta, GA
| | - Demilade Adedinsewo
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States.
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19
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Landry L, Witten T, Anwar AI, Jackson CN, Talbot NC, Ahmadzadeh S, Varrassi G, Shekoohi S, Kaye AD. Angiotensin-Converting Enzyme Inhibitors and Other Medications Associated With Angioedema. Cureus 2023; 15:e49306. [PMID: 38957198 PMCID: PMC11218608 DOI: 10.7759/cureus.49306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/23/2023] [Indexed: 07/04/2024] Open
Abstract
Angioedema is a localized swelling of the dermis, subcutaneous tissues, and/or submucosal tissues caused by fluid extravasation into these tissues. Angioedema is associated with certain vasoactive molecules and is typically mediated by histamine or bradykinin. It manifests clinically as facial edema, swelling of the extremities and urogenital area, and potential involvement of the larynx, leading to dyspnea and inspiratory stridor, which can become life-threatening. Histamine-mediated angioedema is associated with urticaria and pruritus and will show classic signs of allergic (type 1 hypersensitivity) reactions. Bradykinin-mediated angioedema is often familial (hereditary angioedema) and is more often associated with gastrointestinal symptoms (abdominal pain, nausea, vomiting, diarrhea), edema of the extremities and trunk, and a lack of urticaria and pruritus. Angiotensin-converting enzyme inhibitors (ACEIs) are a class of medications commonly prescribed for hypertension, heart failure, and diabetic nephropathy. ACEIs are associated with an increased risk of angioedema, which can range from a mild reaction to severe and life-threatening. ACEI-induced angioedema is a bradykinin-mediated reaction that can occur in individuals with a genetic predisposition. Other medications, such as angiotensin receptor blockers, nonsteroidal anti-inflammatory drugs, and certain antibiotics, most notably those in the beta-lactam class, can also cause drug-induced angioedema. The present investigation describes current knowledge of the pathophysiology, epidemiology, clinical manifestations, predisposing factors, and management of drug-induced angioedema.
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Affiliation(s)
- Layne Landry
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Taylor Witten
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Corrie N Jackson
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Norris C Talbot
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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20
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Eraky AM, Wright A, McDonald D. Pseudo-Allergies in the Emergency Department: A Common Misdiagnosis of Hypersensitivity Type 1 Allergic Reaction. Cureus 2023; 15:e46536. [PMID: 37927771 PMCID: PMC10625449 DOI: 10.7759/cureus.46536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
Type-1 hypersensitivity reaction represents an acute IgE-mediated reaction that can cause life-threatening conditions, such as anaphylactic shock, angioedema, and airway obstruction. Other reactions that can mimic type-1 hypersensitivity reactions include IgE-independent mast cell degranulation, bradykinin-mediated reactions, leukotrienes-mediated reactions, and pseudo-allergies. We use the term pseudo-allergy in this article for histamine-mediated reactions that are mast cell-independent. We did not discuss pseudo-allergic reactions that are not acute or life-threatening, such as celiac disease, Heiner's syndrome, eosinophilic esophagitis, and food protein-induced enterocolitis in our article because the emergency department is not the primary location to diagnose or treat these reactions. Herein, we present some allergic-like reactions that can be life-threatening, such as scombroid food poisoning (SFP), bradykinin-induced angioedema, IgE-independent angioedema, opioid-induced angioedema, and non-steroidal anti-inflammatory drug (NSAID)-induced hypersensitivity and angioedema. These reactions may have different treatments based on their mechanism of reaction. Histamine-mediated reactions, such as SFP, histamine-mediated angioedema, and mast cell degranulation induced by NSAIDs, and opioids can be treated with antihistamines, epinephrine, and corticosteroids. Bradykinin-induced angioedema, including hereditary angioedema and acquired angioedema, can be treated with fresh frozen plasma. Hereditary angioedema can be treated with many FDA-approved targeted medications, such as plasma-derived C1-INH, plasma kallikrein inhibitor (Ecallantide), and selective bradykinin-2 receptor antagonist (Icatibant). However, these targeted agents are not well-studied enough to be used for acquired angioedema. It is crucial for emergency medicine physicians to be familiar with and predict these reactions to prevent misdiagnosis, be prepared to treat these life-threatening conditions appropriately without delay and eliminate patients' exposure to any unnecessary investigations or treatments.
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Affiliation(s)
- Akram M Eraky
- Emergency Medicine, Freeman Health System, Joplin, USA
- Emergency Medicine, Kansas City University of Medicine and Biosciences, Kansas, USA
| | - Alisha Wright
- Emergency Medicine, Freeman Health System, Joplin, USA
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21
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Cutrell S, Alhomoud IS, Mehta A, Talasaz AH, Van Tassell B, Dixon DL. ACE-Inhibitors in Hypertension: A Historical Perspective and Current Insights. Curr Hypertens Rep 2023; 25:243-250. [PMID: 37284934 DOI: 10.1007/s11906-023-01248-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW This review describes the discovery and development of ACE inhibitors as antihypertensive agents, compares their efficacy, tolerability, and safety to ARBs, and highlights the contemporary issues surrounding ACE inhibitor use for HTN. RECENT FINDINGS Angiotensin-converting enzyme (ACE) inhibitors are commonly prescribed medications for the management of hypertension (HTN) and other chronic conditions including heart failure and chronic kidney disease. These agents inhibit ACE, the enzyme that is responsible for converting angiotensin (AT) I to AT II. Inhibiting the synthesis of AT II causes arterial and venous vasodilation, natriuresis, and a decrease in sympathetic activity, resulting in the reduction of blood pressure. ACE inhibitors are first-line therapy in HTN management along with thiazide diuretics, calcium channel blockers, and angiotensin receptor blockers (ARB). Along with inhibiting AT II synthesis, inhibition of ACE causes accumulation of bradykinin, increasing the risk of bradykinin-mediated side effects like angioedema and cough. Since ARBs do not work on ACE in the renin-angiotensin system, the risk of angioedema and cough are lower with ARBs. Recent evidence has also suggested ARBs may have neuroprotective effects compared to other antihypertensives, including ACE inhibitors; however, this warrants further study. Currently, ACE inhibitors and ARBs have an equal class of recommendation for first-line treatment for the management of HTN. Recent evidence has shown ARBs to be just as effective as ACE inhibitors for HTN but with improved tolerability.
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Affiliation(s)
- Stacey Cutrell
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA
| | - Ibrahim S Alhomoud
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraydah, Saudi Arabia
| | - Anurag Mehta
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Azita H Talasaz
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA
| | - Benjamin Van Tassell
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA.
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22
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Wilkerson RG, Winters ME. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. Immunol Allergy Clin North Am 2023; 43:513-532. [PMID: 37394257 DOI: 10.1016/j.iac.2022.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Michael E Winters
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/critcareguys
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23
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Ameer MA, Mushtaq J, Chaudhry H, Patel N, Khan SI. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema: A Case Report With a Review of Management Options. Cureus 2023; 15:e40320. [PMID: 37448396 PMCID: PMC10337988 DOI: 10.7759/cureus.40320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Angiotensin-converting enzyme inhibitors (ACEIs) are widely used for heart failure, renal failure, diabetic nephropathy, stroke, arterial hypertension, and a number of other cardiovascular or related conditions. ACEI-induced angioedema is a rare entity but can result in life-threatening emergencies. It mainly occurs in patients starting on ACEI as an antihypertensive. We present a case of lisinopril-induced angioedema in an African American patient managed in the emergency department. After appropriate evaluation, the patient was declared safe to be observed in the emergency department. Intubation was not performed. Early identification of angioedema is paramount, and emergency physicians should maintain airways or intubate such patients if indicated. There should be a high level of suspicion of angioedema in patients taking ACEIs if they present with symptoms of respiratory compromise.
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Affiliation(s)
| | - Javaria Mushtaq
- Cell Biology and Neuroscience, Rowan University, Stratford, USA
| | - Haroon Chaudhry
- Internal Medicine, Suburban Community Hospital, East Norriton, USA
| | - Nimi Patel
- Internal Medicine, Suburban Community Hospital, East Norriton, USA
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24
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Li J, Bollati C, Aiello G, Bartolomei M, Rivardo F, Boschin G, Arnoldi A, Lammi C. Evaluation of the multifunctional dipeptidyl-peptidase IV and angiotensin converting enzyme inhibitory properties of a casein hydrolysate using cell-free and cell-based assays. Front Nutr 2023; 10:1198258. [PMID: 37284652 PMCID: PMC10240083 DOI: 10.3389/fnut.2023.1198258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/09/2023] [Indexed: 06/08/2023] Open
Abstract
The objective of the study was the evaluation of the potential pleiotropic effect of a commercial casein hydrolysate (CH). After an analysis of the composition, the BIOPEP-UWM database suggested that these peptides contained numerous sequences with potential inhibitory activities on angiotensin converting enzyme (ACE) and dipeptidyl-peptidase IV (DPP-IV). The anti-diabetic and anti-hypertensive effects of these peptides were thus assessed using either cell-free or cell-based assays. In the cell-free system, CH displayed inhibitory properties against DPP-IV (IC50 value equal to 0.38 ± 0.01 mg/mL) and ACE (IC50 value equal to 0.39 ± 0.01 mg/mL). Further, CH reduced the DPP-IV and ACE activities expressed by human intestinal Caco-2 cells by 61.10 ± 1.70% and 76.90 ± 4.47%, respectively, versus untreated cells, after 6 h of treatment at the concentration of 5 mg/mL. This first demonstration of the multifunctional behavior of this material suggests that it may become an anti-diabetic and/or anti-hypertensive ingredient to be included in the formulation of different functional food or nutraceutics.
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Affiliation(s)
- Jianqiang Li
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Carlotta Bollati
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Gilda Aiello
- Department of Human Science and Quality of Life Promotion, Telematic University San Raffaele, Rome, Italy
| | - Martina Bartolomei
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | | | - Giovanna Boschin
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Anna Arnoldi
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Carmen Lammi
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
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25
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Vazirnia P, Choroomi Y, Marfowaa G, Razzak AN, Quinn B. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema With Resultant Airway Obstruction Following Endotracheal Intubation. Cureus 2023; 15:e37594. [PMID: 37197111 PMCID: PMC10183302 DOI: 10.7759/cureus.37594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/19/2023] Open
Abstract
Angiotensin-converting enzyme inhibitor (ACEi)-induced angioedema is a consequence of excessive levels of bradykinin and accounts for nearly a third of angioedema cases when patients present to emergency rooms. While rare, patients can present with swelling in the face, tongue, and airways making it a life-threatening emergency. To secure an airway, endotracheal intubation may be conducted; however, tracheal stenosis is a known complication. In this report, we present a 61-year-old female with a history of ACEi-induced angioedema care in which she was intubated with facial swelling. Upon a repeat hospitalization, the patient developed stridor with respiratory distress. Bronchoscopy revealed severe tracheal stenosis with multilevel damage to tracheal rings, warranting urgent tracheostomy. One month after discharge, the patient was seen by an ENT specialist who performed a transnasal laryngoscopy revealing near total subglottic and tracheal stenosis of 3 cm stenosis length, presumed secondary to traumatic intubation for prior angioedema management. This case highlights the importance of careful intubation practices in patients with suspected airway edema.
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Affiliation(s)
- Parsia Vazirnia
- School of Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Yasmine Choroomi
- School of Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Gifty Marfowaa
- School of Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Abrahim N Razzak
- School of Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Brian Quinn
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
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26
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Irwin TM, Irwin TM, Longanecker A, Bodenhamer WS, Keirns CC. A Case of Refractory Angioedema. J Intensive Care Med 2023; 38:313-320. [PMID: 36514293 DOI: 10.1177/08850666221145310] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Angioedema is an acute disorder that affects mucous membranes and the deepest layers of the skin along with underlying tissue, marked by rapid swelling, large welts, and pain. There are 3 major subtypes of angioedema: mast-cell mediated, bradykinin-mediated, and multifactorial or unclear mechanism subtype. The most common subtype of bradykinin-mediated angioedema is ACE-inhibitor induced, which disproportionately affects African-Americans. It is most often self-limiting and usually responds to the withdrawal of the offending agent. The prolonged duration of angioedema is uncommon in the absence of a persistent stimulus, though it is more likely when there is an abnormality of the metabolic pathways, such as in hereditary angioedema or other gene polymorphisms affecting the complement system. We present a case of severe angioedema that persisted for over a month and required a tracheostomy to manage the airway.
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Affiliation(s)
- Thomas M Irwin
- 145762University of Kansas Cancer Center, Melanoma Project, Westwood, KS, USA
| | | | | | - William Spence Bodenhamer
- Departments of History of Medicine & Internal Medicine (Palliative Care), 12251University of Kansas School of Medicine, Kansas City, KS, USA
| | - Carla C Keirns
- Departments of History of Medicine & Internal Medicine (Palliative Care), 12251University of Kansas School of Medicine, Kansas City, KS, USA
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27
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Mazzoli CA, D Angelo MI, Simonetti L, Cirillo L, Zini A, Gentile M, Gordini G, Coniglio C. Angioedema after rt-PA infusion led to airway emergency: a case report of rescue treatment with fresh frozen plasma. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:223-226. [PMID: 33932385 PMCID: PMC10068524 DOI: 10.1016/j.bjane.2021.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/25/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
The authors report the case of a 71-year-old woman presented to the Emergency Department with acute ischemic stroke. She was treated with rt-PA and interventional endovascular revascularization and developed rapidly progressing angioedema that led to emergency intubation. The standard treatment was not very effective and the swelling improved after infusion of fresh frozen plasma. Angioedema after rt-PA infusion could be a life-threatening emergency that requires quick airway management by skilled professionals. As this condition is triggered by several factors, such as unregulated histamine and bradykinin production, the traditional treatment recommended by the guidelines may not be sufficient and the use of FFP can be considered as a safe and valuable aid.
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Affiliation(s)
- Carlo Alberto Mazzoli
- Ospedale Maggiore, Intensive Care and Prehospital Emergency Service, Department of Anesthesia, Bologna, Italy.
| | - Maura Ida D Angelo
- Ospedale Maggiore, Intensive Care and Prehospital Emergency Service, Department of Anesthesia, Bologna, Italy
| | - Luigi Simonetti
- Ospedale Maggiore, Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luigi Cirillo
- Ospedale Bellaria, Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; University of Bologna, Diagnostic and Experimental Medicine, Department of Specialty, DIMES, Bologna, Italy
| | - Andrea Zini
- Ospedale Maggiore, Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Mauro Gentile
- Ospedale Maggiore, Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giovanni Gordini
- Ospedale Maggiore, Intensive Care and Prehospital Emergency Service, Department of Anesthesia, Bologna, Italy
| | - Carlo Coniglio
- Ospedale Maggiore, Intensive Care and Prehospital Emergency Service, Department of Anesthesia, Bologna, Italy
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28
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Hsu CC, Wong MF, Ho MP. Comment on: COVID-19 presenting as acute epiglottitis: A case report and literature review. Auris Nasus Larynx 2023; 50:169. [PMID: 35431107 PMCID: PMC8995255 DOI: 10.1016/j.anl.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023]
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29
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Strassen U, Bas M, Wirth M, Wirth M, Gröger M, Stelter K, Volkenstein S, Kehl V, Kojda G, Hoffmann TK, Hahn J, Trainotti S, Greve J. Efficacy of human C1 esterase inhibitor concentrate for treatment of ACE-inhibitor induced angioedema. Am J Emerg Med 2023; 64:121-128. [PMID: 36516670 DOI: 10.1016/j.ajem.2022.12.001] [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: 09/23/2022] [Revised: 11/21/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND ACE inhibitor (ACEi) induced angioedema predominantly affects the upper aerodigestive tract. As ACEi induced angioedema is mediated by bradykinin, therapeutic response to antihistamines and glucocorticoids remains unsatisfactory. In bradykinin mediated hereditary angioedema, C1-esterase inhibitor (C1INH) is an effective and approved treatment since many years. Our aim was to evaluate the therapeutic effect of C1INH in ACEi induced angioedema. METHODS We performed a double-blind, parallel-group, multicentre randomised placebo-controlled trial between December 2013 and September 2018. Eligible were adults with ACEi induced angioedema with airway obstruction. Participants were randomised 1:1 to single doses of either C1INH (20 IU/kg) or placebo (0.9% NaCl) i.v in addition to standard care (i.v. 500 mg prednisolone and 2.68 mg clemastine) i.v. Composite symptom scores were assessed at baseline and up to 48 h, at discharge and 1 week after discharge. Physician assessed time to complete oedema resolution (TCER) and time to onset of relief (TOR). RESULTS 30 patients (16 C1INH, 14 placebo) were randomised and dosed. 25 (9 C1INH, 12 placebo) completed the study. TCER was 29.63 h ± 15.56 h in the C1INH and 17.29 h ± 10.40 h in the placebo arm (p = 0.0457). TORs were 4.13 h ± 3.38 h and 2.86 h ± 1.29 h for C1INH and placebo, respectively (p = 0.4443). There were no adverse events related to study medication. CONCLUSIONS In the context of baseline application of steroids and antihistamines C1INH was inferior in the treatment of ACEi induced angioedema when compared to placebo with respect to time to complete resolution of symptoms. Eudra-CT Number: 2012-001670-28.
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Affiliation(s)
- Ulrich Strassen
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany.
| | - Murat Bas
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Magdalena Wirth
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Markus Wirth
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Moritz Gröger
- Department of Otorhinolaryngology, Grosshadern Medical Center of the University of Munich, Germany
| | - Klaus Stelter
- Department of Otorhinolaryngology, Grosshadern Medical Center of the University of Munich, Germany
| | - Stefan Volkenstein
- Department of Otorhinolaryngology, Ruhr-University of Bochum, St. Elisabeth-Hospital Bochum, Germany
| | - Victoria Kehl
- Munich Study Center, Faculty of Medicine, Technical University Munich, Germany; Institute for AI and Informatics in Medicine, Faculty of Medicine, Technical University Munich, Germany
| | - Georg Kojda
- Institute of Pharmacology and Clinical Pharmacology, University Hospital Düsseldorf, Düsseldorf (G.K.), Germany
| | - Thomas K Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University, Medical Center, Ulm, Germany
| | - Janina Hahn
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University, Medical Center, Ulm, Germany
| | - Susanne Trainotti
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany; Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University, Medical Center, Ulm, Germany
| | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University, Medical Center, Ulm, Germany
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Taming the Tongue: The Surgical Approach to Macroglossia. J Craniofac Surg 2023; 34:393-397. [PMID: 36184765 DOI: 10.1097/scs.0000000000009035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/25/2022] [Indexed: 01/11/2023] Open
Abstract
While traditionally in the realm of otorhinolaryngology or oral maxillofacial surgery, conditions involving the tongue may also be managed by plastic surgeons. The authors present an unusual case of acquired macroglossia resulting from angiotensin-converting enzyme inhibitor-induced angioedema and review the literature to discuss its surgical management from a plastic surgery perspective. A 62-year-old female suffered severe airway obstruction, respiratory arrest, and anoxic brain injury from angioedema-associated macroglossia. After tracheostomy, the patient was managed nonsurgically, with bite wound care and medications to minimize angioedema to marginal effect. Ultimately, a partial glossectomy was planned. The edematous distal tongue was amputated and closed primarily. On postoperative day 2, she was successfully weaned off mechanical ventilation and no longer suffers trauma from tongue biting. The simple anterior tongue resection described in this paper was an appropriate approach for our patient. More research is needed to guide plastic surgeons in an optimal approach for clinical scenarios.
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Rocour S, Cochard B, Daniel V, Martin L, Corvaisier M. Large Predominance of Off-Label Prescriptions of C1-Inhibitor Concentrates and Icatibant in a Real-Life Setting: A Retrospective Clinical Study. J Clin Pharmacol 2023; 63:29-39. [PMID: 35871284 DOI: 10.1002/jcph.2125] [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: 03/15/2022] [Accepted: 07/18/2022] [Indexed: 12/15/2022]
Abstract
C1-inhibitor (C1INH) concentrates and the selective bradykinin B2 receptor antagonist icatibant are approved only for treating hereditary angioedema with C1INH deficiency. Yet, they are regularly prescribed off label in other types of bradykinin-mediated angioedema including angiotensin-converting enzyme inhibitor (ACEi)-related and undetermined angioedema. We conducted a retrospective chart review of inpatient prescriptions of C1INH concentrates and icatibant between 2016 and 2020 in the University Hospital of Angers. The first outcome was the proportion of prescriptions with explicit indication. Then, we determined the compliance of prescriptions with European Medicines Agency approvals and the French bradykinin-mediated angioedema reference center guidelines. Finally, we estimated the economic impact of inappropriate prescribing. The therapeutic indication was explicit in 90.4% of prescriptions (n = 66/73). Only 17.8% of prescriptions were for hereditary angioedema with C1INH deficiency, while 31.5% were for ACEi-related and 28.7% for undetermined angioedema. However, most off-label prescriptions were consistent with the French bradykinin-mediated angioedema reference center guidelines (73.3%). We estimated that 13% of drug expenditures were potentially excessive. The predominance of off-label prescriptions may be explained by the infrequency of hereditary angioedema and the absence of approved alternatives in other types of bradykinin-mediated angioedema. Most attacks were related to ACEis. Epinephrine was rarely prescribed as first-line therapy in attacks of unknown origin. Given the high prices of these drugs, we advocate the development of a readily available management algorithm of angioedema to reduce inappropriate prescriptions in our center. In addition, we think that the drug prescription circuit should be redesigned to ensure the traceability of prescribed vials in the dispensing areas.
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Affiliation(s)
- Samuel Rocour
- Department of Dermatology, University Hospital of Angers, Angers, France
| | - Baptiste Cochard
- Department of Pharmacy, University Hospital of Angers, Angers, France.,School of Pharmacy, Health Faculty, University of Angers, Angers, France
| | - Valérie Daniel
- Department of Pharmacy, University Hospital of Angers, Angers, France
| | - Ludovic Martin
- Department of Dermatology, University Hospital of Angers, Angers, France
| | - Mathieu Corvaisier
- Department of Pharmacy, University Hospital of Angers, Angers, France.,School of Pharmacy, Health Faculty, University of Angers, Angers, France.,A4638, Laboratory of Psychology of the Pays de la Loire, University of Angers, Angers, France
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32
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Pezeshki PS, Nowroozi A, Razi S, Rezaei N. Asthma and Allergy. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Perman B, Narechania S, Malesker M. Geriatric Pharmacotherapy Case Series: Recurrent Angioedema Following Discontinuation of ACE Inhibitor Therapy. Sr Care Pharm 2023; 38:16-20. [PMID: 36751921 DOI: 10.4140/tcp.n.2023.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction Angiotensin-converting enzyme inhibitors (ACEIs) are first-line pharmaceutical agents in common chronic conditions such as hypertension and heart failure with reduced ejection fraction. When angioedema occurs, if secondary to ACEIs, discontinuation of the ACEI is necessary to mitigate the risk of recurrent angioedema. While angioedema is a well-known adverse effect of ACEIs, it is not well-known that angioedema may recur even after ACEI discontinuation. Additionally, only few reports in the literature describe this phenomenon. This case describes an older man with a history of chronic obstructive pulmonary disease, hypothyroidism, diabetes mellitus, hypertension, and heart failure who presented from an assisted living facility with recurrent angioedema 12 days after an initial episode of angioedema where his ACEI therapy (enalapril) was discontinued. Assessment Empiric methylprednisolone, diphenhydramine, intramuscular epinephrine, intravenous C1 esterase inhibitor Berinert®, and two units of fresh frozen plasma was given in the emergency department. The patient was monitored in the intensive care unit because of mild airway compromise but did not require invasive airway protection. Serum C4 level was normal, ruling out hereditary angioedema. Outcome Patient was discharged after five days in stable condition with resolution of symptoms. Conclusion ACEIs are the most common cause of drug-induced angioedema in the United States. Angioedema is self-limiting swelling that requires close airway monitoring. While health professionals recognize the risk for angioedema with active ACEI use, it is not well known that the risk of angioedema may occur for months following cessation of ACEI therapy. Increased awareness of delayed ACEI-induced angioedema following ACEI discontinuation is important for both providers and pharmacists to provide appropriate diagnosis and monitoring. Improved awareness would also allow patients with a history of ACEI-induced angioedema to be cognizant of the potential for recurrence following drug discontinuation.
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Affiliation(s)
- Bryton Perman
- Creighton University School of Medicine, Omaha, Nebraska
| | | | - Mark Malesker
- Creighton University School of Medicine, Omaha, Nebraska
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34
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Pitak-Arnnop P, Subbalekha K, Muangchan C, Auychai P, Sirintawat N, Meningaud JP, Neff A. Angiotensin-Converting Enzyme Inhibitor-Induced Non-allergic Perioral Angioedema: A Case-Based Scoping Review. Korean J Fam Med 2023; 44:2-10. [PMID: 34808742 PMCID: PMC9887447 DOI: 10.4082/kjfm.21.0095] [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: 04/30/2021] [Accepted: 05/10/2021] [Indexed: 01/31/2023] Open
Abstract
Patients with angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema (ACEIIA) may visit family physicians. The aim of this article was to describe a case of delayed-onset ACEIIA and to present a concise scoping review. Using a case report and a scoping review study design, we report a case of ACEIIA, with clinically confirmed diagnosis. The symptoms resolved after replacing the offending ACEI with another antihypertensive agent. After excluding other causes of perioral swelling and discontinuation of ACEI, the patient was symptom-free within a few days thereafter. Based on this case presentation, we performed a meta-narrative scoping review including up-todate diagnosis and management of ACEIIA, based on published data in English, French, and German from inception to April 1, 2021. Patients with angioedema of unknown origin should be cautiously examined to rule out oral diseases, including allergy to dental materials and drug-induced angioedema. Clinicopathological aspects and current treatment guidelines for ACEI-associated angioedema are also presented.
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Affiliation(s)
- Poramate Pitak-Arnnop
- Department of Oral and Maxillofacial Surgery, University Hospital of Giessen and Marburg, UKGM GmbH, Campus Marburg, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany,Corresponding Author: Poramate Pitak-Arnnop https://orcid.org/0000-0002-7427-3461 Tel: +49-6421-58-63239, Fax: +49-6421-68990, E-mail:
| | - Keskanya Subbalekha
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Chayawee Muangchan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Prim Auychai
- Department of Pediatric Dentistry, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Nattapong Sirintawat
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Jean-Paul Meningaud
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor University Hospital, AP-HP, Faculty of Medicine, University Paris-Est Créteil Val de Marne (Paris XII), Créteil, France
| | - Andreas Neff
- Department of Oral and Maxillofacial Surgery, University Hospital of Giessen and Marburg, UKGM GmbH, Campus Marburg, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
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35
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Zheng W, Tian E, Liu Z, Zhou C, Yang P, Tian K, Liao W, Li J, Ren C. Small molecule angiotensin converting enzyme inhibitors: A medicinal chemistry perspective. Front Pharmacol 2022; 13:968104. [PMID: 36386190 PMCID: PMC9664202 DOI: 10.3389/fphar.2022.968104] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/17/2022] [Indexed: 10/07/2023] Open
Abstract
Angiotensin-converting enzyme (ACE), a zinc metalloprotein, is a central component of the renin-angiotensin system (RAS). It degrades bradykinin and other vasoactive peptides. Angiotensin-converting-enzyme inhibitors (ACE inhibitors, ACEIs) decrease the formation of angiotensin II and increase the level of bradykinin, thus relaxing blood vessels as well as reducing blood volume, lowering blood pressure and reducing oxygen consumption by the heart, which can be used to prevent and treat cardiovascular diseases and kidney diseases. Nevertheless, ACEIs are associated with a range of adverse effects such as renal insufficiency, which limits their use. In recent years, researchers have attempted to reduce the adverse effects of ACEIs by improving the selectivity of ACEIs for structural domains based on conformational relationships, and have developed a series of novel ACEIs. In this review, we have summarized the research advances of ACE inhibitors, focusing on the development sources, design strategies and analysis of structure-activity relationships and the biological activities of ACE inhibitors.
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Affiliation(s)
- Wenyue Zheng
- Departments of Obstetrics & Gynecology and Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- Health Management Center, West China Second University Hospital, Chengdu, China
| | - Erkang Tian
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases & Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Zhen Liu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases & Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Changhan Zhou
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases & Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Pei Yang
- Departments of Obstetrics & Gynecology and Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- Health Management Center, West China Second University Hospital, Chengdu, China
| | - Keyue Tian
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases & Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Wen Liao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases & Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Juan Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases & Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Changyu Ren
- Department of Pharmacy, Chengdu Fifth People’s Hospital, Chengdu, China
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36
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Lubbe L, Sewell BT, Woodward JD, Sturrock ED. Cryo-EM reveals mechanisms of angiotensin I-converting enzyme allostery and dimerization. EMBO J 2022; 41:e110550. [PMID: 35818993 PMCID: PMC9379546 DOI: 10.15252/embj.2021110550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/21/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022] Open
Abstract
Hypertension (high blood pressure) is a major risk factor for cardiovascular disease, which is the leading cause of death worldwide. The somatic isoform of angiotensin I‐converting enzyme (sACE) plays a critical role in blood pressure regulation, and ACE inhibitors are thus widely used to treat hypertension and cardiovascular disease. Our current understanding of sACE structure, dynamics, function, and inhibition has been limited because truncated, minimally glycosylated forms of sACE are typically used for X‐ray crystallography and molecular dynamics simulations. Here, we report the first cryo‐EM structures of full‐length, glycosylated, soluble sACE (sACES1211). Both monomeric and dimeric forms of the highly flexible apo enzyme were reconstructed from a single dataset. The N‐ and C‐terminal domains of monomeric sACES1211 were resolved at 3.7 and 4.1 Å, respectively, while the interacting N‐terminal domains responsible for dimer formation were resolved at 3.8 Å. Mechanisms are proposed for intradomain hinging, cooperativity, and homodimerization. Furthermore, the observation that both domains were in the open conformation has implications for the design of sACE modulators.
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Affiliation(s)
- Lizelle Lubbe
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Bryan Trevor Sewell
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Electron Microscope Unit, University of Cape Town, Cape Town, South Africa
| | - Jeremy D Woodward
- Electron Microscope Unit, University of Cape Town, Cape Town, South Africa
| | - Edward D Sturrock
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Adverse Effects of Angiotensin-Converting Enzyme Inhibitors in Humans: A Systematic Review and Meta-Analysis of 378 Randomized Controlled Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148373. [PMID: 35886227 PMCID: PMC9324875 DOI: 10.3390/ijerph19148373] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/06/2022] [Accepted: 07/06/2022] [Indexed: 11/29/2022]
Abstract
Background: Although angiotensin-converting enzyme (ACE) inhibitors are among the most-prescribed medications in the world, the extent to which they increase the risk of adverse effects remains uncertain. This study aimed to systematically determine the adverse effects of ACE inhibitors versus placebo across a wide range of therapeutic settings. Methods: Systematic searches were conducted on PubMed, Web of Science, and Cochrane Library databases. Randomized controlled trials (RCTs) comparing an ACE inhibitor to a placebo were retrieved. The relative risk (RR) and its 95% confidence interval (95% CI) were utilized as a summary effect measure. A random-effects model was used to calculate pooled-effect estimates. Results: A total of 378 RCTs fulfilled the eligibility criteria, with 257 RCTs included in the meta-analysis. Compared with a placebo, ACE inhibitors were associated with an significantly increased risk of dry cough (RR = 2.66, 95% CI = 2.20 to 3.20, p < 0.001), hypotension (RR = 1.98, 95% CI = 1.66 to 2.35, p < 0.001), dizziness (RR = 1.46, 95% CI = 1.26 to 1.70, p < 0.001), and hyperkalemia (RR = 1.24, 95% CI = 1.01 to 1.52, p = 0.037). The risk difference was quantified to be 0.037, 0.030, 0.017, and 0.009, respectively. Conclusions: We quantified the relative risk of numerous adverse events associated with the use of ACE inhibitors in a variety of demographics. This information can help healthcare providers be fully informed about any potential adverse consequences and make appropriate suggestions for their patients requiring ACE inhibitor therapy.
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Wu YH, Tsai KC, Ho MP. Tranexamic acid use for ACE inhibitor induced angioedema. Am J Emerg Med 2022; 59:189. [PMID: 35595664 DOI: 10.1016/j.ajem.2022.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022] Open
Affiliation(s)
- Yuan-Hui Wu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kuang-Chau Tsai
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Min-Po Ho
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
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Niazi BA, Kaur M, Mosseri M, Lo A. A Rare Case of Dose-Dependent Losartan-Induced Angioedema. Cureus 2022; 14:e24110. [PMID: 35573493 PMCID: PMC9106102 DOI: 10.7759/cureus.24110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/16/2022] Open
Abstract
Angiotensin converting enzyme inhibitors (ACE-Is) have long been associated with angioedema and cough. These complications are thought to be related to an increase in bradykinin levels. Angiotensin receptor blockers (ARBs) such as losartan, however, are not known to increase bradykinin levels and, therefore, this complication is not as widely recognized. However, there is a significant proportion of patients who develop angioedema on ARB medications after previous episodes of angioedema on ACE-I. Though there is increasing literature to support that the patients may develop angioedema while taking ARBs such as losartan, a dose-dependent nature has not been well documented. We present a patient with a 20-year history of losartan use who developed angioedema suddenly after an increase in dosage. A dose-dependent relationship between ARBs and angioedema has not been well documented and this is the first documented case of angioedema presenting in a dose-dependent manner with losartan use. We hope that our case will bring awareness to the potential dose-dependent relationship between losartan and angioedema in order to aid clinicians when titrating ARB medications in order to expediently diagnose the fatal side-effect of angioedema and to encourage further research.
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Nakano Y, Kuwahara R, Miyamoto S. Spontaneous Rapid Improvement of Small Intestinal Edema. Gastroenterology 2022; 162:e12-e13. [PMID: 34390727 DOI: 10.1053/j.gastro.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/09/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Yoshiko Nakano
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Fushimi-ku, Kyoto, Japan
| | - Ryo Kuwahara
- Department of Radiology, National Hospital Organization Kyoto Medical Center, Fushimi-ku, Kyoto, Japan
| | - Shin'ichi Miyamoto
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Fushimi-ku, Kyoto, Japan.
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Contribution of cyclooxygenase-1-dependent prostacyclin synthesis to bradykinin-induced dermal extravasation. Biomed Pharmacother 2022; 148:112786. [PMID: 35259564 DOI: 10.1016/j.biopha.2022.112786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/02/2022] [Accepted: 03/02/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Non-allergic angioedema is a potentially life-threatening condition caused by accumulation of bradykinin and subsequent activation of bradykinin type 2 receptors (B2). Since COX activity plays a pivotal role in B2 signaling, the aim of this study was to determine which prostaglandins are the key mediators and which COX, COX-1 or COX-2, is predominantly involved. METHODS We used Miles assays to assess the effects of inhibitors of COX, 5-lipoxygenase, epoxyeicosatrienoic acid generation, cytosolic phospholipase A2α and a variety of prostaglandin receptor antagonists on bradykinin-induced dermal extravasation in C57BL/6 and COX-1-deficient mice (COX-1-/-). In addition, the prostacyclin metabolite 6-keto-PGF1α was quantified by ELISA in subcutaneous tissue from C57BL/6 and human dermal microvascular endothelial cells. In the latter, 6-keto-PGF1α was also quantified and identified by LC-MS/MS. RESULTS Unspecific COX inhibition by ibuprofen and diclofenac significantly reduced B2-mediated dermal extravasation in C57BL/6 but not COX-1-/-. Likewise, inhibition of cytosolic phospholipase A2α showed similar effects. Furthermore, extravasation in COX-1-/- was generally lower than in C57BL/6. Of the prostaglandin antagonists used, only the prostacyclin receptor antagonist RO1138452 showed a significant reduction of dermal extravasation. Moreover, 6-keto-PGF1α concentrations were increased after bradykinin treatment in subcutaneous tissue from C57BL/6 as well as in human dermal microvascular endothelial cells and this increase was abolished by diclofenac. CONCLUSION Our findings suggest that COX-1-dependent prostacyclin production is critically involved in dermal extravasation after activation of B2 in small dermal blood vessels. Targeting prostacyclin production and/or signaling appears to be a suitable option for acute treatment of non-allergic angioedema.
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Lee DH, Kim MT, Lee HW, Han JH, Myung CS. The combined effects of telmisartan and ramipril on hypertension and cardiovascular injury. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2022. [DOI: 10.1007/s40005-022-00567-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Chepy A, Veron M, Gautier S, Farhat MM, Pokeerbux R, Venturelli G, Yelnik C, Dubucquoi S, Podevin C, Jendoubi M, Citerne I, Baraffe J, Staumont-Salle D, Launay D, Sanges S. Initial characteristics and follow-up of patients with a diagnosis of angiotensin-converting enzyme inhibitor induced angioedema. Allergy Asthma Proc 2022; 43:155-162. [PMID: 35317893 DOI: 10.2500/aap.2022.43.220005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: A differential diagnosis between angiotensin-converting enzyme inhibitor (ACEi) angioedema (AE) and histaminergic AE (hAE) might be challenging. Follow-up data may help discriminate these conditions but are scarcely reported. Objective: To report on the follow-up of patients with suspected ACEi-AE and to describe the baseline characteristics of AE attacks in patients with a diagnosis of ACEi-AE after follow-up. Methods: Sixty-four patients with suspected ACEi-AE (i.e., with exposure to ACEi before the first attack, no urticaria associated, and normal C1-inhibitor levels) and at least one follow-up visit were included. Data were retrospectively collected at baseline and during the follow-up. Results: After the follow-up, the diagnosis of ACEi-AE was probable in only 30 patients. The remaining patients were reclassified as having probable hAE (21 patients) or undetermined-mechanism AE (13 patients). Patients with ACEi-AE were mostly men (61%), with a median age of 64 years (interquartile range [IQR] ±17 years), with a highly variable delay from ACEi introduction (median: 23 months; interquartile range: 103 months). Attacks preferentially involved lips (50%), tongue (47%), and throat (30%). Interestingly, patients with probable ACEi-AE after a follow-up also frequently presented with a history of allergy and atopic conditions (20%), attacks with preferential evening onset (25%), and spontaneous resolution in < 24 hours (26%), which are usually considered as suggestive of hAE. ACEi-AE attacks responded to icatibant in 79% of the patients. Conclusion: Patients with probable ACEi-AE were mostly men with facial involvement. A third of the patients with an initial suspected diagnosis of ACEi-AE had a final diagnosis of probable hAE. Although a follow-up of all patients should be a standard of care, it is critical to the correct diagnosis in the case of suspected bradykinin-associated AE, which may actually be due to histamine.
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Affiliation(s)
- Aurelien Chepy
- From the Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
| | - Marie Veron
- Centre de Référence des Angiœdèmes à Kinines, F-59000 Lille, France
| | - Sophie Gautier
- Univ. Lille, Inserm, CHU Lille, UMR-S1172, Center for Pharmacovigilance, F-59000 Lille, France
| | - Meryem-Maud Farhat
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
| | - Ryadh Pokeerbux
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
| | - Giorgia Venturelli
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
| | | | - Sylvain Dubucquoi
- From the Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
| | - Celine Podevin
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
| | - Manel Jendoubi
- From the Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
| | - Isabelle Citerne
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
| | - Jennifer Baraffe
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
| | - Delphine Staumont-Salle
- From the Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
| | - David Launay
- From the Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
| | - Sebastien Sanges
- From the Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
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Chu YC, Ho MP. Re: Acute epiglottitis in a COVID-19 positive patient. Am J Emerg Med 2022; 55:230.e1. [PMID: 35148925 PMCID: PMC8776623 DOI: 10.1016/j.ajem.2022.01.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/11/2022] [Accepted: 01/16/2022] [Indexed: 11/26/2022] Open
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Wu J, Wang M, Guo M, Du XY, Tan XZ, Teng FY, Xu Y. Angiotensin Receptor Blocker is Associated with a Lower Fracture Risk: An Updated Systematic Review and Meta-Analysis. Int J Clin Pract 2022; 2022:7581110. [PMID: 35910069 PMCID: PMC9303078 DOI: 10.1155/2022/7581110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 06/13/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are widely used in the treatment of hypertension. Hypertension is often accompanied by osteoporosis. However, the relationship between ACEI/ARB and fractures remains controversial. The purpose of this meta-analysis was to update the potential relationship between ACEI/ARB and fractures. METHODS This meta-analysis was identified through PubMed, EMBASE, Cochrane Library, and Web of Science. Related studies about ACEI/ARB with the risk of fracture were published from inception to June 2022. RESULTS Nine qualified prospective designed studies, involving 3,649,785 subjects, were included in this analysis. Overall, the RRs of ACEI compared with the nonusers were 0.98 (95% CI: 0.88, 1.10; P < 0.001) for composite fractures and 0.96 (95% CI: 0.87, 1.05; P=0.048) for hip fractures; the RRs of ARB compared to the nonusers were 0.82 (95% CI: 0.73, 0.91; P < 0.001) for composite fractures and 0.85 (95% CI: 0.74, 0.97; P=0.028) for hip fractures. Furthermore, in the subgroup analysis, male may benefit from ARB (RR = 0.65, 95% CI: 0.49, 0.89, P=0.028), and the European may also benefit from ARB (RR = 0.86, 95% CI: 0.80, 0.93, P=0.015). CONCLUSIONS ACEI usage will not decrease the risk of osteoporosis fracture. On the contrary, ARB usage can decrease the risk of total fracture and hip fracture, especially for males and Europeans. Compared with ACEI, for patients at higher risk of fracture in cardiovascular diseases such as hypertension, the protective effect of ARB should be considered.
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Affiliation(s)
- Jing Wu
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Sichuan Kidney Disease Clinical Medicine Research Center, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Nephrology Department, Ziyang First People's Hospital, Ziyang, Sichuan 641300, China
| | - Mei Wang
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Sichuan Kidney Disease Clinical Medicine Research Center, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Man Guo
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Sichuan Kidney Disease Clinical Medicine Research Center, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Xin-Yi Du
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Sichuan Kidney Disease Clinical Medicine Research Center, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Xiao-Zhen Tan
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Sichuan Kidney Disease Clinical Medicine Research Center, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Fang-Yuan Teng
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Sichuan Kidney Disease Clinical Medicine Research Center, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Yong Xu
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Sichuan Kidney Disease Clinical Medicine Research Center, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
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Cassano N, Nettis E, Di Leo E, Ambrogio F, Vena GA, Foti C. Angioedema associated with dipeptidyl peptidase-IV inhibitors. Clin Mol Allergy 2021; 19:24. [PMID: 34872575 PMCID: PMC8647342 DOI: 10.1186/s12948-021-00164-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/10/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Dipeptidyl peptidase-IV (DPP-IV) inhibitors, also known as gliptins, are a class of oral antidiabetic agents. Postmarketing reports have documented the occurrence of angioedema in patients treated with gliptins and it was found that these drugs increased the risk of angioedema in patients concurrently treated with angiotensin-converting enzyme inhibitors (ACEIs). The aim of this manuscript is to provide an overview of the risk of angioedema associated with gliptins. METHODS The keywords used for the literature search in the PubMed database included "angioedema" and "dipeptidyl peptidase", "gliptins", or the name of each DPP-IV inhibitor. Articles in English published up to December 2020 were taken into consideration. RESULTS The available data appear to rule out a higher risk of angioedema associated with gliptin monotherapy and have revealed an increased susceptibility in patients simultaneously treated with gliptins and ACEIs. However, one single multicenter phase IV trial and case reports, even if very limited in number, have shown that angioedema can also occur during treatment with DPP-IV inhibitors without the concomitant use of ACEIs. The involvement of other drugs and drug interactions has occasionally been suggested. In a few patients, deficiency of enzymes involved in bradykinin catabolism was detected and this finding can constitute a risk factor for angioedema exacerbated by treatment with DPP-IV inhibitors. CONCLUSIONS This risk of angioedema associated with the use of gliptins has mostly been related to the concurrent administration of ACEIs, and has been considered rare, but it might be underestimated and underreported. The role of additional risk factors or drug interactions deserves further investigations. Caution should be taken when considering the use of DPP-IV inhibitors in patients treated with ACEIs or presenting with other known risk factors for angioedema.
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Affiliation(s)
- Nicoletta Cassano
- Dermatology and Venereology Private Practice, Bari and Barletta, Italy
| | - Eustachio Nettis
- Department of Emergency and Organ Transplantation, School and Chair of Allergy and Clinical Immunology, University of Bari “Aldo Moro”, Bari, Italy
| | - Elisabetta Di Leo
- Section of Allergy and Clinical Immunology, Unit of Internal Medicine, “F. Miulli” Hospital, Strada Provinciale per Santeramo Km 4.100, Acquaviva delle Fonti, Bari, Italy
| | - Francesca Ambrogio
- Unit of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari “Aldo Moro”, Bari, Italy
| | - Gino A. Vena
- Dermatology and Venereology Private Practice, Bari and Barletta, Italy
| | - Caterina Foti
- Unit of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari “Aldo Moro”, Bari, Italy
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Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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Temple R. Encouragement of subgroup assessment by the FDA. Pharm Stat 2021; 20:923-928. [PMID: 34448536 DOI: 10.1002/pst.2163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 06/16/2021] [Accepted: 07/13/2021] [Indexed: 11/07/2022]
Abstract
Responses to a drug treatment can differ among subgroups of the population, including demographic subgroups, groups with different disease characteristics, and groups with different metabolic or excretory functions. The differences can be pharmacokinetic (PK) or pharmacodynamic (PD) affecting toxicity or effectiveness. In recent years wide availability of drug blood level data, including metabolite data, has made PK differences in subgroups very readily detectable, but PD differences are more difficult to detect and need to be carefully examined by assessment of effectiveness and toxicity in demographic and other subgroups, as illustrated by the forest plots examining multiple subgroups typically presented for cardiovascular outcome studies. Such examinations and presentations would probably be more broadly useful and informative if used to examine pooled outcome and toxicity data for symptomatic treatments.
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Affiliation(s)
- Robert Temple
- Food and Drug Administration, Silver Spring, Maryland, USA
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Whitehead WJ, Reid JM. Underreported Risk of Lisinopril-Induced Angioedema in a Veteran Population. Ann Pharmacother 2021; 56:430-435. [PMID: 34282637 DOI: 10.1177/10600280211032404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Lisinopril-induced angioedema (LIA) is a rare but serious adverse drug event (ADE) with a published incidence of 0.1% to 0.7%. It is well known that ADEs are widely underreported; however, LIA is one of the most reported ADEs within the Veterans Health Administration (VHA). OBJECTIVE To estimate the effect of underreporting on the risk of LIA within VHA. METHODS The reported risk of LIA was calculated from reports submitted to the Veterans Affairs (VA) Adverse Drug Event Reporting System (VA ADERS) and the number of veterans prescribed lisinopril. To estimate underreporting, local chart review identified cases of LIA that were compared to reports submitted. The underreporting rate was then applied to the national reported risk. RESULTS Locally, 68 reports of LIA were submitted of the 21 262 patients prescribed lisinopril, for a reported risk of 0.32%. Nationwide, 14 289 reports of LIA were submitted of the 3 109 661 patients prescribed lisinopril, for a crude reported risk of 0.46%. Of the 324 patients identified for chart review, 240 patients were diagnosed with LIA, suggesting that at least 71.7% of cases were unreported. When this underreporting rate is extrapolated to the national reported risk, a better estimate of the risk of LIA within VHA could increase to 1.6%. CONCLUSION AND RELEVANCE When estimating the effect of underreporting, the risk of LIA increases to approximately 1.6% or 1 in 63 patients. Because this ADE may affect more patients than previously understood, providers may wish to take LIA into consideration when prescribing lisinopril.
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Affiliation(s)
- Whitley J Whitehead
- University of Kentucky Good Samaritan Hospital, UK HealthCare, Lexington Kentucky, KY, USA
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Lam M, Beqo A, Thumar R. Overcoming Cough and Angioedema: Advocating for the Use of ARBs Over ACE Inhibitors. Ann Pharmacother 2021; 56:358-362. [PMID: 34192890 DOI: 10.1177/10600280211029952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors have comparable efficacy, but ARBs have a preferential safety profile with particular regard to cough and angioedema. Although guidelines have historically advocated for ACE inhibitor use before ARBs simply because of earlier market entry, data accumulation, and generic availability, updated verbiage advises an "ACE inhibitor or ARB" recommendation, as opposed to the classic "ACE inhibitor then ARB" approach. Despite these updates, clinical inertia in favor of ACE inhibitor use before ARBs overwhelmingly remains. Prescribers and educators should consider an "ARBs only" mentality, especially in high angioedema-risk groups such as black patients.
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Affiliation(s)
| | - Anelsa Beqo
- MCPHS University, Boston, MA, USA.,Steward Good Samaritan Medical Center, Brockton, MA, USA
| | - Ricky Thumar
- MCPHS University, Boston, MA, USA.,Codman Square Health Center, Boston, MA, USA
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