Current Treatment of Angioedema Induced by ACE Inhibitors

Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema: A Case Report With a Review of Management Options

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.

C1 esterase inhibitor for angiotensin-converting enzyme inhibitor-induced angioedema at a community teaching health system: A brief retrospective propensity-matched cohort study

INTRODUCTION

Angiotensin-converting enzyme inhibitor (ACEi)-induced angioedema is a serious emergency that can cause life-threatening symptoms and death if not treated promptly. Potential treatment options for ACEi-induced angioedema include medications with limited evidence for use in this patient population. The purpose of this study was to evaluate the use, clinical efficacy, and angioedema-related medication costs of C1 esterase inhibitor (C1EI) for ACEi-induced angioedema.

METHODS

This was a retrospective, propensity-matched cohort study comparing patients who received C1EI to those who did not receive C1EI for ACEi-induced angioedema. The primary outcome of interest was comparing the proportion of patients who required intubation secondary to ACEi-induced angioedema. Secondary endpoints of interest were also included.

RESULTS

After propensity score matching, 22 patients were stratified into both the non-C1EI group and C1EI group, respectively. There was no difference between the groups with respect to the proportion of intubation (13.6% in the C1EI group vs. 9.1% in the non-C1EI group, p > 0.999). Mean cost of angioedema-related medication therapy was higher in the C1EI group compared to the non-C1EI group [$8758.95 (± $2959.30) vs. $15.91 (± $7.32), p < 0.001].

CONCLUSIONS

In this retrospective cohort study, the use of C1EI for ACEi-induced angioedema did not demonstrate improved outcomes with respect to intubation and resulted in increased costs. Larger, multicenter, prospective studies are needed to further validate the results of this study and to provide more clarity on the role of C1EI therapy in ACEi-induced angioedema.

Case Report: Compromised Airway Following Anesthesia and Its Correlation With the Use of ACE Inhibitors-An Unexpected Clinical Event and Review of Literature

Angiotensin-converting enzyme inhibitors associated angioedema involving the upper aerodigestive tract is indisputably a hazardous airway condition which is clinically poorly recognized and frequently underestimated. We describe and present case of a 70-year old man on ramipril who developed massive tongue swelling post-operatively after unremarkable laryngeal mask anaesthesia which was fortuitously managed conservatively. High index of suspicion, timely recognition and knowledge of pathophysiology and the clinical course should guide airway and further supportive management in these patients.

Effectiveness of C1-INH therapy in angiotensin converting enzyme inhibitor induced angioedema

Introduction

Angiotensin Converting Enzyme Inhibitors (ACEI) are a common cause of Emergency Room presentation for angioedema. Although no treatment guidelines exist, C1 esterase inhibitor concentrate (C1-INH) is used on an off label basis for management of ACEI acquired angioedema (ACEI AAE).

Objective

To evaluate the efficacy of C1-INH in management of ACEI AAE at our local centers.

Results

Nine patients, from 3 academic sites, were identified through Allergy Service consultation data and records from Diagnostic Services Manitoba, Canada from 2010–2020. The majority of the patients (n = 8/9) required endotracheal intubation prior to the initiation of C1-INH. Overall, approximately 56% of patients (n = 5/9) had resolution of angioedema ranging between 12 and 17 h, with a median time of 13.5 h, and no recurrence after the administration of C1-INH concentrate. One patient had transient symptom resolution in 14 h, however, recurrence of angioedema required re-intubation. The remainder of patients (n = 4/9), had resolution of angioedema between 22 and 72 h, with a median time of 33.75 h.

Conclusion

Our findings demonstrate continued ambivalence of the efficacy and role of C1-INH concentrate in the treatment of ACEI AAE, secondary to multiple uncontrolled confounding factors. Further research into characterizing a subgroup of intubated patients in our study that responded to C1-INH concentrate needs to be completed.

C1 esterase inhibitor use in the management of lisinopril-induced angioedema: A case series

OBJECTIVE

Review 4 patients who presented with presumed lisinopril-induced angioedema and received C1 esterase inhibitor (C1-INH).

CASE SUMMARY

Four patients received C1-INH for presumed lisinopril-induced angioedema. In all cases, angioedema was attributed to lisinopril use after the patients' symptoms did not resolve after receiving other interventions. The patients received either 1500 units or 2000 units of C1-INH. All patients' symptoms resolved after receiving a single C1-INH dose, and all were discharged home within 48 hours of receiving C1-INH.

PRACTICE IMPLICATIONS

On the basis of the available literature and our study, C1-INH may effectively treat angiotensin-converting enzyme inhibitor-induced angioedema (ACEi-AE). Owing to the low incidence of ACEi-AE and the high cost of C1-INH, physicians should consider limiting the use of C1-INH to patients who remain symptomatic after the initial interventions and are at risk of a compromised airway.

Acquired angioedema induced by angiotensin-converting enzyme inhibitors - experience of a hospital-based allergy center

Angiotensin-converting enzyme inhibitors (ACEIs) represent an important group of pharmacological compounds, largely prescribed for more than 30 years. They have been extensively evaluated in clinical trials, demonstrating significant reduction of morbidity and mortality of patients with cardiovascular diseases, mainly high blood pressure, myocardial infarction, heart failure and stroke. Besides their beneficial effects and a general good safety profile, it was proven that ACEIs might also induce adverse effects in some patients, most notably angioedema (AE) and chronic cough. The occurrence rate of adverse events induced by ACEIs is low, but the number of suffering patients is relatively high, since ACEIs is one of the most frequently prescribed medication worldwide. The aim of our study was to evaluate clinical pattern, risk factors and general management of ACEI-induced angioedema in a cohort of patients addressed for allergist evaluation in one university hospital in Romania, during a period of 32 months. It was found that ACEI-induced angioedema (ACEI-AE) represented more than half of the total number of patients addressed for angioedema without urticaria, with variable clinical and time-patterns. Most of the patients were referred by general practitioners (GPs) with diagnosis of urticaria or other skin allergy and continued to take ACEIs for months and years after onset of angioedema. We concluded that the awareness of acquired, non-allergic angioedema induced by ACEI therapy in medical practice is still low and there is a need for improved knowledge and interdisciplinary collaboration in this field.