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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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Smolinska S, Antolín-Amérigo D, Popescu FD. Bradykinin Metabolism and Drug-Induced Angioedema. Int J Mol Sci 2023; 24:11649. [PMID: 37511409 PMCID: PMC10380452 DOI: 10.3390/ijms241411649] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Bradykinin (BK) metabolism and its receptors play a central role in drug-induced angioedema (AE) without urticaria through increased vascular permeability. Many cardiovascular and diabetic drugs may cause BK-mediated AE. Angiotensin-converting enzyme inhibitors (ACEIs) and neprilysin inhibitors impair BK catabolism. Dipeptidyl peptidase-IV (DPP-IV) inhibitors reduce the breakdown of BK and substance P (SP). Moreover, angiotensin receptor blockers, thrombolytic agents, and statins may also induce BK-mediated AE. Understanding pathophysiological mechanisms is crucial for preventing and treating drug-induced AE.
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Affiliation(s)
- Sylwia Smolinska
- Department of Clinical Immunology, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Darío Antolín-Amérigo
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Florin-Dan Popescu
- Department of Allergology "Nicolae Malaxa" Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, 022441 Bucharest, Romania
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Arthur J, Caro D, Topp S, Chadwick S, Driver B, Henson M, Norse A, Spencer H, Godwin SA, Guirgis F. Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema. Am J Emerg Med 2023; 63:44-49. [PMID: 36327748 PMCID: PMC10015633 DOI: 10.1016/j.ajem.2022.10.017] [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: 05/20/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 12/07/2022] Open
Abstract
OBJECTIVES The objective of this study is to identify predictors of airway compromise among patients presenting to the emergency department with angioedema in order to develop and validate a risk score to augment clinician gestalt regarding need for intubation. METHODS Retrospective chart review of emergency department patients with a diagnosis of angioedema. After data extraction they were randomly divided into a training and test set. The training set was used to identify factors associated with intubation and to develop a model and risk score to predict intubation. The model and risk score were then applied to the test set. RESULTS A total of 594 patients were included. Past medical history of hypertension, presence of shortness of breath, drooling, and anterior tongue or pharyngeal swelling were independent predictors included in our final model and risk score. The Area Under the Curve for the Receiver Operator Characteristic curve was 87.55% (83.42%-91.69%) for the training set and 86.1% (77.62%-94.60%) for the test set. CONCLUSIONS A simple scoring algorithm may aid in predicting angioedema patients at high and low risk for intubation. External validation of this score is necessary before wide-spread adoption of this decision aid.
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Affiliation(s)
- Jason Arthur
- Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David Caro
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Stephen Topp
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Steven Chadwick
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Brian Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Morgan Henson
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Ashley Norse
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Horace Spencer
- Department of Biostatistics, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Steven A Godwin
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Faheem Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA.
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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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Hasara S, Wilson K, Amatea J, Anderson J. Tranexamic Acid for the Emergency Treatment of Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. Cureus 2021; 13:e18116. [PMID: 34692327 PMCID: PMC8525683 DOI: 10.7759/cureus.18116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Angioedema is a rare but potentially life-threatening adverse effect associated with the use of angiotensin-converting enzyme (ACE) inhibitors. Various therapies, including ecallantide, icatibant, complement-1 esterase inhibitors, and fresh frozen plasma, have been used for treatment with inconsistent results and significant adverse effects. Tranexamic acid (TXA) is used as an alternative for the treatment of hereditary angioedema and it may be an attractive option for the treatment of ACE inhibitor-induced angioedema (ACEi-AE) in the emergency department (ED). The purpose of this study was to evaluate the impact of TXA administration on rates of intubation in patients presenting to the ED with suspected ACEi-AE. METHODS This was an institutional review board-approved, retrospective cohort study conducted at a single-site ED. All patients who received TXA for ACEi-AE in the ED between January 1, 2019 and March 31, 2021 were eligible for inclusion. The primary outcome was the proportion of patients who required intubation for suspected ACEi-AE. RESULTS A total of 16 patients received TXA in the ED for suspected ACEi-AE during the study timeframe. Of these, two patients were intubated prior to administration of TXA. The remaining 14 patients did not require intubation following TXA administration. CONCLUSION Administration of TXA was associated with a low rate of adverse effects and did not contribute to further morbidity when added to standard care in patients presenting to the ED with suspected ACEi-AE.
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Affiliation(s)
- Shannon Hasara
- Department of Pharmacy, Lakeland Regional Health, Lakeland, USA
| | - Kayla Wilson
- Department of Pharmacy, Lakeland Regional Health, Lakeland, USA
| | - John Amatea
- Department of Emergency Medicine, Lakeland Regional Health, Lakeland, USA
| | - Jonathan Anderson
- Department of Emergency Medicine, Lakeland Regional Health, Lakeland, USA
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Mizubuti GB, Ho AMH, Jiang A, Klar G. Angiotensin-converting Enzyme Inhibitor-mediated Angioedema. Anesthesiology 2021; 135:340-341. [PMID: 33940592 DOI: 10.1097/aln.0000000000003810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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