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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: 0] [Impact Index Per Article: 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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2
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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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Rosenbaum S, Wilkerson RG, Winters ME, Vilke GM, Wu MYC. Clinical Practice Statement: What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-Inhibitor? J Emerg Med 2021; 61:105-112. [PMID: 34006418 DOI: 10.1016/j.jemermed.2021.02.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/21/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Angioedema is a complication that has been reported in up to 1.0% of individuals taking angiotensin-converting enzyme inhibitors (ACE-Is). Importantly, the onset of angioedema can occur anywhere from hours to several years after initiation of therapy with ACE-Is. Although most cases of ACE-I-induced angioedema (ACE-I-AE) are self-limiting, a major clinical concern is development of airway compromise, which can potentially require emergent airway management. The underlying pathophysiology of ACE-I-AE is incompletely understood, but is considered to be due in large part to excess bradykinin. Numerous medications have been proposed for the treatment of ACE-I-AE. This article is an update to the 2011 Clinical Practice Committee (CPC) statement from the American Academy of Emergency Medicine. METHODS A literature search in PubMed was performed with search terms angioedema and ACE inhibitors from August 1, 2012 to May 13, 2019. Following CPC guidelines, articles written in English were identified and then underwent a structured review for evaluation. RESULTS The search parameters resulted in 323 articles. The abstracts of these articles were assessed independently by the reviewers, who determined there were 63 articles that were specific to ACE-I-AE, of which 46 were deemed appropriate for grading in the final focused review. CONCLUSIONS The primary focus for the treatment of ACE-I-AE is airway management. In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment. If, however, the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions. Any patient with suspected ACE-I-AE should immediately discontinue that medication.
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Affiliation(s)
| | | | | | - Gary M Vilke
- University of California at San Diego Medical Center, San Diego, California
| | - Marie Yung Chen Wu
- University of California at San Diego Medical Center, San Diego, California
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Adeyeni TA, Domack A, Britt C. What Is the Role of Laryngoscopy in Angioedema Isolated to the Lips, Without Laryngeal Symptoms? Laryngoscope 2020; 130:2740-2741. [PMID: 32246776 DOI: 10.1002/lary.28664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/18/2020] [Accepted: 03/16/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Temitope A Adeyeni
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, U.S.A
| | - Aaron Domack
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, U.S.A
| | - Christopher Britt
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, U.S.A
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Genome-wide association study of angioedema induced by angiotensin-converting enzyme inhibitor and angiotensin receptor blocker treatment. THE PHARMACOGENOMICS JOURNAL 2020; 20:770-783. [PMID: 32080354 PMCID: PMC7674154 DOI: 10.1038/s41397-020-0165-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/26/2020] [Accepted: 02/07/2020] [Indexed: 12/22/2022]
Abstract
Angioedema in the mouth or upper airways is a feared adverse reaction to angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blocker (ARB) treatment, which is used for hypertension, heart failure and diabetes complications. This candidate gene and genome-wide association study aimed to identify genetic variants predisposing to angioedema induced by these drugs. The discovery cohort consisted of 173 cases and 4890 controls recruited in Sweden. In the candidate gene analysis, ETV6, BDKRB2, MME, and PRKCQ were nominally associated with angioedema (p < 0.05), but did not pass Bonferroni correction for multiple testing (p < 2.89 × 10−5). In the genome-wide analysis, intronic variants in the calcium-activated potassium channel subunit alpha-1 (KCNMA1) gene on chromosome 10 were significantly associated with angioedema (p < 5 × 10−8). Whilst the top KCNMA1 hit was not significant in the replication cohort (413 cases and 599 ACEi-exposed controls from the US and Northern Europe), a meta-analysis of the replication and discovery cohorts (in total 586 cases and 1944 ACEi-exposed controls) revealed that each variant allele increased the odds of experiencing angioedema 1.62 times (95% confidence interval 1.05–2.50, p = 0.030). Associated KCNMA1 variants are not known to be functional, but are in linkage disequilibrium with variants in transcription factor binding sites active in relevant tissues. In summary, our data suggest that common variation in KCNMA1 is associated with risk of angioedema induced by ACEi or ARB treatment. Future whole exome or genome sequencing studies will show whether rare variants in KCNMA1 or other genes contribute to the risk of ACEi- and ARB-induced angioedema.
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Sandefur BJ, E Silva LOJ, Lohse CM, Goyal KA, Barbara DW, Castaneda-Guarderas A, Liu XW, Campbell RL. Clinical Features and Outcomes Associated with Angioedema in the Emergency Department. West J Emerg Med 2019; 20:760-769. [PMID: 31539333 PMCID: PMC6754201 DOI: 10.5811/westjem.2019.6.42852] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/26/2019] [Indexed: 11/14/2022] Open
Abstract
Introduction Angioedema represents self-limited, localized swelling of submucosal or subcutaneous tissues. While the underlying etiology may be undeterminable in the emergent setting, nonhistaminergic and histaminergic angioedema respond differently to therapeutic interventions, with implications for empiric treatment. Clinical features and outcome differences among nonhistaminergic vs histaminergic angioedema patients in the emergency department (ED) are poorly characterized. We aim to describe the clinical characteristics and outcomes among ED patients with angioedema by suspected etiology. Methods This was a 10-year retrospective study of adult ED patients with angioedema, using data abstracted from the electronic health record. We evaluated univariable associations of select clinical features with etiology and used them to develop a multivariable logistic regression model for nonhistaminergic vs histaminergic angioedema. Results Among 450 adult angioedema patients, the mean +/− standard deviation age was 57 +/− 18 years, and 264 (59%) were female. Among patients, 30% had suspected nonhistaminergic angioedema, 30% had suspected histaminergic angioedema, and 40% were of unknown etiology. As compared to histaminergic angioedema, nonhistaminergic angioedema was associated with angiotensin-converting enzyme inhibitors (ACEI) or use of angiotensin II receptor blockers (ARB) (odds ratio [OR] [60.9]; 95% confidence interval [CI], 23.16–160.14) and time of onset one hour or more prior to ED arrival (OR [5.91]; 95% CI,1.87–18.70) and was inversely associated with urticaria (OR [0.05]; 95% CI, 0.02–0.15), dyspnea (OR [0.23]; 95% CI, 0.08–0.67), and periorbital or lip edema (OR [0.25]; 95% CI, 0.08–0.79 and OR [0.32]; 95% CI, 0.13–0.79, respectively). Conclusion As compared to histaminergic angioedema, patients with nonhistaminergic angioedema were more likely to present one hour or more after symptom onset and take ACEI or ARB medications, and were less likely to have urticaria, dyspnea, or periorbital or lip angioedema. Identification of characteristics associated with the etiology of angioedema may assist providers in more rapidly initiating targeted therapies.
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Affiliation(s)
| | - Lucas Oliveira J E Silva
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.,Federal University of Rio Grande do Sul, Department of Medicine, Rio Grande do Sul
| | - Christine M Lohse
- Mayo Clinic, Division of Biomedical Statistics and Informatics, Rochester, Minnesota
| | - Kiran A Goyal
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - David W Barbara
- Mayo Clinic, Department of Anesthesiology & Perioperative Medicine, Rochester, Minnesota
| | | | - Xiao-Wei Liu
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.,The First Affiliated Hospital of China Medical University, Department of Emergency Medicine, Liaoning, Shenyang
| | - Ronna L Campbell
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
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Abstract
Incidence of angioedema associated with angiotensin-converting enzyme inhibitors (ACE-I) has been estimated at 0.1%-2.2% of patients receiving treatment. Despite the potential severity of this disease state, standardized treatment is lacking. Traditional pharmacotherapy options include medications that target inflammatory mediators and the angiotensin pathway. However, because ACE-I-induced angioedema is caused by accumulation of bradykinin, these medications fail to target the underlying pathophysiology. Recently, novel therapies that target the kallikrein-bradykinin pathway have been studied. These include icatibant, ecallantide, C1 esterase inhibitors, and fresh-frozen plasma. Recent randomized controlled trials exhibit contradictory results with the use of icatibant. This is a focused review on traditional and novel treatment strategies for ACE-I-induced angioedema.
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Tilney PVR, Irving D, Schaab SR. A 79-Year-Old Man With Angioedema. Air Med J 2018; 37:336-338. [PMID: 30424844 DOI: 10.1016/j.amj.2018.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 08/30/2018] [Indexed: 10/28/2022]
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A score for the differential diagnosis of bradykinin- and histamine-induced head and neck swellings. Eur Arch Otorhinolaryngol 2018; 275:1767-1773. [DOI: 10.1007/s00405-018-4989-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/27/2018] [Indexed: 02/02/2023]
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10
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Driver BE, McGill JW. Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations. Ann Emerg Med 2017; 69:635-639. [PMID: 28110989 DOI: 10.1016/j.annemergmed.2016.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/29/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE Angioedema is an uncommon but important cause of airway obstruction. Emergency airway management of angioedema is difficult. We seek to describe the course and outcomes of emergency airway management for severe angioedema in our institution. METHODS We performed a retrospective, observational study of all intubations for angioedema performed in an urban academic emergency department (ED) between November 2007 and June 2015. We performed a structured review of video recordings of each intubation. We identified the methods of airway management, the success of each method, and the outcomes and complications of the effort. RESULTS We identified 52 patients with angioedema who were intubated in the ED; 7 were excluded because of missing videos, leaving 45 patients in the analysis. Median time from arrival to the ED to the first intubation attempt was 33 minutes (interquartile range 17 to 79 minutes). Nasotracheal intubation was the most common first method (33/45; 73%), followed by video laryngoscopy (7/45; 16%). Two patients required attempts at more invasive airway procedures (retrograde intubation and cricothyrotomy). The intubating laryngeal mask airway was used as a rescue method 5 times after failure of multiple methods, with successful oxygenation, ventilation, and intubation through the laryngeal mask airway in all 5 patients. All patients were successfully intubated. CONCLUSION In this series of ED patients who were intubated because of angioedema, emergency physicians used a range of methods to successfully manage the airway. These observations provide key lessons for the emergency airway management of these critical patients.
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Affiliation(s)
- Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | - John W McGill
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
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Angioedema Due to ACE Inhibitors. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0099-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Leibfried M, Kovary A. C1 Esterase Inhibitor (Berinert) for ACE Inhibitor-Induced Angioedema: Two Case Reports. J Pharm Pract 2016; 30:668-671. [PMID: 27837046 DOI: 10.1177/0897190016677427] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe 2 cases of angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema treated with C1 esterase inhibitor (human) [Berinert]. SUMMARY Case 1 is a 60-year-old Caucasian male with angioedema from lisinopril. He was initially treated with a conventional regimen of an antihistamine, methylprednisolone, epinephrine, and fresh frozen plasma. When symptoms did not resolve, intravenous C1 peptide esterase inhibitor (C1INH) was administered, with clinical improvement. Four hours later, symptoms returned and the patient underwent emergency tracheostomy. Case 2 is a 64-year-old Caucasian male who presented with angioedema due to enalapril. In the emergency department, he received conventional treatment. Endotracheal tube placement was unsuccessful. While the patient was undergoing intubation in the operating room, intravenous C1INH was administered resulting in quick improvement of symptoms. DISCUSSION Angioedema from ACEI occurs at an incidence of 0.7%. Conventional treatment may be of limited benefit due to the mechanism of the reaction. C1INHs, which are indicated for hereditary angioedema, have been utilized in treating ACEI-induced angioedema. According to the Naranjo algorithm scale, the patient in case 1 experienced angioedema that is probably related to lisinopril. C1INH was administered intravenously when symptoms progressed, despite conventional treatment. In case 2, the patient experienced angioedema, which is possibly related to enalapril, and was treated with C1INH. CONCLUSION C1INH (human) was a successful addition to the traditional management of 2 patients with angioedema due to ACEI.
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Affiliation(s)
- Maria Leibfried
- 1 Fairleigh Dickinson University School of Pharmacy, Florham Park, NJ, USA
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13
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Abstract
Infectious and inflammatory conditions of the head and neck may present with impaired airways. An understanding of the pathophysiology will allow for accurate diagnosis and prompt intervention. Preintervention discussion and planning by members of the airway team are crucial in developing a primary and backup plans for safely securing the airway.
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Affiliation(s)
- Gary Linkov
- Temple University Hospital, Philadelphia, PA 19140, USA
| | - Ahmed M S Soliman
- Department of Otolaryngology-Head & Neck Surgery, Voice, Airway & Swallowing Center, Temple University School of Medicine, 3440 North Broad Street Kresge West 312, Philadelphia, PA 19140, USA.
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Linkov G, Cracchiolo JR, Chan NJ, Healy M, Jamal N, Soliman AMS. The role of serial physical examinations in the management of angioedema involving the head and neck: A prospective observational study. World J Otorhinolaryngol Head Neck Surg 2016; 2:7-12. [PMID: 29204542 PMCID: PMC5698507 DOI: 10.1016/j.wjorl.2016.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 12/31/2015] [Accepted: 01/05/2016] [Indexed: 11/28/2022] Open
Abstract
Objective To elucidate the progression of angioedema of the head and neck with routine management and to assess the utility of serial physical exams and fiberoptic laryngoscopy in its management. Methods This study was a prospective observational research. From 2013 to 2014, a prospective observational study was conducted at a tertiary referral center. Forty patient were approached, 7 refused, 33 (18–90 years old) were enrolled. Patients presented with angioedema involving the head and neck over a 12 month period were asked to participate in the study. Physical examination and fiberoptic laryngoscopy were performed at presentation and then repeated at least 1 h later. Results Thirty-three patients with head and neck angioedema from any cause were enrolled (mean age 58, range 23–89 years). The upper lip was the most commonly involved site (58%). On reevaluation, 82% of patients reported subjective improvement in symptoms. The association between subjective improvement and the physical exam, including fiberoptic laryngoscopy findings, was statistically significant (P < 0.001). Conclusion In stable patients with angioedema of any head and neck subsite, self-reported symptoms are associated with clinical stability or improvement as assessed by physical signs and fiberoptic laryngoscopy. Patients' symptoms may be an appropriate surrogate to monitor clinical status without the need for routine serial physical examinations or fiberoptic laryngoscopy, though further study is needed.
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Affiliation(s)
- Gary Linkov
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Jennifer R Cracchiolo
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Norman J Chan
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Megan Healy
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Nausheen Jamal
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Ahmed M S Soliman
- Department of Otolaryngology-Head & Neck Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
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Simón Díaz M, Tirado Sánchez A, Ponce Olivera R. Dermatologic emergencies. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2016. [DOI: 10.1016/j.hgmx.2015.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Urnoski E, Grillo A, Rosini JM. Use of C1 Inhibitor for Angiotensin-Converting Enzyme (ACE) Inhibitor–Induced Angioedema Decreases Mechanical Ventilation Time. J Emerg Med 2015; 49:e173-5. [DOI: 10.1016/j.jemermed.2015.06.076] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 06/16/2015] [Accepted: 06/25/2015] [Indexed: 10/23/2022]
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Culley CM, DiBridge JN, Wilson GL. Off-Label Use of Agents for Management of Serious or Life-threatening Angiotensin Converting Enzyme Inhibitor–Induced Angioedema. Ann Pharmacother 2015; 50:47-59. [DOI: 10.1177/1060028015607037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To evaluate the place in therapy of fresh frozen plasma (FFP), C1 esterase concentrate (C1-INH), ecallantide, and icatibant in the management of angiotensin-converting enzyme inhibitor–induced angioedema (ACEI-IA). Data Sources: A literature search was performed using PubMed (1946 through August 2015) and Embase (<1966 through August 2015). References from identified articles were reviewed. Study Selection and Data Extraction: Consensus papers, practice guidelines, case reports/series, clinical trials, and meeting abstracts published in English and involving humans were included. Data Synthesis: No medications are currently Food and Drug Administration–approved for managing ACEI-IA. Emerging evidence suggests that FFP and medications approved for management of acute attacks of hereditary angioedema, another bradykinin-mediated event, may be effective for use in ACEI-IA. Positive efficacy results were reported with FFP and C1-INH while mixed results have been seen with ecallantide. Off-label icatibant has the most evidence supporting its use in ACEI-IA with rapid symptom resolution (10 minutes to 6 hours) and avoidance of intubation and tracheotomy in several cases. These agents were well-tolerated in ACEI-IA. Conclusion: ACEI-IA is typically a self-limiting event. First-line therapies include ACEI discontinuation, observation, and supportive medications (eg, corticosteroids, antihistamines, and epinephrine). Symptom progression can be life-threatening and may require interventions such as tracheotomy and intubation. Off-label use of FFP and medications approved for hereditary angioedema have resulted in rapid resolution of symptoms and avoidance of intubation. Among these agents, icatibant has the most supporting evidence and has been incorporated into practice guidelines and algorithms as a second-line agent for serious life-threatening ACE-IA.
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Affiliation(s)
- Colleen M. Culley
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
- UPMC Pharmacy Service Line, Pittsburgh, PA, USA
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Chan NJ, Soliman AM. ACE-inhibitor–related angioedema. EAR, NOSE & THROAT JOURNAL 2015. [DOI: 10.1177/014556131509400601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Norman J. Chan
- Department of Otolaryngology–Head and Neck
Surgery Temple University School of Medicine
| | - Ahmed M.S. Soliman
- Temple Head and Neck Institute, Department of
Otolaryngology–Head and Neck Surgery Temple University School of Medicine
Philadelphia
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Kovach TA, Kang DR, Triplett RG. Massive Macroglossia Secondary to Angioedema: A Review and Presentation of a Case. J Oral Maxillofac Surg 2015; 73:905-17. [DOI: 10.1016/j.joms.2014.12.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 12/21/2014] [Accepted: 12/22/2014] [Indexed: 11/16/2022]
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Bartal C, Zeldetz V, Stavi V, Barski L. The role of icatibant-the B2 bradykinin receptor antagonist-in life-threatening laryngeal angioedema in the ED. Am J Emerg Med 2014; 33:479.e1-3. [PMID: 25241359 DOI: 10.1016/j.ajem.2014.08.055] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 08/14/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022] Open
Abstract
Angioedema is a localized, sudden, transient, and often recurrent swelling of the deeper layers of the skin or mucosa with no epidermal component. It is caused by vasoactive substances that produce a transient increase in endothelial permeability. Angioedema involving the laryngeal components is a life-threatening situation for the patient,and it is a challenge for the emergency medicine physician to rapidly achieve a safety airway. Most cases of laryngeal angioedema are induced by histamine release; but 10% are bradykinin induced, which does not respond to the conventional algorithm of treating allergic induced angioedema. We present a case report of an angiotensin converting enzyme (ACE) inhibitor–induced laryngeal angioedema alleviated only after treatment with the new bradykinin receptor inhibitor medication icatibant which was licensed only for use in hereditary angioedema. We reviewed the literature for the use of icatibant in acquired drug-induced angioedema; and because of the similar pathogenesis between the hereditary angioedema and the ACE inhibitor–induced angioedema,we propose an algorithm for careful use of icatibantin life-threatening angioedema in the emergency department.
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Affiliation(s)
- Carmi Bartal
- The Emergency Medicine Department, "Soroka" University Medical Center and Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Vladimir Zeldetz
- The Emergency Medicine Department, "Soroka" University Medical Center and Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Vered Stavi
- Internal Medicine Division, "Soroka" University Medical Center and Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Leonid Barski
- Internal Medicine Division, "Soroka" University Medical Center and Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Chan NJ, Soliman AMS. Angiotensin converting enzyme inhibitor-related angioedema: onset, presentation, and management. Ann Otol Rhinol Laryngol 2014; 124:89-96. [PMID: 25059449 DOI: 10.1177/0003489414543069] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study aimed to determine the duration of use, presentation, and management of angiotensin converting enzyme (ACE) inhibitor-related angioedema patients at an urban academic medical center. METHODS Retrospective chart review. RESULTS Eighty-eight patients who presented with ACE inhibitor-related angioedema between January 1, 2012, and December 31, 2012, were identified. They presented anywhere from 1 day to 20 years after starting an ACE inhibitor. About half the patients (50.7%) presented after taking an ACE inhibitor for at least 1 year. Fifty-five patients were female (62.5%). Twenty-eight patients (31.8%) had an airway intervention with 27 intubated and 1 requiring cricothyroidotomy. Six patients were intubated after more than 1 flexible laryngoscopy. The percentage of patients with involvement of the face, lips, tongue, floor of mouth, soft palate/uvula, and larynx were 12.5%, 60.2%, 39.7%, 6.8%, 17.0%, and 29.5%, respectively. Sixty-eight percent of patients with laryngeal edema were intubated. The majority of patients were treated with a corticosteroid and H1 and H2 receptor antagonists. CONCLUSION Angioedema can occur at any time after starting ACE inhibitor use, with nearly half occurring after 1 year of use. Laryngeal involvement occurred in a minority of patients, but most of these patients were felt to require airway protection.
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Affiliation(s)
- Norman J Chan
- Department of Otolaryngology-Head and Neck Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ahmed M S Soliman
- Department of Otolaryngology-Head and Neck Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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