1
|
Schiepatti A, Minerba P, Puricelli M, Maimaris S, Arpa G, Biagi F, Sanders DS. Systematic review: Clinical phenotypes, histopathological features and prognosis of enteropathy due to angiotensin II receptor blockers. Aliment Pharmacol Ther 2024; 59:432-444. [PMID: 38185985 DOI: 10.1111/apt.17855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/21/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Although enteropathy due to angiotensin II receptor blockers (ARBs) has been known for over 10 years, clinicians' awareness of this condition is still low. AIMS To systematically review the literature about clinical phenotypes, distribution of mucosal changes throughout the gastrointestinal tract and prognosis of enteropathy due to ARBs. METHODS According to PRISMA guidelines, we searched PubMed and Embase for relevant articles up to November 6, 2023. We included full-text papers, letters, case reports and case series describing enteropathy due to ARBs. Patients were classified into subgroups based on endoscopic and histological findings of different regions of the gastrointestinal tract. The protocol was registered with Open Science Framework (https://doi.org/10.17605/OSF.IO/TK67C). RESULTS We included 94 articles reporting 183 cases (101 female, mean age at diagnosis 69 ± 10 years). The clinical picture at diagnosis was characterised by severe diarrhoea (97%) and weight loss (84%, median -13 kg), leading to hospital admission in 167 (95%) patients. Olmesartan (90%) was most frequently implicated. Villous atrophy (VA) was reported in 164/183 (89%) patients. One hundred and nine had only VA, 12 had pan-gastrointestinal involvement, 23 had VA and gastric involvement and 19 had VA and colon involvement (predominantly microscopic colitis). Outcomes were reported for 178/183 (97%) patients, who all recovered clinically on ARBs withdrawal. Histological recovery occurred in all 96 patients with VA at baseline who underwent follow-up duodenal biopsy. CONCLUSIONS Enteropathy due to ARBs is characterised by severe malabsorption often requiring hospital admission and can involve the entire gastrointestinal tract. Clinician awareness can lead to prompt diagnosis and excellent prognosis.
Collapse
Affiliation(s)
- Annalisa Schiepatti
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - Paolo Minerba
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Michele Puricelli
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Stiliano Maimaris
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - Giovanni Arpa
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia, Italy
- Unit of Anatomic Pathology, ICS Maugeri-IRCCS SpA SB, Pavia, Italy
| | - Federico Biagi
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| |
Collapse
|
2
|
Olmesartan-associated sprue-like enteropathy diagnosed by capsule endoscopy and double balloon endoscopy. Clin J Gastroenterol 2021; 14:1649-1654. [PMID: 34480728 DOI: 10.1007/s12328-021-01514-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
Sprue-like enteropathy associated with olmesartan is characterized by villous atrophy in the duodenum. We report the case of an 81-year-old woman diagnosed with olmesartan-associated sprue-like enteropathy with no villous atrophy in the duodenum. The patient had been taking olmesartan for 10 years and complained of diarrhea and weight loss. Despite undergoing general treatment for 2 months, her symptoms showed no improvement. Gastrointestinal endoscopy and pathological findings showed no villous atrophy in the duodenum. However, villous atrophy was observed in the small intestine by capsule endoscopy. Pathological biopsy with double balloon endoscopy provided a definitive diagnosis. Diarrhea improved with the discontinuation of olmesartan and weight increased within a week of withdrawal. After the improvement of clinical symptoms, both endoscopic and pathological findings of villous atrophy in small intestine showed improvement.
Collapse
|
3
|
Odak M, Udongwo N, Alfraji N, Zheng M, Zaidi S. Sprue-Like Enteropathy and Liver Injury: A Rare Emerging Association with Olmesartan. J Investig Med High Impact Case Rep 2021; 9:23247096211037463. [PMID: 34378440 PMCID: PMC8361549 DOI: 10.1177/23247096211037463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Olmesartan-induced enteropathy is an underreported phenomenon, first described in 2012. While olmesartan's antihypertensive properties were confirmed early on, its association with a sprue-like enteropathy was subsequently noted. Although this association has been reported with olmesartan, there have been few reports of this association with other angiotensin-receptor blockers. We present a case of a 79-year-old male who presented with diarrhea, weight loss, jaundice, and transaminitis. Further history revealed that he had been taking olmesartan 40 mg daily for hypertension. Workup of his diarrhea and jaundice included duodenal and liver biopsies revealed findings consistent with a sprue-like enteropathy and an autoimmune hepatitis-like pattern. On discontinuation of olmesartan, his 1-month follow-up revealed significant improvement in his clinical status as well as his liver function tests. Olmesartan is an effective antihypertensive medication; however, physicians must be mindful of its side effect of causing a sprue-like enteropathy and liver injury. Patients should be counseled on discontinuing olmesartan, and they should be started on an alternative therapy for hypertension.
Collapse
Affiliation(s)
- Mihir Odak
- Jersey Shore University Medical Center, Neptune, NJ, USA
| | | | - Nasam Alfraji
- Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Min Zheng
- Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Saddam Zaidi
- Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT, USA
| |
Collapse
|
4
|
Shukla N, Moore K, Gabb GM. Olmesartan-associated duodenal villous atrophy, an emerging clinical issue. Intern Med J 2021; 50:624-626. [PMID: 32431039 DOI: 10.1111/imj.14834] [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: 02/27/2020] [Revised: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 11/30/2022]
Abstract
Duodenal villous atrophy with olmesartan was described in 2012, 10 years following registration of olmesartan. Clinical features are severe watery diarrhoea, usually occurring in association with weight loss. Onset is delayed, with a mean duration of prior exposure to olmesartan of 3 years. Diagnosis may be delayed. Symptoms resolve over weeks following cessation of olmesartan. Epidemiological studies suggest increased risk with olmesartan, rather than a class effect of all angiotensin receptor blockers. Post-marketing surveillance for drug safety remains important.
Collapse
Affiliation(s)
- Nupur Shukla
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Kylies Moore
- Drug Information Service, Pharmacy, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Genevieve M Gabb
- Acute and Urgent Care, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Cardiology, Flinders Medical Centre, Adelaide, South Australia, Australia.,Discipline of Medicine, School of Medicine, Faculty of Health Science, University of Adelaide, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| |
Collapse
|
5
|
Henry P, Dano H, Piessevaux H, Jouret-Mourin A. [An unusual case of olmesartan induced enteropathy]. Ann Pathol 2019; 39:237-240. [PMID: 30712983 DOI: 10.1016/j.annpat.2018.10.007] [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: 05/18/2018] [Revised: 10/18/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Abstract
Olmesartan induced enteropathy was first described in 2012. It is a rare adverse effect of this antihypertensive drug. The clinical presentation commonly includes severe chronic diarrhea leading to weight loss and a variable degree of dehydration. Histological findings are most commonly observed in the duodenum and consist of partial or total villous atrophy, increased intraepithelial lymphocytes and inflammation in the lamina propria. Involvement of gastric and colic mucosa has also been described. We report on the case of a 63-year-old man, treated by olmesartan, who presented with severe chronic diarrhea. Biopsies from different levels of the gastrointestinal tract revealed a pandigestive intraepithelial lymphocytosis.
Collapse
Affiliation(s)
- Paulina Henry
- Service d'anatomie pathologique, cliniques universitaires Saint-Luc, Tour Franklin -1, 10, avenue Hippocrate, 1200 Bruxelles, Belgique.
| | - Hélène Dano
- Service d'anatomie pathologique, cliniques universitaires Saint-Luc, Tour Franklin -1, 10, avenue Hippocrate, 1200 Bruxelles, Belgique
| | - Hubert Piessevaux
- Service de gastroentérologie, cliniques universitaires Saint-Luc, 10, avenue Hippocrate, 1200 Bruxelles, Belgique
| | - Anne Jouret-Mourin
- Service d'anatomie pathologique, cliniques universitaires Saint-Luc, Tour Franklin -1, 10, avenue Hippocrate, 1200 Bruxelles, Belgique
| |
Collapse
|
6
|
Ghaith J, Raslan IA, Szilagyi A, Alameldin M. Case of olmesartan-associated enteropathy and transient positive antitissue transglutaminase serology. BMJ Case Rep 2018; 11:11/1/e225518. [PMID: 30567230 PMCID: PMC6301511 DOI: 10.1136/bcr-2018-225518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Olmesartan-associated enteropathy (OAE) is increasingly being recognised as a major differential diagnosis in patients with villous atrophy and negative coeliac disease (CD) serology. OAE and positive coeliac markers have rarely been reported. We report a case of diarrhoea and small bowel villous blunting associated with a transient elevation of antitissue transglutaminase antibody (ATTG). On discontinuation of olmesartan, symptoms improved, repeat biopsies were normal and levels of ATTG also returned normal. We discuss a possible explanation for the transient elevation in ATTG and the significance of considering OAE/CD overlap.
Collapse
Affiliation(s)
- Jenan Ghaith
- Internal Medicine Residency Program, University of McGill, Montreal, Quebec, Canada
| | - Ismail A Raslan
- Internal Medicine Residency Program, University of McGill, Montreal, Quebec, Canada
| | - Andrew Szilagyi
- Medicine Division of Gastroenterology, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Mona Alameldin
- Department of Pathology, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Canada
| |
Collapse
|
7
|
Lourenço LC, Carvalho E Branco J, Santos L, Martins A, Reis J. Sprue-Like Enteropathy Associated with Olmesartan: An Unrecognized Emerging Drug-Induced Enteropathy? GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:335-336. [PMID: 28868495 PMCID: PMC5580016 DOI: 10.1016/j.jpge.2016.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
| | | | - Liliana Santos
- Gastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Alexandra Martins
- Gastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Jorge Reis
- Gastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| |
Collapse
|
8
|
Hujoel IA, Rubio-Tapia A. Sprue-Like Enteropathy Associated With Olmesartan: A New Kid on the Enteropathy Block. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:61-65. [PMID: 28868435 PMCID: PMC5580180 DOI: 10.1016/j.jpge.2016.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Isabel A Hujoel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alberto Rubio-Tapia
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|