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Hom KA, Hirsch R, Elluru RG. Antihypertensive drug-induced angioedema causing upper airway obstruction in children. Int J Pediatr Otorhinolaryngol 2012; 76:14-9. [PMID: 21885133 DOI: 10.1016/j.ijporl.2011.07.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 07/06/2011] [Accepted: 07/08/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Angioedema is a well-described complication arising from the use of antihypertensive agents in the adult population. However, its occurrence and potential for upper airway compromise in pediatrics has only been sporadically reported in the literature. Our objective is to report and review the occurrence of antihypertensive-induced angioedema in the pediatric population and the potential for airway compromise. METHODS Charts of 42 patients admitted to Cincinnati Children's Hospital Medical Center with the discharge diagnosis of angioedema (ICD-9 code 995.1) from January 2000 to January 2010 were reviewed. Of the 42 charts, 3 cases had angioedema induced by antihypertensive drugs and all 3 resulted in upper airway obstruction. Summary and findings of the data collected from the medical chart review included demographics, chief complaint(s), past medical history, hospital course, antihypertensive drugs used, diagnostic test(s), medical treatment, and time from onset of symptoms to resolution. In addition, a PubMed literature search using the terms angioedema and antihypertensive drugs was performed to review its occurrence in pediatrics. The previous literature case reports were compared to our cases to further characterize and emphasize the clinical features of this occurrence in children and adolescents. RESULTS Despite the well-known occurrence of antihypertensive drug-induced angioedema causing airway obstruction in adults, only 4 case reports have been previously published in children. At our institution, we describe 3 children who developed acute angioedema with upper airway obstruction after the chronic use of antihypertensive medications [2 drugs in the ACE inhibitor class (enalapril and lisinopril), and 1 drug in the calcium channel blocker class (CCB; amlodipine)]. In all 3 cases, the symptoms resolved within 1 week after the antihypertensive agent was discontinued. CONCLUSION Upper airway obstruction can occur at any age when taking antihypertensive drugs. Particular caution should be applied to ACE inhibitors and CCBs in this regard. With the increasing use of antihypertensive agents in the pediatric population, clinicians should be alert to the possibility of angioedema with upper airway obstruction as a potential lethal adverse effect.
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Affiliation(s)
- Katherine A Hom
- Division of Pediatric Otolaryngology, Department of Otolaryngology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Al-Khudari S, Loochtan MJ, Peterson E, Yaremchuk KL. Management of angiotensin-converting enzyme inhibitor-induced angioedema. Laryngoscope 2011; 121:2327-34. [PMID: 22020885 DOI: 10.1002/lary.22349] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To develop and validate a clinical algorithm for management of patients with angiotensin-converting enzyme inhibitor-induced angioedema (AIIA). STUDY DESIGN Prospective cohort observational study. METHODS Over 1 year, 40 patients with AIIA were evaluated by otolaryngology, underwent laryngoscopy, and were followed until disease resolution. The need for airway intervention, disposition for appropriate level of care, and other parameters were analyzed. RESULTS Treatment started within 61.5 minutes of presentation to the emergency department (ED). Mean duration until resolution of edema was 29 hours. Twenty (50%) patients required intensive care unit (ICU) admission, and six (15%) required intubation. Seventeen (42.5%) were monitored and discharged from the ED. Floor-of-mouth edema was present in 19 (47.5%), and massive tongue edema was found in four (10%) patients. The aryepiglottic fold was involved in 20 (50%) patients on laryngoscopy. Older patients (P = .048) with subjective dyspnea (P = .003) and dysphonia (P = .001) were most likely to require ICU admission. Upper lip swelling had a negative correlation with airway edema identifiable on laryngoscopy alone (P = .008). Dysphonia (n = 16) predicted airway edema upon laryngoscopy (P = .001). All 40 patients were triaged successfully without the need for readmission or escalation of level of care. CONCLUSIONS The management protocol was successful in 40 consecutive patients to the appropriate level of care. History and physical examination may predict airway findings identified on laryngoscopy and help guide management when treatment by otolaryngology is not immediately available. A subset of patients will require acute airway intervention and can be identified at initial presentation.
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Affiliation(s)
- Samer Al-Khudari
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan 48202, USA.
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Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol 2011; 105:259-273. [PMID: 20934625 DOI: 10.1016/j.anai.2010.08.002] [Citation(s) in RCA: 652] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/02/2010] [Indexed: 01/17/2023]
Abstract
Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient
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Angioedema and angiotensin-converting enzyme inhibitors: Are demographics a risk? Otolaryngol Head Neck Surg 2008; 139:105-8. [DOI: 10.1016/j.otohns.2008.03.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 03/25/2008] [Accepted: 03/27/2008] [Indexed: 01/13/2023]
Abstract
Objectives The use of angiotensin-converting enzyme inhibitors (ACEI) has become the leading cause of acquired angioedema. Previous studies have suggested that certain patient populations may be at a higher risk for ACEI-induced angioedema. The objective of this study was to evaluate any demographic associations. Study Design A retrospective chart review. Materials and Methods Angioedema patients from 1999 to 2004 treated at a tertiary care hospital were reviewed. Demographics, inciting factors, and comorbid conditions were examined. Results One hundred eighty-two patients met inclusion criteria. Sixty-three percent of patients with angioedema had ACEI triggers. Eighty-one percent of all ACEI angioedema occurred in black patients. Of all angioedema patients, 70% (95% confidence interval [CI], 62%-78%) of black patients noted an ACEI as the inciting agent compared with 44% (95% CI, 30%-59%) in other patient groups. Black patients were 3.03 times more likely to have angioedema from an ACEI than all other patient groups (95% CI, 1.54-5.94). Conclusion This study represents the largest series of patients with angioedema. Although retrospective in nature, the data show that black patients are at a higher risk for ACEI-induced angioedema.
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Lin RY, Cannon AG, Teitel AD. Pattern of hospitalizations for angioedema in New York between 1990 and 2003. Ann Allergy Asthma Immunol 2005; 95:159-66. [PMID: 16136766 DOI: 10.1016/s1081-1206(10)61206-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The epidemiologic characteristics of angioedema have not been well described in the United States, especially regarding hospitalization patterns. This fact is particularly relevant given the increased use of angiotensin-converting enzyme inhibitors, a known cause of angioedema. OBJECTIVE To profile hospital admissions for angioedema in New York State with respect to age, sex, race, comorbidities, and year. METHODS A database of all acute hospitalizations in New York State was examined between 1990 and 2003. Patient admissions that had the principal admission diagnoses of angioedema and other acute allergic disorders (anaphylaxis, urticaria, or allergy unspecified) were extracted. Characteristics of angioedema admissions were tabulated and compared with those of other acute allergic disease admissions with respect to demographic variables and comorbidities. RESULTS There were 6,775 hospitalizations for angioedema during the study period. The number of angioedema hospitalizations increased progressively from 293 in 1990 to 636 in 2003, which exceeded the number of hospitalizations for anaphylaxis that year. African Americans constituted 42% of the angioedema admissions despite being less than 16% of the state population. The increase in hospitalizations for angioedema was most marked in patients with a diagnosis of hypertension, and for each study year, patients admitted with angioedema were consistently older than those admitted with other allergic disorders. CONCLUSIONS Angioedema has become the most common nonasthmatic acute allergic disorder that results in hospitalization in New York State. The predilection for angioedema occurring in patients with hypertension suggests that angiotensin-converting enzyme inhibitor use may play a role in this trend.
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Affiliation(s)
- Robert Y Lin
- New York Medical College, Valhalla, New York, USA.
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Peacock ME, Park DS, Swiec GD, Erley KJ. Perioral Angioedema Associated With Angiotensin-Converting Enzyme Inhibitor. J Periodontol 2005; 76:651-4. [PMID: 15857108 DOI: 10.1902/jop.2005.76.4.651] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Angioedema is a non-pruritic swelling usually limited to the skin and mucous membranes of the face and perioral soft tissues. It can be life threatening but usually is not, and can be managed with conservative medical treatment unless the airway is endangered. Recent reports suggest that angiotensin-converting enzyme (ACE) inhibitors can predispose and/or precipitate angioedema, with a predilection toward patients of African American ancestry. METHODS This case report involved a 65-year-old African American female who was being treated surgically for localized chronic periodontitis. The procedure was performed without incident, and the patient was alert and stable when released. The next day, the patient called and reported that her lips were swollen. She stated that this had happened a number of times over the past several years, sometimes related to eating shellfish and other times without any known precipitating factor. All previous episodes of perioral swelling occurred after ACE inhibitor therapy had been initiated. RESULTS The patient was in no distress, with no other site involvement. She was prescribed oral hydroxyzine and her appearance returned to normal after 5 days. Although the patient had experienced previous episodes of angioedema, none had been in response to any dental procedure. She was referred to the Allergy and Immunology Clinic for skin testing, the results of which were negative to shellfish with good controls. Other potentiating etiologies were also ruled out by the allergist. CONCLUSIONS Angioedema is a recognized possible side effect of ACE inhibitor therapy. The exact mechanism by which ACE inhibitors induce angioedema is not known, although the risk of occurrence is much greater in African Americans. Practitioners should be alert to this potentially fatal condition in patients who take ACE inhibitors or the newer angiotensin II receptor blockers (ARBs).
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Agostoni A, Aygören-Pürsün E, Binkley KE, Blanch A, Bork K, Bouillet L, Bucher C, Castaldo AJ, Cicardi M, Davis AE, De Carolis C, Drouet C, Duponchel C, Farkas H, Fáy K, Fekete B, Fischer B, Fontana L, Füst G, Giacomelli R, Gröner A, Hack CE, Harmat G, Jakenfelds J, Juers M, Kalmár L, Kaposi PN, Karádi I, Kitzinger A, Kollár T, Kreuz W, Lakatos P, Longhurst HJ, Lopez-Trascasa M, Martinez-Saguer I, Monnier N, Nagy I, Németh E, Nielsen EW, Nuijens JH, O'grady C, Pappalardo E, Penna V, Perricone C, Perricone R, Rauch U, Roche O, Rusicke E, Späth PJ, Szendei G, Takács E, Tordai A, Truedsson L, Varga L, Visy B, Williams K, Zanichelli A, Zingale L. Hereditary and acquired angioedema: problems and progress: proceedings of the third C1 esterase inhibitor deficiency workshop and beyond. J Allergy Clin Immunol 2004; 114:S51-131. [PMID: 15356535 PMCID: PMC7119155 DOI: 10.1016/j.jaci.2004.06.047] [Citation(s) in RCA: 437] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Revised: 06/24/2004] [Accepted: 06/24/2004] [Indexed: 01/13/2023]
Abstract
Hereditary angioedema (HAE), a rare but life-threatening condition, manifests as acute attacks of facial, laryngeal, genital, or peripheral swelling or abdominal pain secondary to intra-abdominal edema. Resulting from mutations affecting C1 esterase inhibitor (C1-INH), inhibitor of the first complement system component, attacks are not histamine-mediated and do not respond to antihistamines or corticosteroids. Low awareness and resemblance to other disorders often delay diagnosis; despite availability of C1-INH replacement in some countries, no approved, safe acute attack therapy exists in the United States. The biennial C1 Esterase Inhibitor Deficiency Workshops resulted from a European initiative for better knowledge and treatment of HAE and related diseases. This supplement contains work presented at the third workshop and expanded content toward a definitive picture of angioedema in the absence of allergy. Most notably, it includes cumulative genetic investigations; multinational laboratory diagnosis recommendations; current pathogenesis hypotheses; suggested prophylaxis and acute attack treatment, including home treatment; future treatment options; and analysis of patient subpopulations, including pediatric patients and patients whose angioedema worsened during pregnancy or hormone administration. Causes and management of acquired angioedema and a new type of angioedema with normal C1-INH are also discussed. Collaborative patient and physician efforts, crucial in rare diseases, are emphasized. This supplement seeks to raise awareness and aid diagnosis of HAE, optimize treatment for all patients, and provide a platform for further research in this rare, partially understood disorder.
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Key Words
- aae
- acquired angioedema
- angioedema
- c1 esterase inhibitor
- c1-inh
- hae
- hane
- hano
- hereditary angioedema
- hereditary angioneurotic edema
- angioneurotic edema
- chemically induced angioedema
- human serping1 protein
- aae, acquired angioedema
- aaee, (italian) voluntary association for the study, therapy, and fight against hereditary angioedema
- ace, angiotensin-converting enzyme
- app, aminopeptidase p
- at2, angiotensin ii
- b19v, parvovirus b19
- bmd, bone mineral density
- bvdv, bovine viral diarrhea virus
- c1, first component of the complement cascade
- c1-inh, c1 esterase inhibitor
- c1nh, murine c1 esterase inhibitor gene
- c1nh, human c1 esterase inhibitor gene
- c2, second component of the complement cascade
- c3, third component of the complement cascade
- c4, fourth component of the complement cascade
- c5, fifth component of the complement cascade
- ccm, chemical cleavage of mismatches
- ch50, total hemolytic complement, 50% cell lysis
- cmax, maximum concentration
- cpmp, committee for proprietary medicinal products
- cpv, canine parvovirus
- dhplc, denaturing hplc
- ff, (ovarian) follicular fluid
- ffp, fresh frozen plasma
- hae, hereditary angioedema
- hae-i, hereditary angioedema type i
- hae-ii, hereditary angioedema type ii
- haea, us hae association
- hav, hepatitis a virus
- hbsag, hepatitis b surface antigen
- hbv, hepatitis b virus
- hcv, hepatitis c virus
- hk, high molecular weight kininogen
- hrt, hormone replacement therapy
- huvs, hypocomplementemic urticaria-vasculitis syndrome
- lh, luteinizing hormone
- masp, mannose-binding protein associated serine protease
- mbl, mannan-binding lectin
- mfo, multifollicular ovary
- mgus, monoclonal gammopathies of undetermined significance
- mr, molecular mass
- nat, nucleic acid amplification technique
- nep, neutral endopeptidase
- oc, oral contraceptive
- omim, online mendelian inheritance in man (database)
- pco, polycystic ovary
- pct, primary care trust
- prehaeat, novel methods for predicting, preventing, and treating attacks in patients with hereditary angioedema
- prv, pseudorabies virus
- rhc1-inh, recombinant human c1 esterase inhibitor
- rtpa, recombinant tissue-type plasminogen activator
- shbg, sex hormone binding globulin
- ssca, single-stranded conformational analysis
- tpa, tissue-type plasminogen activator
- uk, united kingdom
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Abstract
Angioedema of the upper airways associated with angiotensin-converting enzyme inhibitors (ACEI) represent a rare but serious problem. We present two cases from our hospital in order to illustrate the therapeutic consequences resulting from angioedema associated with the intake of ACEIs. Surgical airway management should be considered early if medical treatment fails.
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Affiliation(s)
- T Schröder
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde der Westfälischen Wilhelms-Universität Münster, Münster.
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