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Whitehead WJ, Reid JM. Underreported Risk of Lisinopril-Induced Angioedema in a Veteran Population. Ann Pharmacother 2021; 56:430-435. [PMID: 34282637 DOI: 10.1177/10600280211032404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Lisinopril-induced angioedema (LIA) is a rare but serious adverse drug event (ADE) with a published incidence of 0.1% to 0.7%. It is well known that ADEs are widely underreported; however, LIA is one of the most reported ADEs within the Veterans Health Administration (VHA). OBJECTIVE To estimate the effect of underreporting on the risk of LIA within VHA. METHODS The reported risk of LIA was calculated from reports submitted to the Veterans Affairs (VA) Adverse Drug Event Reporting System (VA ADERS) and the number of veterans prescribed lisinopril. To estimate underreporting, local chart review identified cases of LIA that were compared to reports submitted. The underreporting rate was then applied to the national reported risk. RESULTS Locally, 68 reports of LIA were submitted of the 21 262 patients prescribed lisinopril, for a reported risk of 0.32%. Nationwide, 14 289 reports of LIA were submitted of the 3 109 661 patients prescribed lisinopril, for a crude reported risk of 0.46%. Of the 324 patients identified for chart review, 240 patients were diagnosed with LIA, suggesting that at least 71.7% of cases were unreported. When this underreporting rate is extrapolated to the national reported risk, a better estimate of the risk of LIA within VHA could increase to 1.6%. CONCLUSION AND RELEVANCE When estimating the effect of underreporting, the risk of LIA increases to approximately 1.6% or 1 in 63 patients. Because this ADE may affect more patients than previously understood, providers may wish to take LIA into consideration when prescribing lisinopril.
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Affiliation(s)
- Whitley J Whitehead
- University of Kentucky Good Samaritan Hospital, UK HealthCare, Lexington Kentucky, KY, USA
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2
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Germenis AE, Rijavec M, Veronez CL. Leveraging Genetics for Hereditary Angioedema: A Road Map to Precision Medicine. Clin Rev Allergy Immunol 2021; 60:416-428. [PMID: 33507496 DOI: 10.1007/s12016-021-08836-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 12/25/2022]
Abstract
Biochemical studies performed during the last decades resulted in the development of various innovative medicinal products for hereditary angioedema (HAE). These therapeutic agents target the production or the function of bradykinin-the main mediator of HAE due to C1-inhibitor (C1-INH) deficiency. However, despite these remarkable achievements, current knowledge cannot provide convincing explanations for the clinical variability of the disease. As a consequence, treatment indications apply for drugs available for C1-INH deficiency. The advent of high-throughput next-generation sequencing technologies may assist in covering the missing part of our understanding of HAE pathogenesis. During the last 3 years alone, several new entities were added to the already described genotypes. The recent discovery of four novel target genes expands our understanding of other causes which may explain recurrent angioedema in individuals and families with normal C1-INH activity. Furthermore, new genetic technologies allowed the recognition of deep intronic variants associated with the disease, and elegant functional studies characterized new variants for the C1-INH gene. Thus, evidence has been provided regarding pathogenetic aspects remaining obscure for many years, such as the defective intracellular transport of mutant C1-INH, and environmental effect on the disease expression. Therefore, it seems that the stage for Precision Medicine era in HAE management is ready. Disease endotypes are expected to be uncovered and specified targets for therapeutic intervention will be detected, promising a more effective, individualized management of the disease.
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Affiliation(s)
- Anastasios E Germenis
- Department of Immunology and Histocompatibility, School of Medicine, University of Thessaly, 3 Panepistimiou Street, GR-41500, Biopolis Larissa, Greece.
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Camila Lopes Veronez
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, University of California San Diego, San Diego, CA, USA.,Research Service, San Diego Veterans Affairs Healthcare, San Diego, CA, USA
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3
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Sato M, Takahashi M, Kario K. Critical angioedema induced by a renin angiotensin system blocker in the contemporary era of increasing heart failure: A case report and commentary. J Clin Hypertens (Greenwich) 2021; 23:692-695. [PMID: 33492725 PMCID: PMC8029552 DOI: 10.1111/jch.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/28/2020] [Accepted: 01/03/2021] [Indexed: 12/11/2022]
Abstract
Bradykinin‐mediated angioedema, a nonallergic reaction most commonly caused by renin angiotensin system (RAS) blockers, has the potential to lead to a critical condition. RAS blockers are important for treating heart failure and are widely used in clinical settings. We present the case of an 85‐year‐old man who was administered enalapril after percutaneous coronary intervention for an acute myocardial infarction and developed severe angioedema requiring a tracheostomy. He had multiple risks for angioedema including advanced age, smoking history, renal dysfunction, and longstanding use of an angiotensin receptor blocker. The prompt diagnosis of drug‐induced angioedema is critical and depends on physicians' recognition of risk factors and knowledge of pathophysiology. In the present era of increasingly prevalent heart failure, it is imperative that the possibility of angioedema receives attention, especially given the continuing reliance on RAS blockers and the advent of angiotensin receptor neprilysin inhibitors, a new type of heart failure drug.
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Affiliation(s)
- Masafumi Sato
- The Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke-shi, Japan
| | - Masao Takahashi
- The Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke-shi, Japan
| | - Kazuomi Kario
- The Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke-shi, Japan
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4
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Marceau F, Bachelard H, Charest-Morin X, Hébert J, Rivard GE. In Vitro Modeling of Bradykinin-Mediated Angioedema States. Pharmaceuticals (Basel) 2020; 13:ph13090201. [PMID: 32824891 PMCID: PMC7559923 DOI: 10.3390/ph13090201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 12/15/2022] Open
Abstract
Kinins (peptides related to bradykinin, BK) are formed from circulating substrates, the kininogens, by the action of two proteases, the kallikreins. The only clinical application of a BK receptor ligand, the B2 receptor antagonist icatibant, is the treatment of the rare hereditary angioedema (HAE) caused by the deficiency of C1-esterase inhibitor (C1-INH). Less common forms of HAE (genetic variants of factor XII, plasminogen, kininogen) are presumably mediated by increased BK formation. Acquired forms of BK-mediated angioedema, such as that associated with angiotensin-I converting enzyme (ACE) inhibition, are also known. Antibody-based analytical techniques are briefly reviewed, and support that kinins are extremely short-lived, prominently cleared by ACE. Despite evidence of continuous activation of the kallikrein–kinin system in HAE, patients are not symptomatic most of the time and their blood or plasma obtained during remission does not generate excessive immunoreactive BK (iBK), suggesting effective homeostatic mechanisms. HAE-C1-INH and HAE-FXII plasmas are both hyperresponsive to fibrinolysis activation. On another hand, we suggested a role for the alternate tissue kallikrein–kinin system in patients with a plasminogen mutation. The role of the BK B1 receptor is still uncertain in angioedema states. iBK profiles under in vitro stimulation provide fresh insight into the physiopathology of angioedema.
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Affiliation(s)
- François Marceau
- Centre de Recherche du CHU de Québec-Université Laval, Québec, QC G1V 4G2, Canada; (H.B.); (X.C.-M.)
- Correspondence:
| | - Hélène Bachelard
- Centre de Recherche du CHU de Québec-Université Laval, Québec, QC G1V 4G2, Canada; (H.B.); (X.C.-M.)
| | - Xavier Charest-Morin
- Centre de Recherche du CHU de Québec-Université Laval, Québec, QC G1V 4G2, Canada; (H.B.); (X.C.-M.)
| | - Jacques Hébert
- Service D’allergie, CHU de Québec-Université Laval, Québec, QC G1V 4G2, Canada;
| | - Georges E. Rivard
- CHU Sainte-Justine, Université de Montréal, Montréal, QC H3T 1C5, Canada;
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5
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Marceau F, Rivard GE, Gauthier JM, Binkley KE, Bonnefoy A, Boccon-Gibod I, Bouillet L, Picard M, Levesque G, Elfassy HL, Bachelard H, Hébert J, Bork K. Measurement of Bradykinin Formation and Degradation in Blood Plasma: Relevance for Acquired Angioedema Associated With Angiotensin Converting Enzyme Inhibition and for Hereditary Angioedema Due to Factor XII or Plasminogen Gene Variants. Front Med (Lausanne) 2020; 7:358. [PMID: 32766265 PMCID: PMC7380097 DOI: 10.3389/fmed.2020.00358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
Abstract
Bradykinin (BK)-mediated angioedema (AE) states are rare acquired or hereditary conditions involving localized edema of the subcutaneous and submucosal tissues. Citrated plasma from healthy volunteers or patients with hereditary angioedema (HAE) with normal level of C1-inhibitor (C1-INH) was used to investigate pathways of BK formation and breakdown relevant to AE physiopathology. The half-life of BK (100 nM) added to normal plasma was 34 s, a value that was increased ~12-fold when the angiotensin converting enzyme (ACE) inhibitor enalaprilat (130 nM) was added (enzyme immunoassay measurements). The BK half-life was similarly increased ~5-fold following 2 daily oral doses of enalapril maleate in healthy volunteers, finding of possible relevance for the most common form of drug-associated AE. We also addressed the kinetics of immunoreactive BK (iBK) formation and decline, spontaneous or under three standardized stimuli: tissue kallikrein (KLK-1), the particulate material Kontact-APTT™ and tissue plasminogen activator (tPA). Relative to controls, iBK production was rapid (10–20 min) and very intense in response to tPA in plasma of female heterozygotes for variants in gene F12 coding for factor XII (FXII) (p.Thr328Lys, 9 patients; p.Thr328Arg, one). An increased response to Kontact-APTT™ and an early tPA-induced cleavage of anomalous FXII (immunoblots) were also observed. Biotechnological inhibitors showed that the early response to tPA was dependent on plasmin, FXIIa and plasma kallikrein. Results from post-menopausal and pre-menopausal women with HAE-FXII were indistinguishable. The iBK production profiles in seven patients with the plasminogen p.Lys330Glu variant (HAE-PLG) did not significantly differ from those of controls, except for an unexpected, rapid and lanadelumab-resistant potentiation of KLK-1 effect. This enzyme did not cleave plasminogen or factor XII, suggesting a possible idiosyncratic interaction of the plasminogen pathogenic variant with KLK-1 activity. KLK-1 abounds in salivary glands and human saliva, hypothetically correlating with the clinical presentation of HAE-PLG that includes the swelling of the tongue, lips and contiguous throat tissues. Samples from HAE patients with normal C1-INH levels and F12 gene did not produce excessive iBK in response to stimuli. The ex vivo approach provides physiopathological insight into AE states and supports the heterogeneous physiopathology of HAE with normal C1-INH.
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Affiliation(s)
- François Marceau
- Axe Microbiologie-Infectiologie et Immunologie, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Georges E Rivard
- CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Julie M Gauthier
- Molecular Diagnostic Laboratory, Division of Medical Genetics, Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada
| | - Karen E Binkley
- Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Arnaud Bonnefoy
- CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Isabelle Boccon-Gibod
- National Reference Center for Angioedema (CREAK), Grenoble University Hospital, Grenoble, France
| | - Laurence Bouillet
- National Reference Center for Angioedema (CREAK), Grenoble University Hospital, Grenoble, France
| | - Matthieu Picard
- Service d'Immunologie Clinique etl allergie, Département de Médecine, Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada
| | | | - Hannah Laure Elfassy
- Département d'Immunologie-Allergie, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada
| | - Hélène Bachelard
- Axe Endocrinologie et Néphrologie, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Jacques Hébert
- Service d'Allergie, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Konrad Bork
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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6
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Dubrall D, Schmid M, Stingl JC, Sachs B. Angioedemas associated with renin-angiotensin system blocking drugs: Comparative analysis of spontaneous adverse drug reaction reports. PLoS One 2020; 15:e0230632. [PMID: 32214375 PMCID: PMC7098604 DOI: 10.1371/journal.pone.0230632] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/04/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Angioedema is a subcutaneous swelling typically affecting the face, larynx or pharynx. It is a known adverse drug reaction (ADR) of ACE inhibitors (ACEi), angiotensin-II-receptor blockers (ARBs) and aliskiren (renin inhibitor). Several studies have reported pathophysiological mechanisms and risk factors of ACEi-associated angioedemas, whereas little is known for ARBs and aliskiren. The aim of the study was to analyze comparatively ACEi versus ARBs and aliskiren angioedema reports contained in the European ADR database EudraVigilance with regard to reported risk factors and clinical phenotypes. METHODS All spontaneous angioedema reports received between 01/2010-06/2017 reporting either an ACEi, ARB, or aliskiren as "suspected/interacting" drug were identified using the Standardized MedDRA Query "angioedema (narrow)". In order to perform a comparative analysis, odds ratios (ORs) were calculated for angioedema reports of ACEi (n = 3.194) versus ARBs (n = 687) and aliskiren (n = 162). RESULTS More patients with a history of allergy were included in angioedema reports of ARBs (6.8%) and aliskiren (13.6%) versus ACEi (4.3%). "Urticaria" as an ADR was reported more frequently in angioedema reports of ARBs (18.5%) and aliskiren (9.0%) versus ACEi (5.0%). ACEi-associated angioedemas were more often designated as "life-threatening" compared to ARBs (OR 2.2 [1.6-2.9]) and aliskiren-associated angioedemas (OR 14.2 (3.5-57.4). Concomitant therapy with mTOR inhibitors (OR 4.3 [1.0-17.9]) and fibrinolytics (OR 7.8 [1.1-57.2]) was reported more often in ACEi versus ARBs angioedema reports. CONCLUSION The reported clinical phenotypes differed between ACEi versus ARBs and aliskiren angioedema reports. Differences between the patient populations as observed in our study or differences with regard to underlying pathomechanisms could account for this finding. Due to the methodological limitations of spontaneous reporting systems, we cannot draw a firm conclusion in this regard. Hence, further research is necessary to confirm our observation and elucidate the underyling causes.
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Affiliation(s)
- Diana Dubrall
- Institute for Medical Biometry, Informatics and Epidemiology, (IMBIE), University Hospital of Bonn, North Rhine-Westphalia, Germany
- Federal Institute for Drugs and Medical Devices (BfArM), Research Division, North Rhine-Westphalia, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, (IMBIE), University Hospital of Bonn, North Rhine-Westphalia, Germany
| | - Julia Carolin Stingl
- Institute of Clinical Pharmacology, University Hospital of the RWTH Aachen, North Rhine-Westphalia, Germany
| | - Bernhardt Sachs
- Federal Institute for Drugs and Medical Devices (BfArM), Research Division, North Rhine-Westphalia, Germany
- Department for Dermatology and Allergy, University Hospital of the RWTH Aachen, North Rhine-Westphalia, Germany
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7
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Mihaela Leru P, Florin Anton V, Bocsan C, Muntean A, Boda D. Acquired angioedema induced by angiotensin-converting enzyme inhibitors - experience of a hospital-based allergy center. Exp Ther Med 2020; 20:68-72. [PMID: 32508996 DOI: 10.3892/etm.2020.8474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/17/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Polliana Mihaela Leru
- Family Medicine Department, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Internal Medicine Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Vlad Florin Anton
- Internal Medicine Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Corina Bocsan
- Department of Pharmacology, Toxicology and Clinical Pharmacology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
| | - Adriana Muntean
- Department of Immunology and Allergology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania.,Allergy Department, 'Professor Doctor Octavian Fodor' Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Daniel Boda
- Dermatology Research Laboratory, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Dermatology Department, 'Prof. N. Paulescu' National Institute of Diabetes, Nutrition and Metabolic Diseases, 011233 Bucharest, Romania
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8
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Lin SR, Lin SY, Chen CC, Fu YS, Weng CF. Exploring a New Natural Treating Agent for Primary Hypertension: Recent Findings and Forthcoming Perspectives. J Clin Med 2019; 8:E2003. [PMID: 31744165 PMCID: PMC6912567 DOI: 10.3390/jcm8112003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/14/2019] [Accepted: 11/14/2019] [Indexed: 12/13/2022] Open
Abstract
Primary hypertension describes abnormally-high systolic/diastolic blood pressure in a resting condition caused by various genetic or environmental risk factors. Remarkably, severe complications, such as ischemic cardiovascular disease, stroke, and chronic renal disease have led to primary hypertension becoming a huge burden for almost one-third of the total population. Medication is the major regimen for treating primary hypertension; however, recent medications may have adverse effects that attenuate energy levels. Hence, the search for new hypotensive agents from folk or traditional medicine may be fruitful in the discovery and development of new drugs. This review assembles recent findings for natural antihypertensive agents, extracts, or decoctions published in PubMed, and provides insights into the search for new hypotensive compounds based on blood-pressure regulating mechanisms, including the renin-angiotensin-aldosterone system and the sympathetic/adrenergic receptor/calcium channel system.
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Affiliation(s)
- Shian-Ren Lin
- Department of Life Science and Institute of Biotechnology, National Dong Hwa University, Hualien 97401, Taiwan; (S.-R.L.); (C.-C.C.)
- Graduate Institute of Cancer Biology and Drug Discovery, Taipei Medical University, Taipei 110, Taiwan
| | - Shiuan-Yea Lin
- Department of Anatomy, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Ching-Cheng Chen
- Department of Life Science and Institute of Biotechnology, National Dong Hwa University, Hualien 97401, Taiwan; (S.-R.L.); (C.-C.C.)
- Camillian Saint Mary’s Hospital Luodong,160 Zhongzheng S. Rd. Luodong, Yilan 26546, Taiwan
| | - Yaw-Syan Fu
- Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Center for Infectious Disease and Cancer Research, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Ching-Feng Weng
- Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Basic Medical Science, Center for Transitional Medicine, Xiamen Medical College, Xiamen 361023, China
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Sachs B, Meier T, Nöthen MM, Stieber C, Stingl J. [Drug-induced angioedema : Focus on bradykinin]. Hautarzt 2019; 69:298-305. [PMID: 29392343 DOI: 10.1007/s00105-017-4119-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
On a pathophysiological level, angioedema can be differentiated into histamine- and bradykinin-mediated types. The prototype drug-associated, bradykinin-mediated form of angioedema is angiotensin-converting enzyme (ACE) inhibitor-induced angioedema. The hypothesized cause is a decrease in bradykinin degradation via ACE inhibition. In this scenario, other bradykinin-degrading enzymes assume major importance. When the effect of these enzymes is also diminished, e. g., due to genetic variants or external factors, compensation for the inhibition of ACE may be insufficient. An increased risk of angioedema has also been reported for other drugs, particularly when prescribed in combination with ACE inhibitors. Here, the suspected cause also relates to the degradation of bradykinin. When angioedema arises within the context of concomitant ACE inhibitor use, additive bradykinin degradation effects may be implicated.
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Affiliation(s)
- B Sachs
- Klinik für Dermatologie und Allergologie, RWTH Aachen, Aachen, Deutschland. .,Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland.
| | - T Meier
- Abteilung Pharmakovigilanz, Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Deutschland
| | - M M Nöthen
- Institut für Humangenetik, Universität Bonn, Bonn, Deutschland
| | - C Stieber
- Institut für Humangenetik, Universität Bonn, Bonn, Deutschland
| | - J Stingl
- Zentrum für Translationale Medizin, Universität Bonn, Bonn, Deutschland.,Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland
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10
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Imai T, Hyodo M, Uzawa N. Delayed angioedema of the unilateral tongue associated with angiotensin II receptor blocker in a patient with polypharmacy. Australas J Dermatol 2018; 60:e164-e165. [PMID: 30353537 DOI: 10.1111/ajd.12947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Tomoaki Imai
- Department of Oral and Maxillofacial Surgery II, Osaka University Graduate School of Dentistry, Suita, Osaka, Japan
| | - Miho Hyodo
- Department of Oral and Maxillofacial Surgery II, Osaka University Graduate School of Dentistry, Suita, Osaka, Japan
| | - Narikazu Uzawa
- Department of Oral and Maxillofacial Surgery II, Osaka University Graduate School of Dentistry, Suita, Osaka, Japan
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11
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Charest-Morin X, Hébert J, Rivard GÉ, Bonnefoy A, Wagner E, Marceau F. Comparing Pathways of Bradykinin Formation in Whole Blood From Healthy Volunteers and Patients With Hereditary Angioedema Due to C1 Inhibitor Deficiency. Front Immunol 2018; 9:2183. [PMID: 30333824 PMCID: PMC6176197 DOI: 10.3389/fimmu.2018.02183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/04/2018] [Indexed: 12/26/2022] Open
Abstract
Multiple pathways have been proposed to generate bradykinin (BK)-related peptides from blood. We applied various forms of activation to fresh blood obtained from 10 healthy subjects or 10 patients with hereditary angioedema (HAE-1 or −2 only) to investigate kinin formation. An enzyme immunoassay for BK was applied to extracts of citrated blood incubated at 37°C under gentle agitation for 0–2 h in the presence of activators and/or inhibitory agents. Biologically active kinins in extracts were corroborated by c-Fos accumulation in HEK 293a cells that express either recombinant human B2 or B1 receptors (B2R, B1R). Biological evidence of HAE diagnostic and blood cell activation was also obtained. The angiotensin converting enzyme inhibitor enalaprilat, without any effect per se, increased immunoreactive BK (iBK) concentration under active stimulation of blood. Tissue kallikrein (KLK-1) and Kontact-APTT, a particulate material that activates the contact system, rapidly (5 min) and intensely (>100 ng/mL) induced similar iBK generation in the blood of control or HAE subjects. Tissue plasminogen activator (tPA) slowly (≥1 h) induced iBK generation in control blood, but more rapidly and intensely so in that of HAE patients. Effects of biotechnological inhibitors indicate that tPA recruits factor XIIa (FXIIa) and plasma kallikrein to generate iBK. KLK-1, independent of the contact system, is the only stimulus leading to an inconsistent B1R stimulation. Stimulating neutrophils or platelets did not generate iBK. In the HAE patients observed during remission, iBK formation capability coupled to B2R stimulation appears largely intact. However, a selective hypersensitivity to tPA in the blood of HAE patients suggests a role of plasmin-activated FXIIa in the development of attacks. Proposed pathways of kinin formation dependent on blood cell activation were not corroborated.
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Affiliation(s)
- Xavier Charest-Morin
- Axe Microbiologie-Infectiologie et Immunologie, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Jacques Hébert
- Service d'allergie, CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Arnaud Bonnefoy
- Division of Hematology/Oncology, CHU Sainte-Justine, Montréal, QC, Canada
| | - Eric Wagner
- Axe Microbiologie-Infectiologie et Immunologie, CHU de Québec-Université Laval, Québec, QC, Canada
| | - François Marceau
- Axe Microbiologie-Infectiologie et Immunologie, CHU de Québec-Université Laval, Québec, QC, Canada
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Rincic Antulov M, Båtevik RB. Angiotensin-Converting Enzyme Inhibitor-Induced Gastrointestinal Angioedema: The First Danish Case Report. Case Rep Gastroenterol 2018; 12:556-558. [PMID: 30323729 PMCID: PMC6180265 DOI: 10.1159/000486952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 01/17/2018] [Indexed: 11/26/2022] Open
Abstract
Angiotensin-converting enzyme inhibitors (ACEI) are widely used to treat hypertension and congestive heart failure. A rare side effect of ACEI therapy is angioedema, which in very rare cases may present as gastrointestinal angioedema (GA). A 45-year-old female presented with suddenly occurring diffuse abdominal pain. Imaging studies revealed small bowel wall edema. The patient had been on ACEI therapy for the last 6 months. The therapy was withdrawn, and the patient recovered quickly. There is no specific diagnostic test to confirm ACEI-induced GA, but symptoms usually regress completely after therapy discontinuation. An early diagnosis of ACEI-induced GA is important to avoid invasive diagnostic investigations and even laparotomy.
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Affiliation(s)
| | - Runar B Båtevik
- Department of Surgery, Sydvestjysk Sygehus, Esbjerg, Denmark
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13
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Kostis WJ, Shetty M, Chowdhury YS, Kostis JB. ACE Inhibitor-Induced Angioedema: a Review. Curr Hypertens Rep 2018; 20:55. [PMID: 29884969 DOI: 10.1007/s11906-018-0859-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW This study aims to examine current knowledge on the occurrence, pathophysiology, and treatment of angioedema among patients who receive angiotensin-converting enzyme inhibitors. RECENT FINDINGS Angiotensin-converting enzyme inhibitors (ACE-I), a medication class used by an estimated 40 million people worldwide, are associated with angioedema that occurs with incidence ranging from 0.1 to 0.7%. The widespread use of ACE-I resulted in one third of all emergency department visits for angioedema. Angioedema occurs more frequently in African Americans, smokers, women, older individuals, and those with a history of drug rash, seasonal allergies, and use of immunosuppressive therapy. The pathophysiology of ACE-I-induced angioedema involves inhibition of bradykinin and substance P degradation by ACE (kininase II) leading to vasodilator and plasma extravasation. Treatment modalities include antihistamines, steroids, and epinephrine, as well as endotracheal intubation in cases of airway compromise. Patients with a history of ACE-I-induced angioedema should not be re-challenged with this class of agents, as there is a relatively high risk of recurrence. CONCLUSION ACE-I are frequently used therapeutic agents that are associated with angioedema. Their use should be avoided in high-risk individuals and early diagnosis, tracheal intubation in cases of airway compromise, and absolute avoidance of re-challenge are important.
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Affiliation(s)
- William J Kostis
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute, 125 Paterson Street, CAB-4100, New Brunswick, NJ, 08901, USA.
| | - Mrinali Shetty
- Saint Peter's University Hospital, New Brunswick, NJ, USA
| | | | - John B Kostis
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute, 125 Paterson Street, CAB-4100, New Brunswick, NJ, 08901, USA
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Duplin E, Mangé A, McCambridge C, Gérard S, Cestac P, Didier A, Rolland Y. What are the usual causes of angioedema? Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Abstract
Angioedema, as a distinct disease entity, often becomes a clinical challenge for physicians, because it may cause a life-threatening condition, whereas prompt and accurate laboratory diagnostics may not be available. Although the bedside diagnosis needs to be established based on clinical symptoms and signs, family history, and the therapeutic response, later, laboratory tests are available. Currently, only for five out of the nine different types of angioedema can be diagnosed by laboratory testing, and these occur only in a minority of the patient population. Hereditary angioedema with C1-inhibitor (C1-INH) deficiency type I can be diagnosed by the low C1-INH function and concentration, whereas in type II, C1-INH function is low, but its concentration is normal or even elevated. C1q concentration is normal in both forms. Acquired angioedema with C1-INH deficiency type I is characterized by the low C1-INH function and concentration; however, C1q concentration is also low, and autoantibodies against C1-INH cannot be detected. Complement profile of acquired angioedema with C1-INH deficiency type II is similar to that of type I, but in this form, autoantibodies against C1-INH are present. Hereditary angioedema due to a mutation of the coagulation factor XII can be diagnosed exclusively by mutation analysis of FXII gene. Diagnostic metrics are not available for idiopathic histaminergic acquired angioedema, idiopathic non-histaminergic acquired angioedema, acquired angioedema related to angiotensin-converting enzyme inhibitor, and hereditary angioedema of unknown origin; these angioedemas can be diagnosed by medical and family history, clinical symptoms, and therapeutic response and by excluding the forms previously described. Several potential biomarkers of angioedema are used to date only in research. In the future, they could be utilized into the clinical practice to improve the differential diagnosis, therapy, as well as the prognosis of angioedema.
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Brent J, Burkhart K, Dargan P, Hatten B, Megarbane B, Palmer R, White J. Adverse Drug Reactions in the Intensive Care Unit. CRITICAL CARE TOXICOLOGY 2017. [PMCID: PMC7153447 DOI: 10.1007/978-3-319-17900-1_33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.
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Affiliation(s)
- Jeffrey Brent
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, University of Colorado, School of Medicine, Aurora, Colorado USA
| | - Keith Burkhart
- FDA, Office of New Drugs/Immediate Office, Center for Drug Evaluation and Research, Silver Spring, Maryland USA
| | - Paul Dargan
- Clinical Toxicology, St Thomas’ Hospital, Silver Spring, Maryland USA
| | - Benjamin Hatten
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Bruno Megarbane
- Medical Toxicological Intensive Care Unit, Lariboisiere Hospital, Paris-Diderot University, Paris, France
| | - Robert Palmer
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, South Australia Australia
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17
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Mahmoudpour SH, Baranova EV, Souverein PC, Asselbergs FW, de Boer A, Maitland-van der Zee AH. Determinants of angiotensin-converting enzyme inhibitor (ACEI) intolerance and angioedema in the UK Clinical Practice Research Datalink. Br J Clin Pharmacol 2016; 82:1647-1659. [PMID: 27524468 DOI: 10.1111/bcp.13090] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/27/2016] [Accepted: 08/05/2016] [Indexed: 12/24/2022] Open
Abstract
AIM The aim of the present study was to describe the occurrence and determinants of angiotensin-converting enzyme (ACE) inhibitor (ACEI) intolerance and angioedema (AE) among patients initiating ACEI therapy in a real-world primary care population. METHODS Two nested case-control studies were conducted in a cohort of 276 977 patients aged ≥45 years initiating ACEIs from 2007 to 2014 in the UK Clinical Practice Research Datalink (CPRD). Cases of AE occurring for the first time during ACEI therapy (n = 416) were matched with AE-free controls (n = 4335) on the duration of ACEI treatment. Documented switches to angiotensin-II receptor blockers in the prescription records were used to identify ACEI-intolerance cases (n = 24 709), and these were matched with continuous ACEI users (n = 84 238) on the duration of ACEI therapy. Conditional logistic regression was used to assess the associations of demographic factors, comorbidities and comedication with AE and ACEI intolerance. RESULTS AE during ACEI therapy was associated with age over 65 years [odds ratio (OR) 1.36, 95% confidence interval (CI) 1.07, 1.73], history of allergy (OR 1.53, 95% CI 1.19, 1.96), use of calcium channel blockers (OR 1.57, 95% CI 1.23; 2.01), use of antihistamines (OR 21.25, 95% CI 16.44, 27.46) and use of systemic corticosteroids (OR 4.52, 95% CI 3.26, 6.27). ACEI intolerance was significantly associated with more comorbidities and comedication compared with AE, including allergy (OR 2.02, 95% CI 1.96, 2.09), use of antiasthmatic drugs (OR 1.51, 95% CI 1.42, 1.61) and use of antihistamines (OR 1.53, 95% CI 1.43, 1.63). CONCLUSIONS Among ACEI users developing AE or ACEI intolerance, several comorbidities and comedication classes were significantly more prevalent compared with ACEI users not developing these adverse reactions.
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Affiliation(s)
- Seyed Hamidreza Mahmoudpour
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Ekaterina Vitalievna Baranova
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Patrick C Souverein
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht, The Netherlands.,Durrer Center for Cardiogenetic Research, ICIN-Netherlands Heart Institute, Utrecht, The Netherlands.,Institute of Cardiovascular Science, faculty of Population Health Sciences, University College London, London, UK
| | - Anthonius de Boer
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Anke Hilse Maitland-van der Zee
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
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18
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Erickson DL, Coop CA. Angiotensin-converting enzyme inhibitor-associated angioedema treated with c1-esterase inhibitor: A case report and review of the literature. ALLERGY & RHINOLOGY 2016; 7:168-171. [PMID: 27502825 PMCID: PMC5244275 DOI: 10.2500/ar.2016.7.0166] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Case Report: A 59-year old man currently on >5 years of angiotensin-converting enzyme inhibitor (ACEI) therapy presented to the emergency department with angioedema of the tongue and difficulty swallowing. After receiving conventional therapy of antihistamine, steroids, and epinephrine, the patient's condition continued to deteriorate, with imminent intubation. The patient was treated with a C1-esterase inhibitor (C1-INH) and experienced rapid resolution of symptoms, which avoided airway complications. Discussion: Although no therapy has been approved for the treatment of ACEI–associated angioedema (AAE), the conventional therapy (antihistamine, steroids, and epinephrine) often proves ineffective in this bradykinin-mediated angioedema. There are drugs approved and used for hereditary angioedema that may be effective in the acute phase of ACEI-AAE that may prevent the need for further interventions, such as intubation and tracheotomy. These drugs include icatibant, ecallantide, fresh frozen plasma, and C1-INH. Conclusion: The literature and clinical evidence indicate C1-INH can be effectively used in the treatment of ACEI-AAE to halt the progression of the condition, prevent airway compromise and the need for intervention, and lead to rapid resolution of symptoms.
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Affiliation(s)
- Davis Lynn Erickson
- From the Allergy and Immunology Department, San Antonio Military Medical Center, San Antonio, Texas
| | - Christopher Albert Coop
- From the Allergy and Immunology Department, San Antonio Military Medical Center, San Antonio, Texas
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19
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Kamil RJ, Jerschow E, Loftus PA, Tan M, Fried MP, Smith RV, Foster D, Ow TJ. Case-control study evaluating competing risk factors for angioedema in a high-risk population. Laryngoscope 2016; 126:1823-30. [PMID: 27426939 DOI: 10.1002/lary.25821] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 10/10/2015] [Accepted: 11/13/2015] [Indexed: 01/13/2023]
Abstract
OBJECTIVES/HYPOTHESIS Black race is a risk factor for angioedema. The primary aim was to examine the relationship between race-ethnicity and risk factors for angioedema. STUDY DESIGN Using a retrospective case-control study design, data was extracted with the Clinical Looking Glass utility, a data collection and management tool that captures data from electronic medical record systems within the Montefiore Healthcare System. Cases were emergency department (ED) visits with primary or secondary International Classification of Diseases, Ninth Revision, code diagnoses of angioedema in adults aged ≥ 18 years from January 2008 to December 2013 at three Montefiore centers in Bronx, New York. Controls were a random sampling of adult ED visits during the same period. METHODS In primary analyses, angiotensin-converting enzyme inhibitor (ACE-I) and black race were evaluated for synergy. The influence of different risk factors in the development of angioedema was evaluated using logistic regression models. Finally, race-ethnicity was further explored by evaluating for effect modification by stratification of models by race-ethnicity categories. RESULTS There were 1,247 cases and 6,500 controls randomly selected from a larger control pool. ACE-I use (odds ratio [OR] 3.70, 95% confidence interval [CI] 2.98, 4.60), hypertension (OR 1.88, 95% CI 1.55, 2.29), and black race (OR 2.25, 95% CI 1.86, 2.72) were the strongest risk factors. ACE-I use and black race were not synergistic (OR 1.10, 95% CI 0.80, 1.51). Race-ethnicity was an effect modifier for certain risk factors. CONCLUSION Race-ethnicity acts as an effect modifier for particular angioedema risk factors. The two strongest risk factors, ACE-I use and black race, were not synergistic. LEVEL OF EVIDENCE 3b. Laryngoscope, 126:1823-1830, 2016.
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Affiliation(s)
- Rebecca J Kamil
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Elina Jerschow
- Division of Allergy and Immunology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Patricia A Loftus
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Melin Tan
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Marvin P Fried
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, NY
| | - Richard V Smith
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | | | - Thomas J Ow
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A.,Department of Pathology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
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20
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Sala-Cunill A, Guilarte M. The Role of Mast Cells Mediators in Angioedema Without Wheals. CURRENT TREATMENT OPTIONS IN ALLERGY 2015. [DOI: 10.1007/s40521-015-0067-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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21
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[Acute non-allergic angioedema. Rare cause for intensive care unit admission]. Anaesthesist 2015; 64:569-73. [PMID: 26194651 DOI: 10.1007/s00101-015-0055-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 05/31/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
Abstract
Angiotensin-converting enzyme (ACE) inhibitor-induced angioedema usually follows an uneventful clinical course; however, if upper airway structures are involved, life-threatening complications may develop. Thus, affected patients should be carefully monitored in an intensive care unit and, if need be, the airway has to be secured early on. This case report discusses diagnostic and therapeutic approaches in a patient with suspected ACE inhibitor-induced angioedema, who had initially been admitted for neoadjuvant radiochemotherapy of rectal cancer.
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22
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Angiotensin II Receptor Blocker Neprilysin Inhibitor (ARNI): New Avenues in Cardiovascular Therapy. High Blood Press Cardiovasc Prev 2015; 22:241-6. [PMID: 26100410 DOI: 10.1007/s40292-015-0112-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/10/2015] [Indexed: 12/11/2022] Open
Abstract
The burden of cardiovascular disease (CVD) is continuously and progressively raising worldwide. Essential hypertension is a major driver of cardiovascular events, including coronary artery disease, myocardial infarction, ischemic stroke and congestive heart failure. This latter may represent the final common pathway of different cardiovascular diseases, and it is often mediated by progressive uncontrolled hypertension. Despite solid advantages derived from effective and sustained blood pressure control, and the widespread availability of effective antihypertensive medications, the vast majority of the more than 1 billion hypertensive patients worldwide continue to have uncontrolled hypertension. Among various factors that may be involved, the abnormal activation of neurohormonal systems is one consistent feature throughout the continuum of cardiovascular diseases. These systems may initiate biologically meaningful "injury responses". However, their sustained chronic overactivity often may induce and maintain the progression from hypertension towards congestive heart failure. The renin-angiotensin-aldosteron system, the sympathetic nervous system and the endothelin system are major neurohormonal stressor systems that are not only able to elevate blood pressure levels by retaining water and sodium, but also to play a role in the pathophysiology of cardiovascular diseases. More recently, the angiotensin receptor neprilysin inhibitor (ARNI) represents a favourable approach to inhibit neutral endopeptidase (NEP) and suppress the RAAS via blockade of the AT1 receptors, without the increased risk of angioedema. LCZ696, the first-in-class ARNI, has already demonstrated BP lowering efficacy in patients with hypertension, in particular with respect to systolic blood pressure levels, improved cardiac biomarkers, cardiac remodelling and prognosis in patients with heart failure. This manuscript will briefly overview the main pathophysiological and therapeutic aspects of ARNI in the clinical management of hypertension and heart failure.
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23
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Pucar PA, O'Sullivan M, Goudie A, Marr T, Brusch A. Successful treatment of ACE inhibitor‐induced angioedema with icatibant, a bradykinin B2 receptor antagonist. Med J Aust 2015; 202:596-7. [DOI: 10.5694/mja15.01015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 12/11/2014] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Timothy Marr
- Sir Charles Gairdner Hospital, Perth, WA
- University of Western Australia, Perth, WA
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24
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Lipski SM, Casimir G, Vanlommel M, Jeanmaire M, Dolhen P. Angiotensin-converting enzyme inhibitors-induced angioedema treated by C1 esterase inhibitor concentrate (Berinert®): about one case and review of the therapeutic arsenal. Clin Case Rep 2014; 3:126-30. [PMID: 25767713 PMCID: PMC4352369 DOI: 10.1002/ccr3.171] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/06/2014] [Accepted: 09/24/2014] [Indexed: 12/17/2022] Open
Abstract
C1 esterase inhibitor (Berinert®) is generally used to treat severe attack of hereditary angioedema. We describe here the case of a patient who presented with a severe angioedema induced by angiotensin-converting enzyme inhibitors (ACEIs) endangering her life. It could be successfully treated with that medicine.
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Affiliation(s)
- Samuel Michael Lipski
- Ear-Nose-Throat Department, Tivoli University Hospital, Free University of Brussels Brussels, Belgium
| | - Georges Casimir
- Pulmonology and Allergology Unit, University Children's Hospital Queen Fabiola, Free University of Brussels Brussels, Belgium
| | - Martine Vanlommel
- Ear-Nose-Throat Department, Tivoli University Hospital, Free University of Brussels Brussels, Belgium
| | - Mathieu Jeanmaire
- Emergency Department, Tivoli University Hospital, Free University of Brussels Brussels, Belgium
| | - Pierre Dolhen
- Ear-Nose-Throat Department, Tivoli University Hospital, Free University of Brussels Brussels, Belgium
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25
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Postanesthetic Severe Oral Angioedema in Patient's Taking Angiotensin-Converting Enzyme Inhibitor. Case Rep Anesthesiol 2014; 2014:693191. [PMID: 25431681 PMCID: PMC4241279 DOI: 10.1155/2014/693191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 10/17/2014] [Indexed: 01/08/2023] Open
Abstract
Angiotensin-converting enzyme (ACE) inhibitors are the leading cause of a drug-induced angioedema. This occurrence is frequently underdiagnosed, but its relapse can be life-threatening. The authors' intention in reporting this clinical case is to sound a warning about reviewing attitudes and surveillance to try to improve patient perioperative safety.
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Thalanayar PM, Ghobrial I, Lubin F, Karnik R, Bhasin R. Drug-induced visceral angioedema. J Community Hosp Intern Med Perspect 2014; 4:25260. [PMID: 25317271 PMCID: PMC4185149 DOI: 10.3402/jchimp.v4.25260] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 08/02/2014] [Accepted: 08/08/2014] [Indexed: 01/13/2023] Open
Abstract
Angioedema associated with angiotensin converting enzyme inhibitors (ACEIs) is due to the accumulation of bradykinin and its metabolites. Angiotensin receptor blockers (ARBs) produce anti-hypertensive effects by blocking the angiotensin II AT1 receptor action; hence bradykinin-related side effects are not expected. However, we notice the occurrence of ARB-induced angioedema as not a very rare side effect. Visceral drug-induced angioedema has been reported with ACEIs, not with ARBs. This underlying review will help educate readers on the pathophysiology and recent guidelines pertaining to ACEI- and ARB-induced visceral angioedema.
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Affiliation(s)
- Prashanth M Thalanayar
- Department of Internal Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
| | - Ibrahim Ghobrial
- Department of Internal Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
| | - Fritz Lubin
- Department of Internal Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
| | - Reena Karnik
- Department of Internal Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
| | - Robin Bhasin
- Department of Internal Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
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27
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Judge P, Haynes R, Landray MJ, Baigent C. Neprilysin inhibition in chronic kidney disease. Nephrol Dial Transplant 2014; 30:738-43. [PMID: 25140014 PMCID: PMC4425478 DOI: 10.1093/ndt/gfu269] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 07/20/2014] [Indexed: 02/04/2023] Open
Abstract
Despite current practice, patients with chronic kidney disease (CKD) are at increased risk of progression to end-stage renal disease and cardiovascular events. Neprilysin inhibition (NEPi) is a new therapeutic strategy with potential to improve outcomes for patients with CKD. NEPi enhances the activity of natriuretic peptide systems leading to natriuresis, diuresis and inhibition of the renin–angiotensin system (RAS), which could act as a potentially beneficial counter-regulatory system in states of RAS activation such as chronic heart failure (HF) and CKD. Early NEPi drugs were combined with angiotensin-converting enzyme inhibitors but were associated with unacceptable rates of angioedema and, therefore, withdrawn. However, one such agent (omapatrilat) showed promise of NEP/RAS inhibition in treating CKD in animal models, producing greater reductions in proteinuria, glomerulosclerosis and tubulointerstitial fibrosis compared with isolated RAS inhibition. A new class of drug called angiotensin receptor neprilysin inhibitor (ARNi) has been developed. One such drug, LCZ696, has shown substantial benefits in trials in hypertension and HF. In CKD, HF is common due to a range of mechanisms including hypertension and structural heart disease (including left ventricular hypertrophy), suggesting that ARNi could benefit patients with CKD by both retarding the progression of CKD (hence delaying the need for renal replacement therapy) and reducing the risk of cardiovascular disease. LCZ696 is now being studied in a CKD population.
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Affiliation(s)
- Parminder Judge
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
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28
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Wadelius M, Marshall SE, Islander G, Nordang L, Karawajczyk M, Yue QY, Terreehorst I, Baranova EV, Hugosson S, Sköldefors K, Pirmohamed M, Maitland-van der Zee AH, Alfirevic A, Hallberg P, Palmer CNA. Phenotype standardization of angioedema in the head and neck region caused by agents acting on the angiotensin system. Clin Pharmacol Ther 2014; 96:477-81. [PMID: 24960520 PMCID: PMC4172548 DOI: 10.1038/clpt.2014.138] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/18/2014] [Indexed: 11/10/2022]
Abstract
Angioedema is a potentially life-threatening adverse reaction to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. To study the genetic etiology of this rare adverse event, international consortia and multicenter recruitment of patients are needed. To reduce patient heterogeneity, we have standardized the phenotype. In brief, it comprises swelling in the head and neck region that first occurs during treatment. It should not coincide with urticaria or have another likely cause such as hereditary angioedema.
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Affiliation(s)
- M Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - S E Marshall
- Medical Research Institute, College of Medicine, Dentistry and Nursing, University of Dundee, Ninewells Hospital, Dundee, UK
| | - G Islander
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | - L Nordang
- Department of Surgical Sciences, Otorhinolaryngology, and Head & Neck Surgery, Uppsala University, Uppsala, Sweden
| | - M Karawajczyk
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Q-Y Yue
- Medical Products Agency, Uppsala, Sweden
| | - I Terreehorst
- Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands
| | - E V Baranova
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - S Hugosson
- Department of Otorhinolaryngology, Örebro University Hospital and Örebro University, Örebro, Sweden
| | - K Sköldefors
- Department of Otorhinolaryngology, Hudiksvall Hospital, Hudiksvall, Sweden
| | - M Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - A-H Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - A Alfirevic
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - P Hallberg
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - C N A Palmer
- Medical Research Institute, College of Medicine, Dentistry and Nursing, University of Dundee, Ninewells Hospital, Dundee, UK
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Abstract
Much has been written about hereditary angioedema (HAE) in recent literature; however, the prevalence of angiotensin-converting enzyme inhibitor-induced angioedema (ACEiIA) far exceeds that of HAE. Similarly, multiple therapies have been developed for HAE, yet no definitive therapy is available for ACEiIA. In this article, we discuss the mechanism, prevalence, pathophysiology, and management of ACEiIA, with focus on newer therapies recently approved for HAE and how they may be effective for ACEiIA.
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30
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IgE-Mediated Anaphylaxis to Foods, Venom, and Drugs: Influence of Serum Angiotensin Converting Enzyme Levels and Genotype. J Allergy (Cairo) 2012; 2012:258145. [PMID: 23316249 PMCID: PMC3536050 DOI: 10.1155/2012/258145] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 10/21/2012] [Accepted: 10/22/2012] [Indexed: 11/17/2022] Open
Abstract
Circulating angiotensin-II protects the circulation against sudden falls in blood pressure and is generated by the enzymatic action of angiotensin converting enzyme (ACE) on angiotensin-I. The ACE genes have 2 allelic forms, “I” and “D.” The “D” genotype has both highest angiotensin-II generation and serum ACE levels compared to “I”.
120 patients with IgE-anaphylaxis, 119 healthy controls, and 49 atopics had serum ACE levels, ACE genotype, and renin levels determined.
Plasma renin levels were identical for all groups.
Serum ACE levels and genotypes were similar for healthy controls (HC) and atopics, but lower in anaphylaxis (P = 0.012), with ACE genotypes also showing increased “I” genes (P = 0.009). This effect was more pronounced in subjects manifesting airway angioedema and cardiovascular collapse (AACVS) than mild cutaneous and respiratory (CRA) symptoms. AACVS was significantly associated with the presence of “I” genes. For “ID” genotype OR is 5.6, 95% CI 1.8 to 17.4, and for “II” genotype OR is 44, 95% CI 5 to 1891 within the anaphylaxis group = 0.001.
The results show a difference in the genotype frequency between control and anaphylaxis, suggesting a role for the renin angiotensin system in anaphylaxis manifesting with airway angioedema and cardiovascular collapse.
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Mangiafico S, Costello-Boerrigter LC, Andersen IA, Cataliotti A, Burnett JC. Neutral endopeptidase inhibition and the natriuretic peptide system: an evolving strategy in cardiovascular therapeutics. Eur Heart J 2012; 34:886-893c. [PMID: 22942338 DOI: 10.1093/eurheartj/ehs262] [Citation(s) in RCA: 184] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hypertension and heart failure (HF) are common diseases that, despite advances in medical therapy, continue to be associated with high morbidity and mortality. Therefore, innovative therapeutic strategies are needed. Inhibition of the neutral endopeptidase (NEPinh) had been investigated as a potential novel therapeutic approach because of its ability to increase the plasma concentrations of the natriuretic peptides (NPs). Indeed, the NPs have potent natriuretic and vasodilator properties, inhibit the activity of the renin-angiotensin-aldosterone system, lower sympathetic drive, and have antiproliferative and antihypertrophic effects. Such potentially beneficial effects can be theoretically achieved by the use of NEPinh. However, studies have shown that NEPinh alone does not result in clinically meaningful blood pressure-lowering actions. More recently, NEPinh has been used in combination with other cardiovascular agents, such as angiotensin-converting enzyme inhibitors, and antagonists of the angiotensin receptor. Another future possible combination would be the use of NEPinh with NPs or their newly developed chimeric peptides. This review summarizes the current knowledge of the use and effects of NEPinh alone or in combination with other therapeutic agents for the treatment of human cardiovascular disease such as HF and hypertension.
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Affiliation(s)
- Sarah Mangiafico
- Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Mayo Clinic and Mayo Clinic College of Medicine, Guggenheim 9, 200 First Street SW, Rochester, MN 55901, USA
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32
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Tadevosyan A, MacLaughlin EJ, Karamyan VT. Angiotensin II type 1 receptor antagonists in the treatment of hypertension in elderly patients: focus on patient outcomes. Patient Relat Outcome Meas 2011; 2:27-39. [PMID: 22915967 PMCID: PMC3417921 DOI: 10.2147/prom.s8384] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Indexed: 12/18/2022] Open
Abstract
Hypertension in the elderly is one of the main risk factors of cardiovascular and cerebrovascular diseases. Knowledge regarding the mechanisms of hypertension and specific considerations in managing hypertensive elderly through pharmacological intervention(s) is fundamental to improving clinical outcomes. Recent clinical studies in the elderly have provided evidence that angiotensin II type 1 (AT(1)) receptor antagonists can improve clinical outcomes to a similar or, in certain populations, an even greater extent than other classical arterial blood pressure-lowering agents. This newer class of antihypertensive agents presents several benefits, including potential for improved adherence, excellent tolerability profile with minimal first-dose hypotension, and a low incidence of adverse effects. Thus, AT(1) receptor antagonists represent an appropriate option for many elderly patients with hypertension, type 2 diabetes, heart failure, and/or left ventricular dysfunction.
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Affiliation(s)
- Artavazd Tadevosyan
- Departments of Medicine, Montreal Heart Institute and Université de Montréal, Montreal, QC, Canada
| | | | - Vardan T Karamyan
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
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33
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Bluestein HM, Hoover TA, Banerji AS, Camargo CA, Reshef A, Herscu P. Angiotensin-converting enzyme inhibitor-induced angioedema in a community hospital emergency department. Ann Allergy Asthma Immunol 2010; 103:502-7. [PMID: 20084844 DOI: 10.1016/s1081-1206(10)60267-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACE-Is) are associated with angioedema, a potentially life-threatening adverse reaction. Although multiple studies have been conducted in tertiary care emergency departments (EDs), scarce data are available about the presentation and management of ACE-I-induced angioedema (AIIA) in the community hospital ED. OBJECTIVE To describe the frequency, presentation, and management of AIIA in patients seen in a community hospital ED. METHODS A 5-year medical record review of all patients seen with angioedema at a community hospital ED. Data abstraction focused on demographic factors, initial clinical characteristics, and ED management and disposition of patients with AIIA. RESULTS We identified 166 ED visits for angioedema, including a subset of 50 visits for AIIA (30%; 95% confidence interval, 23%-38%). The AIIA was significantly more likely to be associated with an age of 65 years or older (P = .02), unilateral symptoms (P = .02), and absence of urticaria or itching (P < .001). The ED treatment choices and admission rates were similar between patients with and without AIIA. Community hospital admission rates for AIIA (14%) were significantly lower than those from a comparable tertiary care study (41%) (P = .003); ambulance transport to the ED was nearly 3-fold higher in the tertiary care center study (P = .006). Admission was most strongly related to lack of improvement (P < .001) and history of angioedema in AIIA (P = .009). CONCLUSIONS Angioedema frequency, presentation, and management are similar in community and tertiary care EDs (30%). Urticaria or itching may help differentiate AIIA from allergic reactions, which are otherwise similar in community ED presentation and management.
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Affiliation(s)
- Hazel M Bluestein
- Montgomery Family Practice Residency Program, Montgomery Hospital Medical Center, Norristown, Pennsylvania, USA
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