Losartan-induced angioedema

Angiotensin II receptor blocker-induced angioedema in the oral floor and epiglottis

We report the rare case of angioedema (also known as Quincke edema), which was induced by valsartan, an angiotensin II receptor blocker (ARB). ARBs are a new class of antihypertensive agent that is developed to exclude the adverse effects of angiotensin-converting enzyme inhibitors. In theory, ARBs do not contribute to the occurrence of angioedema because they do not increase the serum level of bradykinin, the responsible substance for angioedema. However, some reports of ARB-induced angioedema have recently been published. In this study, we present the forth case and the first Asian case of angioedema due to valsartan, which is one of the ARBs. Otolaryngologist should be wary of the prescribing ARB and discontinue ARBs treatment soon, if angioedema is recognized.

Acute urticaria and angioedema: diagnostic and treatment considerations

Urticaria is defined as wheals consisting of three features: (i) central swelling of various sizes, with or without surrounding erythema; (ii) pruritus or occasional burning sensations; and (iii) the skin returning to normal appearance, usually within 1-24 hours. Angioedema is defined as: (i) abrupt swelling of the lower dermis and subcutis; (ii) occasional pain instead of pruritus; (iii) commonly involving the mucous membranes; and (iv) skin returning to normal appearance, usually within 72 hours. Acute urticaria and angioedema is defined by its duration (<6 weeks) compared with chronic urticaria and angioedema. The most common causes are infections, medications, and foods. The best tools in the evaluation of these patients are a comprehensive history and physical examination. There are a variety of skin conditions that may mimic acute urticaria and angioedema and the various reaction patterns associated with different drugs. Oral antihistamines are first-line treatment. In the event of a life-threatening reaction involving urticaria with angioedema, epinephrine may be needed to stabilize the patient. This review focuses on the value of a comprehensive clinical evaluation at the onset of symptoms. It underscores the importance of coordination of care among physicians, and the development of an action plan for evidence-based investigations, diagnosis, and therapy.

Perioral Angioedema Associated With Angiotensin-Converting Enzyme Inhibitor

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).

Angioneurotic edema of the upper airways and antihypertensive therapy

Angioneurotic edema is a non-pitting edema which is usually limited to the skin and the mucous membranes of the face and upper aerodigestive tract. The risk of acute upper airway obstruction makes angioneurotic edema a concern for emergency room physicians, internists and otolaryngologists because prompt recognition of the condition and immediate institution of therapy is essential for proper airway management. Angiotensin-converting enzyme (ACE) inhibitors have recently been associated with angioneurotic edema, the probable link being the reduction in angiotensin II and the potentiation of bradykinin, resulting in vasodilatation, increased vascular permeability and angioedema. We report four cases of acquired angioneurotic edema, which were probably related to ACE inhibitor use. These cases are discussed, including a review of the literature, methods of diagnosis, pathophysiology and treatment of angioedema. Care should be taken when antihypertensive ACE inhibitor treatments are started and patients should be warned of the potential risk of angioneurotic edema.

Valsartan-induced angioedema

OBJECTIVE

To report a case of dose-dependent angioedema secondary to the use of the angiotensin-receptor blocker (ARB) valsartan.

CASE SUMMARY

A 64-year-old Hispanic woman presented with swelling of the lips shortly after an increase in her valsartan dose for uncontrolled hypertension. Other potential causes were not identified. The angioedema subsequently resided after a dosage reduction and observation. Use of the Naranjo probability scale indicated a probable relationship between the angioedema and valsartan therapy in this patient.

DISCUSSION

Drug-induced angioedema is often associated with the use of angiotensin-converting enzyme (ACE) inhibitors and is probably secondary to their effects on bradykinin levels. ARBs are thought to produce few, if any, cases of angioedema if excess bradykinin levels are the root cause of angioedema secondary to ACE inhibitor use. Several potential ARB-induced cases of angioedema have been reported. The exact mechanism of angioedema induced by drugs in both of these classes is unknown. Animal data suggest that there may be a relationship between ARB use and increased tissue bradykinin levels secondary to stimulation of angiotensin II AT2 receptors.

CONCLUSIONS

This is the third reported case of valsartan-induced angioedema and the first thought to be dose dependent. Practitioners should be aware of this potential adverse effect of valsartan, although the underlying cause is still not known.

Angioedema in heart failure: occurrence with ACE inhibitors and safety of angiotensin receptor blocker therapy

Angioedema is a well-known side effect of treatment with an angiotensin-converting enzyme (ACE) inhibitor and one that we have been willing to accept in view of the incidence of the problem and the clear benefits of this class of agents in numerous clinical situations. Angioedema is also seen with angiotensin receptor blocker (ARB) therapy but much less frequently than with ACE inhibitors. The mechanism for angioedema with ARB therapy remains poorly defined. ACE inhibitor-related angioedema occurs more commonly in black patients. The basis for an increased risk of angioedema in black patients remains unclear. Angioedema can be life-threatening but more times than not it can be managed with conservative treatment measures including specifically the discontinuation of the medication and/or administration of an antihistamine and/or epinephrine. Occasionally, maneuvers to protect the integrity of the airway may be needed. In a heart failure patient having previously experienced ACE inhibitor-related angioedema, ARBs should be used cautiously since angioedema has been reported with ARB therapy in heart failure patients. The need to reduce renin-angiotensin aldosterone system activity in a heart failure patient would seem to justify the small risk of angioedema with ARB therapy in a patient having previously experienced ACE inhibitor-related angioedema.

Angioedema associated with candesartan

Most large clinical trials report that the frequency of angioedema caused by angiotensin-converting enzyme (ACE) inhibitors is 0.1-0.2%. The most common theory for this rare but potentially fatal adverse drug reaction cites ACE inhibitor-mediated accumulation of bradykinin as the culprit. Because angiotensin II receptor blockers (ARBs) do not exert their effects on ACE, they are not expected to cause bradykinin accumulation and therefore angioedema. Recently, several cases of angioedema related to the administration of ARBs have been documented in the literature. The existence of ARB-induced angioedema suggests that additional or alternate mechanisms not involving bradykinin are present in drug-induced angioedema. While taking candesartan for hypertension, a 53-year-old woman with known ACE inhibitor intolerance developed angioedema. During her hospitalization, candesartan was stopped and immunosuppressive therapy was administered. Within 24 hours, the angioedema had resolved completely and the patient was discharged. In light of the recent literature on ARB-induced angioedema, ACE inhibitor-intolerant patients who begin ARB therapy should receive appropriate counseling and be monitored closely for this adverse reaction.

Current concepts of pharmacotherapy in hypertension: ACE inhibitor-related angioedema: can angiotensin-receptor blockers be safely used?

Angioedema is a well-recognized side effect of angiotensin-converting enzyme (ACE) inhibitor therapy. Angioedema can also be seen with angiotensin receptor blocker therapy but much less frequently than is the case with ACE inhibitors. For unclear reasons, ACE inhibitor-related angioedema occurs more commonly in black patients. Angioedema can be life threatening but more times than not its occurrence can be managed with conservative treatment measures including discontinuation of the medication and/or administration of an antihistamine. Occasionally, epinephrine and/or steroid therapy may be warranted. In a patient having experienced ACE inhibitor-related angioedema, angiotensin receptor blockers should be used cautiously if at all. If angiotensin receptor blocker therapy is being considered in a patient with prior ACE inhibitor-related angioedema there should be some justification for the use. Such justification might include the presence of heart failure or proteinuric nephropathic states among other considerations.

Drug-induced angioedema without urticaria

Angioedema without urticaria is a clinical syndrome characterised by self-limiting local swellings involving the deeper cutaneous and mucosa tissue layers. Most occurrences of angioedema respond to treatment with a histamine H1 receptor blocker (antihistamine) because they are an allergic or parallergic reaction. A small number of cases do not respond to antihistamine treatment. Such cases tend to occur in patients with deficiency or dysfunction of the inhibitor of the first component of the complement (C1-INH), but more rarely can occur in patients with other conditions and as an adverse drug reaction. Angioedema is well documented in patients taking ACE inhibitors. Considering that 35 to 40 million patients are treated worldwide with ACE inhibitors, this drug class could account for several hundred deaths per year from laryngeal oedema. ACE inhibitors certainly do not mediate angioedema through an allergic or idiosyncratic reaction. For this reason the relationship with this drug is often missed and consequently quite underestimated. Rare instances of angioedema have also been reported with angiotensin II receptor antagonists. This adverse effect seems to occur less frequently with angiotensin II receptor antagonists than with ACE inhibitors. However, we do not know whether this adverse effect has the same mechanism with the 2 classes of medications. Some cases of severe angioedema have been recently reported after treatment with fibrinolytic agents. Scattered reports suggest the possibility of angioedema associated with the use of estrogens, antihypertensive drugs other than ACE inhibitors, and psychotropic drugs. Angioedema can also occur with nonsteroidal anti-inflammatory drugs. Prevention of angioedema relies first on the patient history. Estrogen and ACE inhibitors should be avoided in a patient with congenital or acquired C1-INH deficiency. In the case of ACE inhibitors, the appearance of angioedema following long term treatment does not lessen the probability that such an agent could be the cause. The most important action to take in a patient with suspected drug-induced angioedema is to discontinue the pharmacological agent. Epinephrine (adrenaline), diphenydramine and intravenous methylprednisolone have been proposed for the medical management of airway obstruction, but so far no controlled studies have demonstrated their efficacy. If the acute airway obstruction leads to life-threatening respiratory compromise an emergency cricothyroidotomy must be performed.

Drug-induced urticaria. Recognition and treatment

Urticaria is the second most common cutaneous manifestation of drug allergy. Drug-induced urticaria is seen in 0.16% of medical inpatients and accounts for 9% of chronic urticaria or angioedema seen in dermatology outpatient departments. Occurring within 24 hours of drug ingestion, it is most commonly caused by penicillins, sulfonamides and nonsteroidal anti-inflammatory drugs. Drug-induced urticaria is seen in association with anaphylaxis, angioedema, and serum sickness. Diagnosis requires a detailed history, knowledge of the most likely agents sometimes supplemented with in vitro and skin testing. For mild reactions, avoidance of the causative drug and treatment with antihistamines will suffice. For anaphylactic shock, treatment with epinephrine (adrenaline), corticosteroids and antihistamines is required. Patients should be educated to inform medical staff about previous drug reactions, and to avoid these and cross-reacting drugs if possible. Medical staff need to routinely enquire about allergy and avoid unnecessary prescriptions.

Angiotensin II receptor blockers for the treatment of hypertension

The rising incidence of stroke, congestive heart failure (CHF) and end stage renal disease (ESRD) has signalled a need to increase awareness, treatment and control of hypertension. There continues to be a need for effective antihypertensive medications since hypertension is a major precursor to various forms of cardiovascular disease. The renin-angiotensin (AT) aldosterone system (RAAS) is a key component to the development of hypertension and can be one target of drug therapy. Angotensin II (ATII) receptor blockers (ARBs) are the most recent class of agents available to treat hypertension, which work by by inhibiting ATII at the receptor level. Currently, national consensus guidelines recommend that ARBs should be reserved for hypertensive patients who cannot tolerate angiotensin converting enzyme (ACE) inhibitors (ACEIs). ARBs, however, are moving to the forefront of therapy with a promising role in the area of renoprotection and CHF. Recent trials such as the The Renoprotective Effect of the Angiotensin-Receptor Antagonist Irbesartan in Patients with Nephropathy Due to Type 2 Diabetes Trial (IDNT), the Effect of Irbesartan on the Development of Diabetic Nephropathy in Patients with Type 2 Diabetes (IRMA2), and The Effects of Losartan on Renal and Cardiovascular Outcomes in Patients with Type 2 Diabetes and Nephropathy (RENAAL) study have demonstrated the renoprotective effects of ARBs in patients with Type 2 diabetes. The Valsartan Heart Failure Trial (Val-HeFT) adds to the growing body of evidence that ARBs may improve morbidity and mortality in CHF patients. As a class, ARBs are well tolerated and have a lower incidence of cough and angioedema compared to ACEIs. This article reviews the differences among the ARBs, existing efficacy data in hypertension, and explores the role of ARBs in CHF and renal disease.

New competition in the realm of renin-angiotensin axis inhibition; the angiotensin II receptor antagonists in congestive heart failure

OBJECTIVE

To critically review the studies comparing angiotensin II (AgII) receptor antagonists with placebo or angiotensin-converting enzyme (ACE) inhibitors in patients with congestive heart failure (CHF).

DATA SOURCES

A MEDLINE search (1988 to January 2000) was used to identify pertinent literature. Additional references were also retrieved from selected articles.

STUDY SELECTION

As most published CHF studies were performed with candesartan and losartan, these agents are the main focus of this article. However, all identified comparative clinical studies were reviewed and included, regardless of the agent used.

DATA SYNTHESIS

AgII receptor antagonists inhibit the effects of AgII at its sub-type 1 receptor, independently of AgII's synthesis pathway. They present a hemodynamic profile similar to that of ACE inhibitors, without reflex neurohormonal activation. They have been shown to be at least as effective as ACE inhibitors in improving symptoms, exercise capacity, and New York Heart Association functional class in CHF patients. Although the ELITE (Evaluation of Losartan in the Elderly) trial suggested that losartan improved survival compared with captopril, this study was not designed to look at mortality. ELITE-II, an adequately powered study, showed no difference in mortality rates between patients taking captopril and those taking losartan. The combination of AgII receptor antagonists and ACE inhibitors provides additional benefit on blood pressure lowering and prevention of ventricular remodeling. AgII receptor antagonists are well tolerated, with an incidence of adverse effects similar to or lower than that of ACE inhibitors. Their lack of effect on bradykinin degradation might explain their lower incidence of cough.

CONCLUSIONS

The data cumulated thus far in patients with CHF highlight that ACE inhibitors must remain the treatment of choice and that AgII receptor antagonists may be considered as an acceptable alternative for patients who are intolerant to ACE inhibitors.

Angiotensin II receptor blockers in patients with ACE inhibitor-induced angioedema

OBJECTIVE

To determine the safety of using angiotensin II receptor blockers in patients who have experienced angioedema following treatment with angiotensin-converting enzyme (ACE) inhibitors.

DATA SOURCES

Clinical literature identified through MEDLINE (January 1966-August 1999). Key search terms included angioneurotic edema, angiotensin-converting enzyme inhibitors, receptors-angiotensin, and losartan.

DATA SYNTHESIS

ACE inhibitor-induced angioedema occurs with an incidence of 0.1-0.5%. Alternative therapy is necessary for patients who experience this potentially life-threatening adverse effect. Since angiotensin II receptor blockers do not increase concentrations of bradykinin, the proposed mechanism of ACE inhibitor-induced angioedema, they were presumed to be safe alternatives. Recent case reports, however, document angioedema following therapy with angiotensin II receptor blockers; 32% of the reported patients experienced a prior episode of angioedema attributed to ACE inhibitor therapy.

CONCLUSIONS

Until the exact cause of both ACE inhibitor- and angiotensin II receptor blocker-induced angioedema is determined, angiotensin II receptor blockers should be used with extreme caution in patients with a prior history of angioedema.