Angioedema associated with aspirin and rofecoxib

Angioedema without urticaria after recent initiation of celecoxib

Angioedema is potentially life-threating swelling of integument and mucosa that has multiple potential aetiologies with varying mechanisms. Drug-induced angioedema is often easily correlated with the offending agent and can be prevented with discontinuation of the medication. Many medications have now been implicated in drug-induced angioedema but the two most common are ACE inhibitors and non-steroidal anti-inflammatory drugs (NSAIDs). This case highlights severe angioedema secondary to celecoxib and reviews varying aetiologies of angioedema and NSAID hypersensitivity reactions.

Mirabegron Associated Angioedema: A Case Report

Purpose: To review a case of angioedema associated with mirabegron. Summary: A 77-year-old woman presented to the emergency department with swelling of the left anterior side of the tongue beginning 90 minutes prior to arrival. She noticed tingling on her tongue while eating a hamburger, chips, and ice cream. The patient had no history of medication-related allergies. Home medications include acetaminophen, aspirin, biotin, black cohosh, Co-enzyme Q-10, cranberry, fish oil, multivitamin, alendronate, and mirabegron all taken orally. The patient reports being on mirabegron for 3 to 4 years but recently decided to self-taper off the medication. Her initial laboratory test results were unremarkable. The patient was diagnosed with left tongue angioedema, and she received methylprednisolone, epinephrine, famotidine, and 2 units of plasma. After medication administration, the patient underwent a flexible nasopharyngeal laryngoscopy resulting in no significant angioedema in the pharynx and hypopharynx with a small area of possible edema noted on the right base of tongue/lingual tonsil. Patient's symptoms improved with medication treatment and discontinuation of mirabegron. The use of Naranjo et al. adverse-event probability scale revealed that mirabegron was the possible (score of 4) cause of the patient's left tongue angioedema. Conclusion: A 77-year-old woman developed drug induced tongue angioedema associated with mirabegron after being compliant on this medication for 3 to 4 years. Patient was self-tapering her dose of mirabegron. This patient responded well to medication treatment and discontinuation of drug. To our knowledge, this is the second case report of mirabegron induced angioedema.

591 A Case of Idiopathic Recurrent Isolated Orbital Angioedema with Exophthalmos

Background

Idiopathic angioedema is a term applied to recurrent episodes of angioedema of unknown etiology. The following is a case report of idiopathic recurrent isolated orbital angioedema with exophthalmos which responds to prolonged courses of oral corticosteroids.

Methods

A 67 year old Caucasian female with aspirin exacerbated respiratory disease (AERD) sought treatment for an acute, progressive painless left eye swelling with exophthalmos without visual deficits or urticaria. High dose corticosteroids were initiated followed by a low maintenance dose. The swelling subsided after one year of corticosteroid therapy.

Ten years later, orbital swelling with exophthalmos returned in the same eye. No medications, such as aspirin1 or non steroidal anti-inflammatory drugs,2 were associated with the swelling. A CT of the orbits revealed an isolated proptosis with swelling of the medial and inferior rectus muscles and mild hypertrophy and swelling of the left lacrimal gland. A complete history and physical examination were negative. The family history likewise was negative.

Results

High-dose systemic glucocorticoid therapy was initiated. Symptoms resolved after 1 month of tapered corticosteroid therapy, however, swelling reoccurred in the orbit within one week. Low dose maintenance corticosteroids were reinitiated with resolution of the orbital swelling. Work-up for acquired C1 esterase deficiency is negative.

Conclusions

An atypical case of recurrent idiopathic isolated orbital angioedema with exophthalmos in a patient with AERD and no triggering factor, systemic findings and a negative evaluation is presented.

Tolerance to coxibs in patients with intolerance to non-steroidal anti-inflammatory drugs (NSAIDs): a systematic structured review of the literature

Adverse events triggered by non-steroidal anti-inflammatory drugs (NSAIDs) are among the most common drug-related intolerance reactions in medicine; they are possibly related to inhibition of cyclooxygenase-1. Coxibs, preferentially inhibiting cyclooxygenase-2, may therefore represent safe alternatives in patients with NSAID intolerance. We reviewed the literature in a systematic and structured manner to identify and evaluate studies on the tolerance of coxibs in patients with NSAID intolerance. We searched MEDLINE (1966–2006), the COCHRANE LIBRARY (4th Issue 2006) and EMBASE (1966–2006) up to December 9, 2006, and analysed all publications included using a predefined evaluation sheet. Symptoms and severity of adverse events to coxibs were analysed based on all articles comprising such information. Subsequently, the probability for adverse events triggered by coxibs was determined on analyses of double-blind prospective trials only. Among 3,304 patients with NSAID intolerance, 119 adverse events occurred under coxib medication. All adverse events, except two, have been allergic/urticarial in nature; none was lethal, but two were graded as life-threatening (grade 4). The two non-allergic adverse events were described as a grade 1 upper respiratory tract haemorrhage, and a grade 1 gastrointestinal symptom, respectively. In 13 double-blind prospective studies comprising a total of 591 patients with NSAID intolerance, only 13 adverse reactions to coxib provocations were observed. The triggering coxibs were rofecoxib (2/286), celecoxib (6/208), etoricoxib (4/56), and valdecoxib (1/41). This review documents the good tolerability of coxibs in patients with NSAID intolerance, for whom access to this class of drugs for short-term treatment of pain and inflammation is advantageous.

Risk of hospitalization for angio-oedema among users of newer COX-2 selective inhibitors and other nonsteroidal anti-inflammatory drugs

AIM

To examine the risk of angio-oedema among users of the newer cyclooxygenase (COX)-2 selective inhibitors celecoxib and rofecoxib and other non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) in a population-based case-control study.

METHODS

Cases of angio-oedema were identified from hospital discharge registries from three Danish counties between 1 January 2000 and 31 December 2003 (n = 377) and 10 matched population controls per case were selected from the Civil Registration System (n = 3747). Data on newer COX-2 selective inhibitor and other NSAID use (current and former) were obtained from prescription databases. Data on potential confounding factors were also collected. Conditional logistic regression was used to compute relative risks for angio-oedema according to drug exposure.

RESULTS

The crude relative risks for the newer COX-2 selective inhibitors were higher than those for other NSAIDs. After adjustment for confounding, the relative risk for current use of newer COX-2 selective inhibitors was 0.96 [95% confidence interval (CI) 0.46, 2.03], whereas the risk for other NSAIDs was 1.77 (95% CI 1.23, 2.58).

CONCLUSION

Our data support the hypothesis that newer COX-2 selective inhibitors are safe in relation to angio-oedema. However, given other current health concerns related to these drugs, their use should continue to be carefully monitored.