Increased bronchial reactivity and potentiated skin responses in hypertensive subjects suffering from coughs during ACE-inhibitor therapy

Exploring the relationship between plasma substance P and glottal incompetence in the elderly

We speculated that increased blood-plasma levels of Substance P may serve as an indicator of glottal incompetence, which is usually indicated by reduced maximum phonation time. We performed an initial study to test the plausibility of this hypothesis. Patients with dysphonia caused by glottal incompetence were asked to perform vocal exercises for six months to reduce glottal incompetence and we compared the plasma concentration of Substance P before and after the vocal exercise to detect correlation between maximum phonation time and plasma concentration of Substance P. Based on the results, we further hypothesized that patients exhibiting dysphonia with maximum phonation time less than 14 s, in particular less than 10 sec, caused by glottal incompetence may have increased plasma concentration of Substance P with the results of elevated thresholds of cough reflex associated with subclinical aspiration in airways. Further study is needed on patients with decreased Substance P levels, with low scores on Activities of Daily Living and who are hospitalized with aspiration pneumonia.

The immunomodulatory effects of antihypertensive therapy: A review

Hypertension remains the leading preventable risk factor for stroke and coronary artery disease, significantly contributing to all-cause global mortality and predisposing patients to renal and heart failure, as well as peripheral vascular disease. Due to the widespread usage of antihypertensive drugs, global mean blood pressure has remained unchanged or even slightly decreased over the past four decades. However, considering the broad spectrum of mechanisms involved in the action of antihypertensive drugs and the prevalence of their target receptors on immune cells, possible immunomodulatory effects which may exert beneficial effects of lowering blood pressure but also potentially alter immune function should be considered. In this review, we attempt to assess the consequences to immune system function of administering the five most commonly prescribed groups of antihypertensive drugs and to explain the mechanisms behind those interactions. Finally, we show potential gaps in our understanding of the effects of antihypertensive drugs on patient health. With regard to the widespread use of these drugs in the adult population worldwide, the discussed results may be of vital importance to evidence-based decision-making in daily clinical practice.

Psoriatic erythroderma associated with enalapril

A 59-year-old man with a 35-year personal and positive family history of psoriasis was admitted to our department for treatment of psoriatic erythroderma. The patient had commenced therapy with enalapril 10 mg b.i.d. for the treatment of hypertension approximately 6 weeks before hospitalization. Five weeks after the initiation of enalapril, his psoriasis began to flare, and for a period of about 1 week it reached the extent of erythroderma. The patient did not associate the psoriatic flare with other factors such as infections, trauma, or stress. The patient presented with diffuse erythema and pronounced desquamation covering his entire trunk, scalp, and extremities (Figure). Nearly 100% of the body surface area was involved. The palms and soles were also affected, displaying erythema, hyperkeratosis, and painful fissures. The nails showed pits, oil spots, and subungual hyperkeratosis. The patient also had psoriatic arthritis affecting the interphalangeal joints of his fingers. Laboratory tests revealed an elevated erythrocyte sedimentation rate, an elevated creatinine level of 180 mmol/L, a blood urea nitrogen level of 10.8 mmol/L, and a uric acid level of 716 mmol/L. Urinalysis showed proteinuria of 1.5 g/24 h. The patient's renal condition was diagnosed as chronic tubulointerstitial nephritis, most probably related to his dermatologic disease. Allopurinol and dietary measures were recommended. Following treatment with methotrexate and replacement of enalapril therapy, the erythema and scaling gradually subsided and became confined to his pre-eruptive chronic plaques (approximately 5% of body surface area). Rechallenge with enalapril was not performed.

Captopril-induced bilateral parotid and submandibular sialadenitis

Two cases of sialadenitis following treatment with captopril are described. In case 1, an upper chest and facial erythema and dryness of the mouth accompanied the swelling of the salivary glands. In case 2, a conjunctival erythema accompanied the sialadenitis. None of the patients had previously used captopril, and, in both cases, the swelling occurred within the first hour after the drug intake; the patients had a complete recovery within a few hours after captopril was withdrawn. It is possible that the reported effect was caused by a type-B idiosyncratic adverse drug reaction.

Patients with congestive heart failure and their conceptions of their sleep situation

AIM

To describe, from a nursing perspective, how patients with CHF conceived their sleep situation.

BACKGROUND

Sleep disturbances are very common in patients with congestive heart failure (CHF). Polysomnographic studies have shown that the total duration of sleep is shorter and the sleep structure disturbed, with frequent arousals and sleep stage changes.

METHODS

A qualitative descriptive design inspired by a phenomenographic approach was employed. Conceptions were collected through interviews with 20 strategically chosen CHF patients.

FINDINGS

The findings showed that the patients' sleep was affected by their daily activities, the disease itself and cardiac symptoms. The sleep disturbances gave effects such as fatigue, listlessness, loss of concentration and loss of temper. These effects led to a need for daytime sleep, seclusion, counselling and information. Patients handled their sleep disturbances through coping mechanisms related to developed patterns of daily life and through support from their psychosocial environment.

CONCLUSIONS

Through an increased awareness of the causes of sleep disturbances in CHF patients, nurses can more effectively meet their caring needs and reduce the psychological stressors that patients develop. Information and education, both to patients and the next of kin, about the disease and the sleep situation, especially good sleeping habits, can help patients to better cope with sleep disturbances.

Intermediate but not low doses of aspirin can suppress angiotensin-converting enzyme inhibitor-induced cough

This self-matched control study aimed to compare the efficiency of two different regimens of active treatment: aspirin in low (100 mg daily) versus intermediate (500 mg daily) doses in abolishing angiotensin-converting enzyme inhibitor (ACEI)-induced cough. A dry bothersome cough is the most common adverse class effect of all angiotensin-converting enzyme inhibitors. Prostaglandins (PG) have been pinpointed as playing a leading role in the genesis of ACEI-associated cough. The role of different doses of the most commonly used PG inhibitor-aspirin-in ACEI cough modification was not yet elucidated. Of 350 consecutive ACEI-treated patients, we identified 34 (9.7%) nonsmoking ACEI-related coughers. Patients with lung disease, nonsteroidal anti-inflammatory drug (NSAID) treatment, and those who did not agree to participate in the study were excluded. In the remaining 14 ACEI coughers (eight men, six women; mean age, 63 +/- 11 years), the treatment was discontinued; the dry cough completely disappeared, but returned in all patients within 1 week after ACEI reintroduction. At the end of the rechallenge period, patients started a low dose of aspirin for 1 week, switching thereafter to the intermediate dose of aspirin for an additional week. On each visit the cough severity (CS, 0-4) and frequency (CF, 0-10) scores were registered. Low doses of aspirin were ineffective in suppressing ACEI-induced cough, whereas intermediate doses completely abolished cough in five patients and reduced coughing in all but one patient; CS and CF decreased, respectively, from 2.5 +/- 1.0 to 0.9 +/- 1.1, P < .002 and from 6.6 +/- 2.4 to 2.4 +/- 1.1, P < .0002. Overall, intermediate doses of aspirin beneficially modified cough scores in 13 (93%) patients, enabling nine (64%) to continue ACEI treatment. Aspirin did not influence blood pressure control either in hypertensives or in postinfarction patients. We conclude that intermediate but not low doses of aspirin probably can suppress ACEI-induced cough. These findings propose a new alternative therapeutic approach for patients with ACEI-related cough, especially those in whom ACEI treatment seems to be essential.

Effect of angiotensin-converting enzyme inhibition on bronchial responsiveness

The effect of angiotensin-converting enzyme (ACE) inhibition on bronchial responsiveness has not been clearly established. Because ACE degrades bradykinin and substance P, inhibition of the enzyme may lead to accumulation of these potent bronchoconstrictors in the lung, potentially leading to enhanced bronchial reactivity or bronchospasm. Previous studies of the effect of ACE inhibition on airway responsiveness have yielded conflicting results. A randomized, double-blind, placebo-controlled study was therefore conducted to evaluate the effect of a 14-day course of oral lisinopril (10 mg for days 1-3, 20 mg for days 4-14) on bronchial responsiveness to inhaled methacholine in a group of healthy volunteers. No significant change in methacholine responsiveness occurred in any of the participants receiving lisinopril. The mean ( +/- SD) concentration of methacholine producing a decrease in FEV1 of 20% from baseline (PC20; mg/mL) was 23.3 +/- 5.0 before the study and 23.5 +/- 4.5 at the end of the study for the lisinopril group, and 23.0 +/- 4.6 before the study and 21.8 +/- 6.9 after the study for the placebo group. The 14-day course of ACE inhibitor therapy did not enhance nonspecific bronchial responsiveness in healthy volunteers.

Toxicodynamic analysis of inflammatory reactions by an angiotensin converting enzyme inhibitor (lisinopril) in guinea-pig skin

There have been reports of rash and angioedema in the treatment of hypertension with angiotensin converting enzyme (ACE) inhibitors. To evaluate the inflammatory reaction, we continuously infused lisinopril for three days into the peritoneal cavity of ovalbumin-sensitized guinea-pigs and tested intradermal inflammation with ovalbumin. Inflammatory responses were measured in two perpendicular directions serially, and the areas of rash were used as an index of inflammatory reaction induced by lisinopril. Inflammatory responses were dose-dependently enhanced by treatment with lisinopril. Plasma concentration of lisinopril required to produce 50% of the maximum potentiation of the inflammatory reaction in guinea-pig skin was 40 times plasma unbound concentration after the clinical treatment of lisinopril in patients.

Dyspnoea, asthma, and bronchospasm in relation to treatment with angiotensin converting enzyme inhibitors

OBJECTIVE

To evaluate the occurrence of asthma and dyspnoea precipitated or worsened by angiotensin converting enzyme inhibitors.

DESIGN

Summary of reports of adverse respiratory reaction in relation to treatment with angiotensin converting enzyme inhibitors that were submitted to Swedish Adverse Drug Reactions Advisory Committee and to World Health Organisation's international drug information system until 1992. Sales of angiotensin converting enzyme inhibitors in Sweden were also summarised.

SUBJECTS

Patients receiving angiotensin converting enzyme inhibitors who reported adverse respiratory reactions.

MAIN OUTCOME MEASURES

Clinical characteristics of adverse reactions of asthma, bronchospasm, and dyspnoea.

RESULTS

In Sweden 424 adverse respiratory reactions were reported, of which most (374) were coughing. However, 36 patients had adverse drug reactions diagnosed as asthma, bronchospasm, or dyspnoea. In 33 of these cases the indication for treatment with angiotensin converting enzyme inhibitors was hypertension, in only three heart failure. The respiratory symptoms occurred in about half of the patients within the first two weeks of treatment, and about one third needed hospitalisation or drug treatment. Dyspnoea symptoms occurred in conjunction with other symptoms from the airways or skin in 23 out of the 36 cases. In the WHO database there were 318 reports of asthma or bronchospasm, 516 reports of dyspnoea, and 7260 reports of cough in relation to 11 different angiotensin converting enzyme inhibitors.

CONCLUSION

Symptoms of airway obstruction in relation to treatment with angiotensin converting enzyme inhibitors seem to be a rare but potentially serious reaction generally occurring within the first few weeks of treatment.

Could the pharmacological differences observed between angiotensin II antagonists and inhibitors of angiotensin converting enzyme be clinically beneficial?

Over the past several years, angiotensin I converting enzyme (ACE) inhibitors, compounds that block the formation of angiotensin II (ANG II), have become widely used in the treatment of cardiovascular disease. Recently, a new class of orally active, non-peptide inhibitors of the renin-angiotensin system, the ANG II receptor antagonists have also become available. Since both classes of compounds block the renin-angiotensin system, although at different sites, it remains to be determined whether blockade of ANG II receptors will have any specific advantage over inhibition of ACE. The following review assesses the actions of ANG II antagonists and suggests ways in which blockade of ANG II receptors may differ both pharmacologically and clinically from inhibition of ACE.

Enalapril. A reappraisal of its pharmacology and therapeutic use in hypertension

Enalapril, an angiotensin converting enzyme (ACE) inhibitor usually administered orally once daily, decreases blood pressure by lowering peripheral vascular resistance without increasing heart rate or output. It is effective in lowering blood pressure in all grades of essential and renovascular hypertension. Patients not responding adequately to enalapril monotherapy usually respond with the addition of a thiazide diuretic (or a calcium antagonist or beta-blocker), and rarely require a third antihypertensive agent. Enalapril is at least as effective as other established and newer ACE inhibitors, and members of other antihypertensive drug classes including diuretics, beta-blockers, calcium antagonists and alpha-blockers, but therapy with enalapril may be less frequently limited by serious adverse effects or treatment contraindications than with other drug classes. The most frequent adverse effect limiting all ACE inhibitor therapy in clinical practice is cough. This favourable profile of efficacy and tolerability, and the substantial weight of clinical experience, explain the increasing acceptance of enalapril as a major antihypertensive treatment and supports its use as logical first-line therapeutic option.

Enalaprilat, but not cilazaprilat, increases inflammatory skin reactions in guinea-pigs

The inflammatory effects of enalaprilat and cilazaprilat were tested in an experimental model of ovalbumin-sensitised guinea-pigs. Enalaprilat, but not cilazaprilat, enhanced the ovalbumin-induced inflammatory skin responses. The effect of enalaprilat was dose-dependent. Enalaprilat significantly increased the skin content of substance P and histamine. Cilazaprilat did not alter the level of these inflammatory mediators. Enalaprilat, applied locally, but not cilazaprilat, enhanced the inflammatory reactions caused by intradermal injections of allergen and substance P. Both angiotensin converting enzyme (ACE) inhibitors enhanced the inflammatory skin response evoked by bradykinin. Our study strongly indicates that enalaprilat has pro-inflammatory properties, whereas the new long-acting ACE inhibitor cilazaprilat does not. This might give a better safety profile of cilazaprilat.

Hyperresponsiveness of the extrathoracic airway in patients with captopril-induced cough

It has been suggested that cough from captopril may originate from an increased sensitivity of receptors in the extrathoracic airway (EA). To explore this hypothesis, we assessed the responsiveness of EA and bronchi and the cough sensitivity to inhaled histamine in nine hypertensive patients with captopril-induced cough (group 1) during treatment and one month after withdrawal of the drug treatment. Nine patients who were asymptomatic while receiving captopril (group 2) and nine patients receiving no current treatment (group 3) served as controls. The EA responsiveness was assessed by using the maximal midinspiratory flow (MIF50) as an arbitrary index of EA constriction and was expressed as the histamine concentration causing a 25 percent decrease in MIF50 (PC25MIF50). PC15FEV1 was the index of bronchial responsiveness and PCcough (dose causing five or more coughs) was that of cough sensitivity. Airway hyperresponsiveness (EA-HR or BHR) was diagnosed when PC25MIF50 or PC15FEV1 were 8 mg/ml or lower. Patients with captopril-cough, as compared with controls, had significantly lower values of PC25MIF50, PC15FEV1, and PCcough; EA-HR and BHR were found, respectively, in seven and three of these patients and in none of the control subjects. In all the patients of group 1, cough and EA-HR resolved after withdrawal of captopril treatment, while BHR persisted in one. PC25MIF50, PC15FEV1, and PCcough were all significantly improved. Our findings suggest that cough during captopril therapy may originate from receptors in the EA.

Angiotensin-converting enzyme inhibitors and their influence on inflammation, bronchial reactivity and cough. A research review

Synthetic orally active angiotensin-converting enzyme (ACE) inhibitors have been successfully used in the treatment of congestive heart failure and hypertension, particularly in hypertensive subjects with increased renin-angiotensin-aldosterone-system activity. Adverse skin reactions, angioneurotic oedema and rapidly decreasing lung function in asthmatics have been reported following medication with ACE inhibitors. Furthermore, these drugs have been associated with a persistent dry cough in subjects without previous known bronchial hyper-reactivity. There is reason to believe that an ACE inhibitor-induced cough is due to an increased inflammatory state in the airways of susceptible individuals, and that this cough might thereby have pathophysiological features in common with the cough seen as an early symptom of asthma. All inflammatory responses, wheal and flare reactions, infiltration of neutrophils, eosinophils, basophils and monocytes were enhanced by ACE inhibitors. A dose-response relationship for the proinflammatory effect of the ACE inhibitor has been demonstrated.