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Bacak BJ, Castle MS, Barbot C, Srikantha L, Stern NA, Vandjelovic ND. Airway Involvement and Intervention in Non-ACE-Inhibitor-Induced Angioedema. Laryngoscope 2024; 134:2282-2287. [PMID: 37902118 DOI: 10.1002/lary.31127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/29/2023] [Accepted: 10/10/2023] [Indexed: 10/31/2023]
Abstract
OBJECTIVES Characterize the presentation of patients with non-angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema and determine risk factors associated with patient disposition and possible need for airway intervention. METHODS The medical records of adult patients in the Emergency Department (ED) and diagnosed with non-ACEI-induced angioedema over 4.5 years were included. Demographics, vital signs, etiology, timeline, presenting symptoms, physical exam including flexible laryngoscopy, medical management, and disposition were examined. Statistical analyses were conducted using SPSS V 23.0 software calculating and comparing means, standard deviations, medians, and correlation of categorical and ordinate variables. RESULTS A total of 181 patients with non-ACEI-induced angioedema were evaluated with flexible laryngoscopy by otolaryngology. Notably, 11 patients (6.1%) required airway intervention and were successfully intubated. Statistically significant factors (p ≤ 0.05) associated with airway intervention included the diastolic blood pressure (DBP) and mean arterial pressure (MAP) (p = 0.006 and 0.01 respectively), symptoms of dysphonia (p = 0.018), the presence of oropharyngeal, supraglottic, and hypopharyngeal edema (p ≤ 0.001 for each site), and the number of edematous anatomic subsites documented on physical exam (p < 0.001). Other patient demographics, prior history of angioedema, heart rate, systolic blood pressure, symptom onset, number of symptoms at presentation, and medication administered in the ED did not correlate with airway intervention. CONCLUSION Dysphonia, DBP, MAP, anatomic location of edema and edema in multiple sites are associated with airway intervention and a higher level of care in non-ACEI-induced angioedema and can be useful in risk assessment in patient management. LEVEL OF EVIDENCE 4 Laryngoscope, 134:2282-2287, 2024.
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Affiliation(s)
- Bartholomew J Bacak
- Department of Otolaryngology - Head and Neck Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Michael S Castle
- Department of Otolaryngology - Head and Neck Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Chantal Barbot
- Department of Otolaryngology - Head and Neck Surgery, Detroit Medical Center, Detroit, Michigan, U.S.A
| | - Luxman Srikantha
- Department of Otolaryngology - Head and Neck Surgery, Detroit Medical Center, Detroit, Michigan, U.S.A
| | - Noah A Stern
- Department of Otolaryngology - Head and Neck Surgery, Detroit Medical Center, Detroit, Michigan, U.S.A
| | - Nathan D Vandjelovic
- Department of Otolaryngology - Head and Neck Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
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Rubin S, Tomaszewski M. Prediction and prevention of ACE-inhibitor-induced angioedema-an unmet clinical need in management of hypertension. Hypertens Res 2024; 47:257-260. [PMID: 37945891 DOI: 10.1038/s41440-023-01491-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Sébastien Rubin
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
- Renal Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK.
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK.
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3
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Ameer MA, Mushtaq J, Chaudhry H, Patel N, Khan SI. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema: A Case Report With a Review of Management Options. Cureus 2023; 15:e40320. [PMID: 37448396 PMCID: PMC10337988 DOI: 10.7759/cureus.40320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Angiotensin-converting enzyme inhibitors (ACEIs) are widely used for heart failure, renal failure, diabetic nephropathy, stroke, arterial hypertension, and a number of other cardiovascular or related conditions. ACEI-induced angioedema is a rare entity but can result in life-threatening emergencies. It mainly occurs in patients starting on ACEI as an antihypertensive. We present a case of lisinopril-induced angioedema in an African American patient managed in the emergency department. After appropriate evaluation, the patient was declared safe to be observed in the emergency department. Intubation was not performed. Early identification of angioedema is paramount, and emergency physicians should maintain airways or intubate such patients if indicated. There should be a high level of suspicion of angioedema in patients taking ACEIs if they present with symptoms of respiratory compromise.
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Affiliation(s)
| | - Javaria Mushtaq
- Cell Biology and Neuroscience, Rowan University, Stratford, USA
| | - Haroon Chaudhry
- Internal Medicine, Suburban Community Hospital, East Norriton, USA
| | - Nimi Patel
- Internal Medicine, Suburban Community Hospital, East Norriton, USA
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4
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Irwin TM, Irwin TM, Longanecker A, Bodenhamer WS, Keirns CC. A Case of Refractory Angioedema. J Intensive Care Med 2023; 38:313-320. [PMID: 36514293 DOI: 10.1177/08850666221145310] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Angioedema is an acute disorder that affects mucous membranes and the deepest layers of the skin along with underlying tissue, marked by rapid swelling, large welts, and pain. There are 3 major subtypes of angioedema: mast-cell mediated, bradykinin-mediated, and multifactorial or unclear mechanism subtype. The most common subtype of bradykinin-mediated angioedema is ACE-inhibitor induced, which disproportionately affects African-Americans. It is most often self-limiting and usually responds to the withdrawal of the offending agent. The prolonged duration of angioedema is uncommon in the absence of a persistent stimulus, though it is more likely when there is an abnormality of the metabolic pathways, such as in hereditary angioedema or other gene polymorphisms affecting the complement system. We present a case of severe angioedema that persisted for over a month and required a tracheostomy to manage the airway.
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Affiliation(s)
- Thomas M Irwin
- 145762University of Kansas Cancer Center, Melanoma Project, Westwood, KS, USA
| | | | | | - William Spence Bodenhamer
- Departments of History of Medicine & Internal Medicine (Palliative Care), 12251University of Kansas School of Medicine, Kansas City, KS, USA
| | - Carla C Keirns
- Departments of History of Medicine & Internal Medicine (Palliative Care), 12251University of Kansas School of Medicine, Kansas City, KS, USA
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5
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Arthur J, Caro D, Topp S, Chadwick S, Driver B, Henson M, Norse A, Spencer H, Godwin SA, Guirgis F. Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema. Am J Emerg Med 2023; 63:44-49. [PMID: 36327748 PMCID: PMC10015633 DOI: 10.1016/j.ajem.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 12/07/2022] Open
Abstract
OBJECTIVES The objective of this study is to identify predictors of airway compromise among patients presenting to the emergency department with angioedema in order to develop and validate a risk score to augment clinician gestalt regarding need for intubation. METHODS Retrospective chart review of emergency department patients with a diagnosis of angioedema. After data extraction they were randomly divided into a training and test set. The training set was used to identify factors associated with intubation and to develop a model and risk score to predict intubation. The model and risk score were then applied to the test set. RESULTS A total of 594 patients were included. Past medical history of hypertension, presence of shortness of breath, drooling, and anterior tongue or pharyngeal swelling were independent predictors included in our final model and risk score. The Area Under the Curve for the Receiver Operator Characteristic curve was 87.55% (83.42%-91.69%) for the training set and 86.1% (77.62%-94.60%) for the test set. CONCLUSIONS A simple scoring algorithm may aid in predicting angioedema patients at high and low risk for intubation. External validation of this score is necessary before wide-spread adoption of this decision aid.
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Affiliation(s)
- Jason Arthur
- Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David Caro
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Stephen Topp
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Steven Chadwick
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Brian Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Morgan Henson
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Ashley Norse
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Horace Spencer
- Department of Biostatistics, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Steven A Godwin
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Faheem Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA.
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6
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Perman B, Narechania S, Malesker M. Geriatric Pharmacotherapy Case Series: Recurrent Angioedema Following Discontinuation of ACE Inhibitor Therapy. Sr Care Pharm 2023; 38:16-20. [PMID: 36751921 DOI: 10.4140/tcp.n.2023.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction Angiotensin-converting enzyme inhibitors (ACEIs) are first-line pharmaceutical agents in common chronic conditions such as hypertension and heart failure with reduced ejection fraction. When angioedema occurs, if secondary to ACEIs, discontinuation of the ACEI is necessary to mitigate the risk of recurrent angioedema. While angioedema is a well-known adverse effect of ACEIs, it is not well-known that angioedema may recur even after ACEI discontinuation. Additionally, only few reports in the literature describe this phenomenon. This case describes an older man with a history of chronic obstructive pulmonary disease, hypothyroidism, diabetes mellitus, hypertension, and heart failure who presented from an assisted living facility with recurrent angioedema 12 days after an initial episode of angioedema where his ACEI therapy (enalapril) was discontinued. Assessment Empiric methylprednisolone, diphenhydramine, intramuscular epinephrine, intravenous C1 esterase inhibitor Berinert®, and two units of fresh frozen plasma was given in the emergency department. The patient was monitored in the intensive care unit because of mild airway compromise but did not require invasive airway protection. Serum C4 level was normal, ruling out hereditary angioedema. Outcome Patient was discharged after five days in stable condition with resolution of symptoms. Conclusion ACEIs are the most common cause of drug-induced angioedema in the United States. Angioedema is self-limiting swelling that requires close airway monitoring. While health professionals recognize the risk for angioedema with active ACEI use, it is not well known that the risk of angioedema may occur for months following cessation of ACEI therapy. Increased awareness of delayed ACEI-induced angioedema following ACEI discontinuation is important for both providers and pharmacists to provide appropriate diagnosis and monitoring. Improved awareness would also allow patients with a history of ACEI-induced angioedema to be cognizant of the potential for recurrence following drug discontinuation.
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Affiliation(s)
- Bryton Perman
- Creighton University School of Medicine, Omaha, Nebraska
| | | | - Mark Malesker
- Creighton University School of Medicine, Omaha, Nebraska
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7
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Ohyama K, Shindo J, Takahashi T, Takeuchi H, Hori Y. Pharmacovigilance study of the association between dipeptidyl peptidase-4 inhibitors and angioedema using the FDA Adverse Event Reporting System (FAERS). Sci Rep 2022; 12:13122. [PMID: 35907939 PMCID: PMC9338932 DOI: 10.1038/s41598-022-17366-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022] Open
Abstract
Dipeptidyl peptidase-4 (DPP-4) plays a minor role in degrading vasoactive peptides that cause angioedema when angiotensin-converting enzyme (ACE) is present and fully functional. This study investigated the association between DPP-4 inhibitors (DPP-4Is) and angioedema, including cases where the concomitant use of ACE inhibitors (ACEIs) was absent. We obtained data from the US Food and Drug Administration Adverse Event Reporting System and performed a disproportionality analysis, using the reporting odds ratio (ROR) and information component (IC) for signal detection in patients aged ≥ 40 years, stratified by age group and sex. No signal was detected for DPP-4Is when the entire dataset was analyzed. However, a signal was detected for the entire female subset group, the three stratified female groups aged ≥ 60 years, and males in their 40 s. After excluding the data of concomitant ACEI users, most ROR and IC values were lower and significant only for females in their 60 s and males aged ≥ 80 years. Regarding individual DPP-4Is signals, those detected for saxagliptin and sitagliptin in some age groups disappeared after excluding the data of ACEI users. Notably, linagliptin was the only DPP-4I where signals were detected in most female groups, regardless of age and without concomitant ACEI use. Our findings suggest that some DPP-4Is were associated with a higher reporting of angioedema as per age and sex, even in the absence of concomitant ACEI use.
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Affiliation(s)
- Katsuhiro Ohyama
- Center for Experiential Pharmacy Practice, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo, Japan.
| | - Junichiro Shindo
- Center for Experiential Pharmacy Practice, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo, Japan
| | - Tomohiro Takahashi
- Center for Experiential Pharmacy Practice, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo, Japan
| | - Hironori Takeuchi
- Hospital Pharmacy, Tokyo Medical University Hospital, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, Japan
| | - Yusuke Hori
- Center for Experiential Pharmacy Practice, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo, Japan
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8
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Dabek RJ, Pina NA, Sheber BA, Axentiev A, Scott MC. A Case Report of Delayed Post-operative Angioedema Associated With Angiotensin-Converting Enzyme Inhibitor Use. Cureus 2021; 13:e18800. [PMID: 34692263 PMCID: PMC8523184 DOI: 10.7759/cureus.18800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 11/05/2022] Open
Abstract
Angiotensin-converting enzyme inhibitors are known to precipitate angioedema. Drug-induced angioedema is rare in the perioperative setting. Even fewer cases described hours following a minor procedure. In this case report, we present a 45-year-old female who developed drug-induced angioedema hours following an obstetric procedure.
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Affiliation(s)
- Robert J Dabek
- General Surgery, Ascension St. Agnes Hospital, Baltimore, USA
| | - Nancy A Pina
- General Surgery, Ross University School of Medicine, Bridgetown, BRB
| | | | - Anna Axentiev
- General Surgery, Ascension St. Agnes Hospital, Baltimore, USA
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9
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Association of Variants Near the Bradykinin Receptor B 2 Gene With Angioedema in Patients Taking ACE Inhibitors. J Am Coll Cardiol 2021; 78:696-709. [PMID: 34384552 DOI: 10.1016/j.jacc.2021.05.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/06/2021] [Accepted: 05/18/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Angioedema is a rare but potentially life-threatening adverse reaction associated with angiotensin-converting enzyme (ACE) inhibitors. Identification of potential genetic factors related to this adverse event may help identify at-risk patients. OBJECTIVES The aim of this study was to identify genetic factors associated with ACE inhibitor-associated angioedema. METHODS A genomewide association study involving patients of European descent, all taking ACE inhibitors, was conducted in a discovery cohort (Copenhagen Hospital Biobank), and associations were confirmed in a replication cohort (Swedegene). Cases were defined as subjects with angioedema events and filled prescriptions for ACE inhibitors ≤180 days before the events. Control subjects were defined as those with continuous treatment with ACE inhibitors without any history of angioedema. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed for angioedema risk using logistic mixed model regression analysis. Summary statistics from the discovery and replication cohorts were analyzed using a fixed-effects meta-analysis model. RESULTS The discovery cohort consisted of 462 cases and 53,391 ACE inhibitor-treated control subjects. The replication cohort consisted of 142 cases and 1,345 ACE inhibitor-treated control subjects. In the discovery cohort, 1 locus, residing at chromosome 14q32.2, was identified that associated with angioedema at the genomewide significance level of P <5 × 10-8. The lead variant at this locus, rs34485356, is an intergenic variant located 60 kb upstream of BDKRB2 (OR: 1.62; 95% CI: 1.38 to 1.90; P = 4.3 × 10-9). This variant was validated in our replication cohort with a similar direction and effect size (OR: 1.60; 95% CI: 1.13 to 2.25; P = 7.2 × 10-3). We found that carriers of the risk allele had significantly lower systolic (-0.46 mm Hg per T allele; 95% CI: -0.83 to -0.10; P = 0.013) and diastolic (-0.26 mm Hg per T allele; 95% CI: -0.46 to -0.05; P = 0.013) blood pressure. CONCLUSIONS In this genomewide association study involving individuals treated with ACE inhibitors, we found that common variants located in close proximity to the bradykinin receptor B2 gene were associated with increased risk for ACE inhibitor-related angioedema.
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10
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Kedarisetty S, Tint D, Michael A, Soliman AMS. Recurrent angioedema: Experience at a tertiary care urban medical center. Laryngoscope Investig Otolaryngol 2021; 6:13-20. [PMID: 33614924 PMCID: PMC7883605 DOI: 10.1002/lio2.511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/21/2020] [Accepted: 12/07/2020] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To determine the demographics, presentation, management, and outcomes of patients with recurrent angioedema. To compare the findings to patients with ACE inhibitor related angioedema. METHODS Retrospective case series with chart review of patients who presented to a tertiary-care hospital between January 2010 and December 2017 with two or more episodes of angioedema. Excluded were patients with anaphylactic reaction, medication induced angioedema, or angioedema secondary to an infectious etiology. A group of 88 patients who presented during the same time period with ACE inhibitor related angioedema was used as a control. Statistical analysis was conducted using a two-tailed Fisher exact test and a multivariate logistical regression model to determine significant associations. RESULTS Ninety-one patients were identified; 61 met the selection criteria and had 217 total episodes of angioedema episodes presenting to the emergency department. Fifty percent were Caucasian or Hispanic. The average number of episodes was 3.5 (range: 2-23). The lips and tongue were the most commonly affected sites (37% and 39%). The larynx and floor of mouth were least likely to be involved (7% and 6%). Only 1 patient was found to have C1 esterase inhibitor deficiency. Twenty-eight percent of patients had asthma, allergic rhinitis, food allergies, or atopic dermatitis. Only 11% of episodes required airway intervention. No patients required airway intervention after admission. CONCLUSION Recurrent angioedema was primarily idiopathic, was less severe than ACE inhibitor angioedema, and was associated with an atopic history. There was less frequent worsening of symptoms after admission, and recurrences occurred more frequently are at the same anatomic subsite. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Suraj Kedarisetty
- Department of Otolaryngology – Head and Neck SurgeryLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - Derrick Tint
- Department of Otolaryngology – Head and Neck SurgeryLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - Alexander Michael
- Department of Otolaryngology – Head and Neck SurgeryLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - Ahmed M. S. Soliman
- Department of Otolaryngology – Head and Neck SurgeryLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
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11
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ACE inhibitor-mediated angioedema. Int Immunopharmacol 2019; 78:106081. [PMID: 31835086 DOI: 10.1016/j.intimp.2019.106081] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/19/2019] [Accepted: 11/23/2019] [Indexed: 02/07/2023]
Abstract
Angioedema (AE) occurring during ACE inhibitor therapy (ACEi-AE) is a rare complication involving between 0.1 and 0.7% of treated patients. AE can also complicate other therapeutic regimens that block the renin-angiotensin aldosterone system. Other drugs, such as immune suppressors, some type of antidiabetics or calcium antagonists, can increase the likelihood of ACEi-AE when associated to ACEi. There is a clear ethnic predisposition, since African-Americans or Hispanics show a higher prevalence of this condition compared to Caucasians. At least in African-Americans the genetic predisposition accounts for a general higher prevalence of AE, independently from the cause. People that experience ACEi-AE may have some recurrence when they are switched to an angiotensin-receptor blocker (ARB); however, epidemiological studies on large cohorts have shown that angiotensin receptor blockers (ARB) do not increase the likelihood of AE compared to other antihypertensives. Clinical manifestations consist of edema of face, lips, tongue, uvula and upper airways, requiring intubation or tracheotomy in severe cases. Attacks last for 48-72 h and require hospital admission in most cases. Intestinal involvement with sub-occlusive symptoms has also been reported. The pathogenesis of ACEi-AE depends mainly on a reduced catabolism and accumulation of bradykinin, which is normally metabolized by ACE. Genetic studies have shown that some single nucleotide polymorphisms at genes encoding relevant molecules for bradykinin metabolism and action may be involved in ACEi-AE, giving a basis for the ethnic predisposition. Treatment of ACEi-AE is still a matter of debate. Corticosteroids and antihistamines do not show efficacy. Some therapeutic attempts have shown some efficacy for fresh frozen plasma or C1 inhibitor concentrate infusion. Interventional studies with the specific bradykinin receptor antagonist icatibant have shown conflicting results; there might be a different ethnic predisposition to icatibant efficacy which has been proven in caucasian but not in black patients.
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12
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Wong A, Seger DL, Lai KH, Goss FR, Blumenthal KG, Zhou L. Drug Hypersensitivity Reactions Documented in Electronic Health Records within a Large Health System. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1253-1260.e3. [PMID: 30513361 DOI: 10.1016/j.jaip.2018.11.023] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/13/2018] [Accepted: 11/19/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hypersensitivity reactions (HSRs) are immunologic responses to drugs. Identification of HSRs documented in the electronic health record (EHR) is important for patient safety. OBJECTIVE To examine HSR epidemiology using longitudinal EHR data from a large United States health care system. METHODS Patient demographic information and drug allergy data were obtained from the Partners Enterprise-wide Allergy Repository for 2 large tertiary care hospitals from 2000 to 2013. Drug-induced HSRs were categorized into immediate and delayed HSRs based on typical phenotypes. Causative drugs and drug groups were assessed. The prevalence of HSRs was determined, and sex and racial differences were analyzed. RESULTS Among 2.7 million patients, 377,474 (13.8%) reported drug-induced HSRs, of whom 70.3% were female and 77.5% were white. A total of 580,456 HSRs were reported, of which 53.1% were immediate reaction phenotypes. Common immediate HSRs included hives (48.8%), itching (15.0%), and angioedema (14.1%). Delayed HSR phenotypes (46.9%) were largely rash (99.0%). Penicillins were associated with the most immediate (33.0%) and delayed (39.0%) HSRs. Although most HSRs were more prevalent in females and white patients, notable differences were identified for certain rare HSRs including acute interstitial nephritis, which appeared more commonly in males (0.02% vs 0.01%, P < .001). Asian patients had more fixed drug eruptions (0.007% vs 0.002%, P = .021) and severe cutaneous adverse reactions (0.05% vs 0.04%, P < .001). CONCLUSIONS Drug HSRs were reported in 13.8% of patients. Almost one-half of reported immediate HSR phenotypes were hives, and almost all reported delayed HSR phenotypes were rash. HSRs largely affected female and white patients, but differences were identified for specific rare HSRs.
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Affiliation(s)
- Adrian Wong
- Department of Pharmacy Practice, MCPHS University, Boston, Mass; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass
| | - Diane L Seger
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass; Clinical and Quality Analysis, Partners HealthCare, Somerville, Mass
| | - Kenneth H Lai
- Clinical and Quality Analysis, Partners HealthCare, Somerville, Mass; Department of Computer Science, Brandeis University, Waltham, Mass
| | - Foster R Goss
- Department of Emergency Medicine, University of Colorado, Aurora, Colo
| | - Kimberly G Blumenthal
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
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13
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Do TP, Seetasith A, Belleli R, Schlienger RG, Corda S, Burudpakdee C, Streefkerk HJ, Behr S. A Database Cohort Study to Assess the Risk of Angioedema Among Patients with Heart Failure Initiating Angiotensin-Converting Enzyme Inhibitors in the USA. Am J Cardiovasc Drugs 2018; 18:205-211. [PMID: 29177815 DOI: 10.1007/s40256-017-0256-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Real-world evidence on the risk of angioedema associated with angiotensin-converting enzyme inhibitors (ACEIs) in patients with heart failure (HF) is scarce. OBJECTIVE This non-interventional study aimed to estimate the incidence of and risk factors for angioedema in patients with HF initiating an ACEI in real-world practice. METHODS This was a retrospective cohort study using claims data from the PharMetrics Plus database, supplemented with consumer health data, from 1 January 2007 to 31 March 2015. Patients with HF initiating an ACEI were followed up for a maximum of 1 year, until the first occurrence of angioedema or until cohort exit. Angioedema incidence rates were estimated and stratified by potential risk factors such as race, age, sex, and time from initiation of ACEI therapy. For each risk factor, the unadjusted and adjusted hazard ratio (HR) was calculated; exploratory analyses were carried out to account for all potential confounders. RESULTS We identified 21,639 patients with HF initiating an ACEI (mean age 58 years; 35.6% women; mean follow-up 205 days). The 1-year incidence of angioedema per 1000 patient-years was 3.3 [95% confidence interval (CI) 2.4-4.5]. The incidence was higher in Black [6.2 (95% CI 3.1-12.5)] than in non-black [2.9 (95% CI 2.1-4.1)] patients, higher in women [5.2 (95% CI 3.4-7.9)] than in men [2.3 (95% CI 1.5-3.6)], and greatest in the first 30 days of ACEI therapy. CONCLUSIONS The risk of angioedema in patients with HF initiating an ACEI observed in this study is in line with published estimates for the general patient population treated with ACEIs.
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Affiliation(s)
- Thy P Do
- Novartis Pharma AG, Postfach, 4002, Basel, Switzerland
| | | | | | | | - Stefano Corda
- Novartis Pharma AG, Postfach, 4002, Basel, Switzerland
| | | | | | - Sigrid Behr
- Novartis Pharma AG, Postfach, 4002, Basel, Switzerland
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Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor–Induced Upper Airway Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1402-1409.e3. [DOI: 10.1016/j.jaip.2017.03.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/02/2017] [Accepted: 03/08/2017] [Indexed: 01/14/2023]
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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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Epidemiology of ACE Inhibitor Angioedema Utilizing a Large Electronic Health Record. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:744-749. [PMID: 28377081 DOI: 10.1016/j.jaip.2017.02.018] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 02/08/2017] [Accepted: 02/20/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEIs) are a common cause of drug-induced angioedema in the United States. Most epidemiologic ACEI angioedema data are from large multicenter clinical trials. OBJECTIVE The objective of this study was to identify the incidence of and risk factors for ACEI angioedema using a large integrated electronic health record (EHR). METHODS We conducted a retrospective cohort study of all ACEI prescriptions in the outpatient setting of a large academic center between January 1, 2000, and September 30, 2008. We determined frequency, timing, and risk factors for ACEI angioedema within 5 years of prescription. All data were derived from EHR sources, with angioedema defined by EHR reactions of angioedema, swelling, edema, or lip, eye, face, tongue, throat or mouth swelling. RESULTS Among 134,945 patients prescribed an ACEI, 0.7% (n = 888) developed angioedema during the subsequent 5 years. Sex was similar but patients who developed ACEI angioedema were younger (61.5 vs 62.7 years, P = .007). Patients with ACEI angioedema were more likely to have a history of nonsteroidal anti-inflammatory drug allergy compared with patients who did not develop angioedema (7.1% vs 4.2%, P < .001). We identified a 0.07% incidence of ACEI angioedema within 1 month of prescription and a 0.23% incidence during the first year. Incidence of angioedema was relatively constant annually over the subsequent 4 years (0.10% to 0.12%). CONCLUSIONS The incidence of ACEI angioedema within a large EHR is consistent with large clinical trial data. We observed a persistent and relatively constant annual risk; however, angioedema risk factors and underlying genetic and pathophysiological mechanisms require further study.
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Straka BT, Ramirez CE, Byrd JB, Stone E, Woodard-Grice A, Nian H, Yu C, Banerji A, Brown NJ. Effect of bradykinin receptor antagonism on ACE inhibitor-associated angioedema. J Allergy Clin Immunol 2016; 140:242-248.e2. [PMID: 27913306 DOI: 10.1016/j.jaci.2016.09.051] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/23/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The B2 receptor antagonist icatibant is approved for treatment of attacks of hereditary angioedema. Icatibant has been reported to decrease time-to-resolution of angiotensin-converting enzyme (ACE) inhibitor-associated angioedema in 1 study of European patients. OBJECTIVE We sought to test the hypothesis that a bradykinin B2 receptor antagonist would shorten time-to-resolution from ACE inhibitor-associated angioedema. METHODS Patients with ACE inhibitor-associated angioedema (defined as swelling of lips, tongue, pharynx, or face during ACE inhibitor use and no swelling in the absence of ACE inhibitor use) were enrolled at Vanderbilt University Medical Center from October 2007 through September 2015 and at Massachusetts General Hospital in 2012. C1 inhibitor deficiency and patients with bowel edema only were excluded. Patients were randomized within 6 hours of presentation to subcutaneous icatibant 30 mg or placebo at 0 and 6 hours later. Patients assessed severity of swelling using a visual analog scale serially following study drug administration or until discharge. RESULTS Thirty-three patients were randomized and 31 received treatment, with 13 receiving icatibant and 18 receiving placebo. One patient randomized to icatibant did not complete the visual analog scale and was excluded from analyses. Two-thirds of patients were black and two-thirds were women. Time-to-resolution of symptoms was similar in placebo and icatibant treatment groups (P = .19 for the primary symptom and P > .16 for individual symptoms of face, lip, tongue, or eyelid swelling). Frequency of administration of H1 and H2 blockers, corticosteroids, and epinephrine was similar in the 2 treatment groups. Time-to-resolution of symptoms was similar in black and white patients. CONCLUSIONS This study does not support clinical efficacy of a bradykinin B2 receptor antagonist in ACE inhibitor-associated angioedema.
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Affiliation(s)
- Brittany T Straka
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Claudia E Ramirez
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - James B Byrd
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth Stone
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | | | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn
| | | | - Nancy J Brown
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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Giménez-Arnau AM, Grattan C, Zuberbier T, Toubi E. An individualized diagnostic approach based on guidelines for chronic urticaria (CU). J Eur Acad Dermatol Venereol 2016; 29 Suppl 3:3-11. [PMID: 26053290 DOI: 10.1111/jdv.13196] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/14/2015] [Indexed: 11/29/2022]
Abstract
Chronic urticaria (CU), defined as the spontaneous or inducible appearance of hives, angioedema or both for 6 weeks or more, presents with a number of subtypes which all substantially impair patients' quality of life (QoL). International urticaria guidelines give clear recommendations on workup and treatment but the occurrence of CU with multiple causes and triggers (sometimes with more than one subtype occurring in a single patient) presents challenges for an individualized assessment by physicians. This review summarizes recent guidance on the classification, diagnosis and assessment of CU subtypes and discusses how currently available patient assessment tools and laboratory tests can be used in clinical practice as part of an individualized patient management plan.
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Affiliation(s)
- A M Giménez-Arnau
- Department of Dermatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - C Grattan
- Norfolk & Norwich University Hospital and St John's Institute of Dermatology, Norwich, UK
| | - T Zuberbier
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - E Toubi
- Division of Allergy and Clinical Immunology, Bnai-Zion Medical Centre, Haifa, Israel
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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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Minguet J, Sutton G, Ferrero C, Gomez T, Bramlage P. LCZ696 : a new paradigm for the treatment of heart failure? Expert Opin Pharmacother 2015; 16:435-46. [PMID: 25597387 DOI: 10.1517/14656566.2015.1000300] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Heart failure (HF) represents a significant healthcare issue because of its ever-increasing prevalence, poor prognosis and complex pathophysiology. Currently, blockade of the renin-angiotensin-aldosterone system (RAAS) is the cornerstone of treatment; however, the combination of RAAS blockade with inhibition of neprilysin (NEP), an enzyme that degrades natriuretic peptides, has recently emerged as a potentially superior treatment strategy. AREAS COVERED Following the results of the recent Phase III Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure clinical trial in patients with chronic HF with reduced ejection fraction (HF-REF), this review focuses on LCZ696 , a first-in-class angiotensin receptor NEP inhibitor. This drug consists of a supramolecular complex containing the angiotensin receptor inhibitor valsartan in combination with the NEP inhibitor prodrug, AHU377. Following oral administration, the LCZ696 complex dissociates and the NEP inhibitor component is metabolized to the active form (LBQ657). Aspects of the trial that might be relevant to clinical practice are also discussed. EXPERT OPINION Speculation that LCZ696 will pass the scrutiny of regulatory agencies for HF-REF appears to be justified, and it is likely to become a core therapeutic component in the near future. Replication of the eligibility criteria and titration protocol used in the PARADIGM-HF trial would be valuable in clinical practice and may minimize the risk of adverse events. Although long-term data remain to be generated, the promising results regarding hypertension are likely to expedite acceptance of the drug for HF-REF.
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Affiliation(s)
- Joan Minguet
- Institute for Research and Medicine Advancement (IRMEDICA) , Barcelona , Spain
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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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