1
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Sychev IV, Denisenko NP, Kachanova AA, Lapshtaeva AV, Abdullaev SP, Goncharova LN, Mirzaev KB, Sychev DA. Pharmacogenetic markers of development of angioneurotic edema as a secondary side effect to enalapril in patients with essential arterial hypertension. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2024; 35:37-47. [PMID: 37742663 DOI: 10.3233/jrs-230006] [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] [Indexed: 09/26/2023]
Abstract
BACKGROUND Angioneurotic edema is the most dangerous complication in angiotensin-converting enzyme inhibitors (ACEIs) therapy. Based on the current data, the clinical and genetic predictors of angioedema development are still understudied, which demonstrates the relevance of this study. OBJECTIVE To reveal the pharmacogenetic predictors of the angioedema as a secondary side effect to enalapril in patients with essential arterial hypertension. METHODS The study enrolled 111 subjects randomized into two groups: study group, patients with the angioedema as a secondary side effect to enalapril; and control group, patients without adverse drug reaction. All patients underwent pharmacogenetic testing. RESULTS An association between the development of the angioneurotic edema and the genotypes AA rs2306283 of gene SLCO1B1, TT rs4459610 of gene ACE, and CC rs1799722 of gene BDKRB2 in patients was revealed. CONCLUSION The findings justify further investigations of the revealed genetic predictors of angioedema with larger-size patient populations.
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Affiliation(s)
- Ivan V Sychev
- Department of Faculty Therapy, Ogarev Mordovia State University, Saransk, Russian Federation
| | - Natalia P Denisenko
- Research Institute of Molecular and Personalized Medicine, Department of Clinical Pharmacology and Therapy named after Academician B.E. Votchal, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Anastasiya A Kachanova
- Predictive and Prognostic Biomarkers Department, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Anna V Lapshtaeva
- Department of Immunology, Microbiology and Virology, Ogarev Mordovia State University, Saransk, Russian Federation
| | - Sherzod P Abdullaev
- Research Institute of Molecular and Personalized Medicine, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Ludmila N Goncharova
- Department of Faculty Therapy, Ogarev Mordovia State University, Saransk, Russian Federation
| | - Karin B Mirzaev
- Research Institute of Molecular and Personalized Medicine, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Dmitry A Sychev
- Clinical Pharmacology and Therapy Department named after Academician B.E. Votchal, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
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2
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Smolinska S, Antolín-Amérigo D, Popescu FD. Bradykinin Metabolism and Drug-Induced Angioedema. Int J Mol Sci 2023; 24:11649. [PMID: 37511409 PMCID: PMC10380452 DOI: 10.3390/ijms241411649] [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: 06/23/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Bradykinin (BK) metabolism and its receptors play a central role in drug-induced angioedema (AE) without urticaria through increased vascular permeability. Many cardiovascular and diabetic drugs may cause BK-mediated AE. Angiotensin-converting enzyme inhibitors (ACEIs) and neprilysin inhibitors impair BK catabolism. Dipeptidyl peptidase-IV (DPP-IV) inhibitors reduce the breakdown of BK and substance P (SP). Moreover, angiotensin receptor blockers, thrombolytic agents, and statins may also induce BK-mediated AE. Understanding pathophysiological mechanisms is crucial for preventing and treating drug-induced AE.
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Affiliation(s)
- Sylwia Smolinska
- Department of Clinical Immunology, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Darío Antolín-Amérigo
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Florin-Dan Popescu
- Department of Allergology "Nicolae Malaxa" Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, 022441 Bucharest, Romania
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3
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Arendse LB, Cozier GE, Eyermann CJ, Basarab GS, Schwager SL, Chibale K, Acharya KR, Sturrock ED. Probing the Requirements for Dual Angiotensin-Converting Enzyme C-Domain Selective/Neprilysin Inhibition. J Med Chem 2022; 65:3371-3387. [PMID: 35113565 DOI: 10.1021/acs.jmedchem.1c01924] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Selective inhibition of the angiotensin-converting enzyme C-domain (cACE) and neprilysin (NEP), leaving the ACE N-domain (nACE) free to degrade bradykinin and other peptides, has the potential to provide the potent antihypertensive and cardioprotective benefits observed for nonselective dual ACE/NEP inhibitors, such as omapatrilat, without the increased risk of adverse effects. We have synthesized three 1-carboxy-3-phenylpropyl dipeptide inhibitors with nanomolar potency based on the previously reported C-domain selective ACE inhibitor lisinopril-tryptophan (LisW) to probe the structural requirements for potent dual cACE/NEP inhibition. Here we report the synthesis, enzyme kinetic data, and high-resolution crystal structures of these inhibitors bound to nACE and cACE, providing valuable insight into the factors driving potency and selectivity. Overall, these results highlight the importance of the interplay between the S1' and S2' subsites for ACE domain selectivity, providing guidance for future chemistry efforts toward the development of dual cACE/NEP inhibitors.
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Affiliation(s)
- Lauren B Arendse
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town 7925, South Africa.,Department of Integrative Biomedical Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
| | - Gyles E Cozier
- Department of Biology and Biochemistry, University of Bath, Claverton Down, Bath BA2 7AY, U.K
| | - Charles J Eyermann
- Drug Discovery and Development Centre (H3D), University of Cape Town, Rondebosch, Cape Town 7701, South Africa
| | - Gregory S Basarab
- Drug Discovery and Development Centre (H3D), University of Cape Town, Rondebosch, Cape Town 7701, South Africa
| | - Sylva L Schwager
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town 7925, South Africa.,Department of Integrative Biomedical Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
| | - Kelly Chibale
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town 7925, South Africa.,Drug Discovery and Development Centre (H3D), University of Cape Town, Rondebosch, Cape Town 7701, South Africa.,Department of Chemistry, University of Cape Town, Rondebosch, Cape Town 7701, South Africa.,South African Medical Research Council Drug Discovery and Development Research Unit, University of Cape Town, Rondebosch, Cape Town 7701, South Africa
| | - K Ravi Acharya
- Department of Biology and Biochemistry, University of Bath, Claverton Down, Bath BA2 7AY, U.K
| | - Edward D Sturrock
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town 7925, South Africa.,Department of Integrative Biomedical Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
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4
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Sravanthi MV, Suma Kumaran S, Sharma N, Milekic B. Republished: ACE inhibitor induced visceral angioedema: an elusive diagnosis. Drug Ther Bull 2022; 60:13-15. [PMID: 34031178 DOI: 10.1136/dtb.2021.236391rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Sharmil Suma Kumaran
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Nishant Sharma
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Bojana Milekic
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
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5
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Kinins and Their Receptors as Potential Therapeutic Targets in Retinal Pathologies. Cells 2021; 10:cells10081913. [PMID: 34440682 PMCID: PMC8391508 DOI: 10.3390/cells10081913] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 12/29/2022] Open
Abstract
The kallikrein-kinin system (KKS) contributes to retinal inflammation and neovascularization, notably in diabetic retinopathy (DR) and neovascular age-related macular degeneration (AMD). Bradykinin type 1 (B1R) and type 2 (B2R) receptors are G-protein-coupled receptors that sense and mediate the effects of kinins. While B2R is constitutively expressed and regulates a plethora of physiological processes, B1R is almost undetectable under physiological conditions and contributes to pathological inflammation. Several KKS components (kininogens, tissue and plasma kallikreins, and kinin receptors) are overexpressed in human and animal models of retinal diseases, and their inhibition, particularly B1R, reduces inflammation and pathological neovascularization. In this review, we provide an overview of the KKS with emphasis on kinin receptors in the healthy retina and their detrimental roles in DR and AMD. We highlight the crosstalk between the KKS and the renin–angiotensin system (RAS), which is known to be detrimental in ocular pathologies. Targeting the KKS, particularly the B1R, is a promising therapy in retinal diseases, and B1R may represent an effector of the detrimental effects of RAS (Ang II-AT1R).
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6
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Mohanty S, Bangaari A, Gnanasekaran K. Case Report: Compromised Airway Following Anesthesia and Its Correlation With the Use of ACE Inhibitors-An Unexpected Clinical Event and Review of Literature. Front Surg 2021; 8:631456. [PMID: 33829036 PMCID: PMC8021017 DOI: 10.3389/fsurg.2021.631456] [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: 11/20/2020] [Accepted: 02/08/2021] [Indexed: 11/24/2022] Open
Abstract
Angiotensin-converting enzyme inhibitors associated angioedema involving the upper aerodigestive tract is indisputably a hazardous airway condition which is clinically poorly recognized and frequently underestimated. We describe and present case of a 70-year old man on ramipril who developed massive tongue swelling post-operatively after unremarkable laryngeal mask anaesthesia which was fortuitously managed conservatively. High index of suspicion, timely recognition and knowledge of pathophysiology and the clinical course should guide airway and further supportive management in these patients.
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Affiliation(s)
| | - Ashish Bangaari
- Department of Anaesthesia, MIOT International, Chennai, India
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7
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Sravanthi MV, Suma Kumaran S, Sharma N, Milekic B. ACE inhibitor induced visceral angioedema: an elusive diagnosis. BMJ Case Rep 2020; 13:13/11/e236391. [DOI: 10.1136/bcr-2020-236391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
ACE inhibitors are widely used and well-tolerated drugs. Angioedema is a well-known adverse effect, which involves the viscera rarely. This is a case of a 44-year-old African-American man with newly diagnosed hypertension, who presented with lower abdominal pain and diarrhoea. Based on the clinical picture and radiographic findings, lisinopril-induced intestinal angioedema was diagnosed. He recovered with supportive treatment, and the lisinopril was permanently discontinued. The mechanism of angioedema is thought to be the inhibition of ACE-mediated degradation of bradykinin, which is a peptide responsible for vasodilation and increased vascular permeability. While the external angioedema is unmistakable, intestinal angioedema has a relatively non-specific presentation and chronology, often leading to missed diagnosis and unnecessary interventions. Most common symptoms are abdominal pain and diarrhoea. Characteristic radiographic findings include ‘doughnut sign’ and ‘stacked coin’ appearance. Treatment is supportive. ACE inhibitors should be discontinued to prevent a recurrence.
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8
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Cao DY, Saito S, Veiras LC, Okwan-Duodu D, Bernstein EA, Giani JF, Bernstein KE, Khan Z. Role of angiotensin-converting enzyme in myeloid cell immune responses. Cell Mol Biol Lett 2020; 25:31. [PMID: 32508938 PMCID: PMC7249647 DOI: 10.1186/s11658-020-00225-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/05/2020] [Indexed: 02/07/2023] Open
Abstract
Angiotensin-converting enzyme (ACE), a dicarboxypeptidase, plays a major role in the regulation of blood pressure by cleaving angiotensin I into angiotensin II (Ang II), a potent vasoconstrictor. Because of its wide substrate specificity and tissue distribution, ACE affects many diverse biological processes. In inflammatory diseases, including granuloma, atherosclerosis, chronic kidney disease and bacterial infection, ACE expression gets upregulated in immune cells, especially in myeloid cells. With increasing evidences connecting ACE functions to the pathogenesis of these acquired diseases, it is suggested that ACE plays a vital role in immune functions. Recent studies with mouse models of bacterial infection and tumor suggest that ACE plays an important role in the immune responses of myeloid cells. Inhibition of ACE suppresses neutrophil immune response to bacterial infection. In contrast, ACE overexpression in myeloid cells strongly induced bacterial and tumor resistance in mice. A detailed biochemical understanding of how ACE activates myeloid cells and which ACE peptide(s) (substrate or product) mediate these effects could lead to the development of novel therapies for boosting immunity against a variety of stimuli, including bacterial infection and tumor.
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Affiliation(s)
- Duo-Yao Cao
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA
| | - Suguru Saito
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA
| | - Luciana C Veiras
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA
| | - Derick Okwan-Duodu
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA.,Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Davis Res. Bldg., Rm. 2014, 8700 Beverly Blvd, Los Angeles, CA 90048 USA
| | - Ellen A Bernstein
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA
| | - Jorge F Giani
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA.,Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Davis Res. Bldg., Rm. 2014, 8700 Beverly Blvd, Los Angeles, CA 90048 USA
| | - Kenneth E Bernstein
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA.,Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Davis Res. Bldg., Rm. 2014, 8700 Beverly Blvd, Los Angeles, CA 90048 USA
| | - Zakir Khan
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA.,Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Davis Res. Bldg., Rm. 2014, 8700 Beverly Blvd, Los Angeles, CA 90048 USA
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9
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Roche JA, Roche R. A hypothesized role for dysregulated bradykinin signaling in COVID-19 respiratory complications. FASEB J 2020; 34:7265-7269. [PMID: 32359101 PMCID: PMC7267506 DOI: 10.1096/fj.202000967] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 01/13/2023]
Abstract
As of April 20, 2020, over time, the COVID-19 pandemic has resulted in 157 970 deaths out of 2 319 066 confirmed cases, at a Case Fatality Rate of ~6.8%. With the pandemic rapidly spreading, and health delivery systems being overwhelmed, it is imperative that safe and effective pharmacotherapeutic strategies are rapidly explored to improve survival. In this paper, we use established and emerging evidence to propose a testable hypothesis that, a vicious positive feedback loop of des-Arg(9)-bradykinin- and bradykinin-mediated inflammation → injury → inflammation, likely precipitates life threatening respiratory complications in COVID-19. Through our hypothesis, we make the prediction that the FDA-approved molecule, icatibant, might be able to interrupt this feedback loop and, thereby, improve the clinical outcomes. This hypothesis could lead to basic, translational, and clinical studies aimed at reducing COVID-19 morbidity and mortality.
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Affiliation(s)
- Joseph A Roche
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Renuka Roche
- College of Health and Human Services, Eastern Michigan University, Ypsilanti, MI, USA
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10
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Arendse LB, Danser AHJ, Poglitsch M, Touyz RM, Burnett JC, Llorens-Cortes C, Ehlers MR, Sturrock ED. Novel Therapeutic Approaches Targeting the Renin-Angiotensin System and Associated Peptides in Hypertension and Heart Failure. Pharmacol Rev 2019; 71:539-570. [PMID: 31537750 PMCID: PMC6782023 DOI: 10.1124/pr.118.017129] [Citation(s) in RCA: 201] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite the success of renin-angiotensin system (RAS) blockade by angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 receptor (AT1R) blockers, current therapies for hypertension and related cardiovascular diseases are still inadequate. Identification of additional components of the RAS and associated vasoactive pathways, as well as new structural and functional insights into established targets, have led to novel therapeutic approaches with the potential to provide improved cardiovascular protection and better blood pressure control and/or reduced adverse side effects. The simultaneous modulation of several neurohumoral mediators in key interconnected blood pressure-regulating pathways has been an attractive approach to improve treatment efficacy, and several novel approaches involve combination therapy or dual-acting agents. In addition, increased understanding of the complexity of the RAS has led to novel approaches aimed at upregulating the ACE2/angiotensin-(1-7)/Mas axis to counter-regulate the harmful effects of the ACE/angiotensin II/angiotensin III/AT1R axis. These advances have opened new avenues for the development of novel drugs targeting the RAS to better treat hypertension and heart failure. Here we focus on new therapies in preclinical and early clinical stages of development, including novel small molecule inhibitors and receptor agonists/antagonists, less conventional strategies such as gene therapy to suppress angiotensinogen at the RNA level, recombinant ACE2 protein, and novel bispecific designer peptides.
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Affiliation(s)
- Lauren B Arendse
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - A H Jan Danser
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Marko Poglitsch
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Rhian M Touyz
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - John C Burnett
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Catherine Llorens-Cortes
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Mario R Ehlers
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Edward D Sturrock
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
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11
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Davin L, Marechal P, Lancellotti P, Martinez C, Pierard L, Radermecker R. Angioedema: a rare and sometimes delayed side effect of angiotensin-converting enzyme inhibitors. Acta Cardiol 2019; 74:277-281. [PMID: 30328786 DOI: 10.1080/00015385.2018.1507477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The effects of angiotensin converting enzyme (ACE) inhibitors result from the inhibition of the ACE (kininase II) to ultimately influence both the renin-angiotensin system and the degradation of the bradykinin (BK) metabolism. ACE inhibitors block the degradation of BK and substance P by ACE. In addition, an active metabolite of BK (Des-Arg9-BK) is catalysed by kininase I and its degradation is controlled in part by the conversion enzyme. These molecules have been associated with increased plasma extravasation associated with ACE inhibitors. ACE inhibitors are the leading cause of drug-induced Angioedema (AE). Symptoms of AE mainly occur after the first month of treatment by ACE. However, very late onset cases, sometimes after several years of stable therapy, are also described in the literature. It has been observed that patients previously stable under ACE inhibitor will most likely develop AE soon after the addition of another medication, including the combination of aspirin or non-steroid anti-inflammatory drugs with ACE inhibitor which has proved to be the most common cause, accounting for close to 50% of all AE cases related to ACE inhibitors. This side effect of ACE inhibitors, sometimes very late and rare, deserves to be recalled.
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Affiliation(s)
- Laurent Davin
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
- GIGA Cardiovascular Sciences University Hospital of Liege
| | - Patrick Marechal
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
| | - Patrizio Lancellotti
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
- GIGA Cardiovascular Sciences University Hospital of Liege
| | - Christophe Martinez
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
| | - Luc Pierard
- University of Liege Hospital; CHU Sart Tilman Liege Belgium; Department of Cardiology
- GIGA Cardiovascular Sciences University Hospital of Liege
| | - Regis Radermecker
- Diabetes, Nutrition and Metabolic disorders Unit CHU Liege; Clinical Pharmacology, Liege University, Belgium
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12
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Sachs B, Meier T, Nöthen MM, Stieber C, Stingl J. [Drug-induced angioedema : Focus on bradykinin]. Hautarzt 2019; 69:298-305. [PMID: 29392343 DOI: 10.1007/s00105-017-4119-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
On a pathophysiological level, angioedema can be differentiated into histamine- and bradykinin-mediated types. The prototype drug-associated, bradykinin-mediated form of angioedema is angiotensin-converting enzyme (ACE) inhibitor-induced angioedema. The hypothesized cause is a decrease in bradykinin degradation via ACE inhibition. In this scenario, other bradykinin-degrading enzymes assume major importance. When the effect of these enzymes is also diminished, e. g., due to genetic variants or external factors, compensation for the inhibition of ACE may be insufficient. An increased risk of angioedema has also been reported for other drugs, particularly when prescribed in combination with ACE inhibitors. Here, the suspected cause also relates to the degradation of bradykinin. When angioedema arises within the context of concomitant ACE inhibitor use, additive bradykinin degradation effects may be implicated.
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Affiliation(s)
- B Sachs
- Klinik für Dermatologie und Allergologie, RWTH Aachen, Aachen, Deutschland. .,Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland.
| | - T Meier
- Abteilung Pharmakovigilanz, Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Deutschland
| | - M M Nöthen
- Institut für Humangenetik, Universität Bonn, Bonn, Deutschland
| | - C Stieber
- Institut für Humangenetik, Universität Bonn, Bonn, Deutschland
| | - J Stingl
- Zentrum für Translationale Medizin, Universität Bonn, Bonn, Deutschland.,Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland
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13
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Chen SX, Hermelin D, Weintraub SJ. Possible donor-dependent differences in efficacy of fresh frozen plasma for treatment of ACE inhibitor-induced angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2087-2088. [PMID: 30836229 DOI: 10.1016/j.jaip.2019.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Sara X Chen
- Division of Hospital Medicine, Department of Medicine, Saint Louis Veterans Affairs Medical Center, Saint Louis, Mo; Department of Medicine, Washington University School of Medicine, Saint Louis, Mo
| | - Daniela Hermelin
- Department of Pathology, Saint Louis University School of Medicine, Saint Louis, Mo
| | - Steven J Weintraub
- Division of Hospital Medicine, Department of Medicine, Saint Louis Veterans Affairs Medical Center, Saint Louis, Mo; Department of Medicine, Washington University School of Medicine, Saint Louis, Mo.
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14
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Patel H, Kant S, Chow R. A rare presentation of angioedema with isolated retropharyngeal and supraglottic involvement. J Community Hosp Intern Med Perspect 2019; 9:36-39. [PMID: 30788074 PMCID: PMC6374935 DOI: 10.1080/20009666.2018.1562855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/18/2018] [Indexed: 11/07/2022] Open
Abstract
Angiotensin converting-enzyme (ACE) inhibitors are commonly prescribed drugs with multiple indications including congestive heart failure, hypertension, and diabetic nephropathy. ACE inhibitor induced angioedema is commonly seen across emergency departments and clinics, with transient swelling of lips, tongue, and other facial structures being the common presentation. Isolated airway obstruction as a result of pharyngeal and laryngeal swelling without facial swelling is a rare presentation. We present a case of a patient on lisinopril therapy for one year who experienced severe airway compromise without the classic symptoms of ACE inhibitor induced angioedema. He required emergent cricothyroidotomy to secure his airway, as fiberoptic laryngoscopy showed 90% obstruction and inability to visualize true vocal cords. His ACE inhibitor therapy was discontinued, and he was discharged home within a few days with no residual symptoms.
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Affiliation(s)
- H Patel
- Department of Medicine, American University of Antigua, New York, USA
| | - S Kant
- Department of Nephrology/Internal Medicine, University of Maryland, Maryland, USA
| | - R Chow
- Department of Nephrology/Internal Medicine, University of Maryland, Maryland, USA
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15
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Yılmaz İ. Angiotensin-Converting Enzyme Inhibitors Induce Cough. Turk Thorac J 2019; 20:36-42. [PMID: 30664425 DOI: 10.5152/turkthoracj.2018.18014] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 09/18/2018] [Indexed: 01/13/2023]
Abstract
Angiotensin-converting enzyme inhibitors (ACE-I) are widely used in diseases, such as hypertension, congestive heart failure, and myocardial infarction. Although these drugs are well tolerated, one out of five patients discontinues ACE-I due to drug side effects, mainly chronic cough. However, the pathogenesis of ACE-I-induced cough remains controversial and requires further study. In this review, the mechanisms that are suggested in ACE-I-induced cough pathophysiology will be discussed in detail in light of the current literature.
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Affiliation(s)
- İnsu Yılmaz
- Department of Chest Diseases, Division of Immunology and Allergy, Erciyes University School of Medicine, Kayseri, Turkey
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16
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Charest-Morin X, Hébert J, Rivard GÉ, Bonnefoy A, Wagner E, Marceau F. Comparing Pathways of Bradykinin Formation in Whole Blood From Healthy Volunteers and Patients With Hereditary Angioedema Due to C1 Inhibitor Deficiency. Front Immunol 2018; 9:2183. [PMID: 30333824 PMCID: PMC6176197 DOI: 10.3389/fimmu.2018.02183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/04/2018] [Indexed: 12/26/2022] Open
Abstract
Multiple pathways have been proposed to generate bradykinin (BK)-related peptides from blood. We applied various forms of activation to fresh blood obtained from 10 healthy subjects or 10 patients with hereditary angioedema (HAE-1 or −2 only) to investigate kinin formation. An enzyme immunoassay for BK was applied to extracts of citrated blood incubated at 37°C under gentle agitation for 0–2 h in the presence of activators and/or inhibitory agents. Biologically active kinins in extracts were corroborated by c-Fos accumulation in HEK 293a cells that express either recombinant human B2 or B1 receptors (B2R, B1R). Biological evidence of HAE diagnostic and blood cell activation was also obtained. The angiotensin converting enzyme inhibitor enalaprilat, without any effect per se, increased immunoreactive BK (iBK) concentration under active stimulation of blood. Tissue kallikrein (KLK-1) and Kontact-APTT, a particulate material that activates the contact system, rapidly (5 min) and intensely (>100 ng/mL) induced similar iBK generation in the blood of control or HAE subjects. Tissue plasminogen activator (tPA) slowly (≥1 h) induced iBK generation in control blood, but more rapidly and intensely so in that of HAE patients. Effects of biotechnological inhibitors indicate that tPA recruits factor XIIa (FXIIa) and plasma kallikrein to generate iBK. KLK-1, independent of the contact system, is the only stimulus leading to an inconsistent B1R stimulation. Stimulating neutrophils or platelets did not generate iBK. In the HAE patients observed during remission, iBK formation capability coupled to B2R stimulation appears largely intact. However, a selective hypersensitivity to tPA in the blood of HAE patients suggests a role of plasmin-activated FXIIa in the development of attacks. Proposed pathways of kinin formation dependent on blood cell activation were not corroborated.
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Affiliation(s)
- Xavier Charest-Morin
- Axe Microbiologie-Infectiologie et Immunologie, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Jacques Hébert
- Service d'allergie, CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Arnaud Bonnefoy
- Division of Hematology/Oncology, CHU Sainte-Justine, Montréal, QC, Canada
| | - Eric Wagner
- Axe Microbiologie-Infectiologie et Immunologie, CHU de Québec-Université Laval, Québec, QC, Canada
| | - François Marceau
- Axe Microbiologie-Infectiologie et Immunologie, CHU de Québec-Université Laval, Québec, QC, Canada
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17
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Meta-analysis of genome-wide association studies on the intolerance of angiotensin-converting enzyme inhibitors. Pharmacogenet Genomics 2017; 27:112-119. [PMID: 28030426 DOI: 10.1097/fpc.0000000000000264] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify single nucleotide polymorphisms (SNPs) associated with switching from an angiotensin-converting enzyme (ACE)-inhibitor to an angiotensin receptor blocker. METHODS Two cohorts of patients starting ACE-inhibitors were identified within the Rotterdam Study in the Netherlands and the Genetics of Diabetes Audit and Research in Tayside Scotland study in Scotland. Cases were intolerant patients who switched from an ACE-inhibitor to an angiotensin receptor blocker and controls were individuals who used ACE-inhibitors continuously for at least 2 years and did not switch. Genome-wide association study (GWAS) using an additive model was run in these sets and the results were meta-analysed using Genome-Wide Association Meta Analysis software. RESULTS A total of 972 cases out of 5161 ACE-inhibitor starters were identified. Eight SNPs within four genes reached the genome-wide association study significance level (P<5×10) in the meta-analysis [RNA binding protein, Fox-1 homolog (Caenorhabditis elegans), γ-aminobutyric acid receptor subunit γ-2, sarcoma (Src) homology 2 (SH2) B adaptor protein 1 and membrane bound O-acyltransferase domain containing 1]. The strongest associated SNP was located in an intron of RNA binding protein, Fox-1 homolog (Caenorhabditis elegans), which contains an RNA binding protein [rs2061538: minor allele frequency=0.16, odds ratio=1.52 (95% confidence interval: 1.32-1.76), P=6.2×10]. CONCLUSION These results indicate that genetic variation in the above-mentioned genes may increase the risk of ACE-inhibitor-induced adverse reactions.
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18
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Angioedema Due to ACE Inhibitors. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0099-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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19
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Abstract
Objective: To report a case of olmesartan medoxomil-induced angioedema in an angiotensin-converting enzyme (ACE) inhibitor–naïve patient. Case Summary: A 61-year-old white woman with hypertension experienced significant swelling of her face, neck, and lips 10 days after initiation of olmesartan medoxomil 20 mg/day. After discontinuation of the drug, symptoms resolved within 10 days. Use of the Naranjo probability scale indicated a probable association between angioedema and olmesartan medoxomil. Discussion: An angiotensin receptor blocker (ARB) is, in many cases, considered a safe alternative to an ACE inhibitor since serum bradykinin is thought not to be affected. However, angioedema has been reported with the use of ARBs, suggesting alternative pathways or mechanisms that result in this adverse reaction. Although not proven in humans, one explanation is that a secondary stimulation of angiotensin II AT2 receptors produces an increase in tissue bradykinin, resulting in angioedema. Conclusions: As of February 26, 2007, this is the first published reported case of olmesartan medoxomil–induced angioedema. Practitioners should be aware of this rare but potentially serious adverse event.
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Affiliation(s)
- Diane Nykamp
- Department of Clinical and Administrative Services, College of Pharmacy and Health Sciences, Mercer University, Atlanta, GA 30341, USA.
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20
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Kageyama T, Okanoue Y, Takai R, Suenaga T. Cardiovascular Instability Preceded by Orolingual Angioedema after Alteplase Treatment. Intern Med 2016; 55:409-12. [PMID: 26875969 DOI: 10.2169/internalmedicine.55.4772] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
An 87-year-old man taking antihypertensive medications, including 10 mg enalapril, daily visited our hospital complaining of motor aphasia, dysarthria, and right hemiparesis. Magnetic resonance imaging revealed an ischemic lesion in the left frontal lobe including the insular cortex and severe stenosis of the left middle cerebral artery. After he received intravenous alteplase infusion, he developed orolingual angioedema followed by transient bradycardia with subsequent hypotension, resulting in the deterioration of his neurological signs and expansion of the ischemic lesion. Orolingual angioedema after intravenous alteplase infusion may follow cardiovascular instability and disease progression in stroke patients.
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21
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Sala-Cunill A, Guilarte M. The Role of Mast Cells Mediators in Angioedema Without Wheals. CURRENT TREATMENT OPTIONS IN ALLERGY 2015. [DOI: 10.1007/s40521-015-0067-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Isolated Visceral Angioedema Induced by Angiotensin-Converting Enzyme Inhibitor. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2015; 23:162-165. [PMID: 28868452 PMCID: PMC5580168 DOI: 10.1016/j.jpge.2015.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 09/27/2015] [Indexed: 11/23/2022]
Abstract
Visceral angioedema is a rare complication of therapy with angiotensin-converting enzyme (ACE) inhibitors. Clinical presentation includes nausea, vomiting, abdominal pain and diarrhea. Early detection of this entity can prevent recurrent episodes and unnecessary invasive procedures, including surgery. This article describes a 46-year-old-woman who presented to the emergency department with abdominal pain, associated with nausea and vomiting. She had been taking ramipril for 15 days. A computed tomography was performed which revealed thickening of a jejunal segment, with submucosal edema. ACE inhibitor-associated angioedema was suspected and the medication was discontinued, with resolution of symptoms in 48 h. After 7 months of follow-up, the patient is asymptomatic. Despite of its rarity, ACE inhibitor-induced small-bowel angioedema should be included in the differential diagnosis when patients receiving ACE inhibitor therapy present with abdominal complaints.
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23
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Culley CM, DiBridge JN, Wilson GL. Off-Label Use of Agents for Management of Serious or Life-threatening Angiotensin Converting Enzyme Inhibitor–Induced Angioedema. Ann Pharmacother 2015; 50:47-59. [DOI: 10.1177/1060028015607037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To evaluate the place in therapy of fresh frozen plasma (FFP), C1 esterase concentrate (C1-INH), ecallantide, and icatibant in the management of angiotensin-converting enzyme inhibitor–induced angioedema (ACEI-IA). Data Sources: A literature search was performed using PubMed (1946 through August 2015) and Embase (<1966 through August 2015). References from identified articles were reviewed. Study Selection and Data Extraction: Consensus papers, practice guidelines, case reports/series, clinical trials, and meeting abstracts published in English and involving humans were included. Data Synthesis: No medications are currently Food and Drug Administration–approved for managing ACEI-IA. Emerging evidence suggests that FFP and medications approved for management of acute attacks of hereditary angioedema, another bradykinin-mediated event, may be effective for use in ACEI-IA. Positive efficacy results were reported with FFP and C1-INH while mixed results have been seen with ecallantide. Off-label icatibant has the most evidence supporting its use in ACEI-IA with rapid symptom resolution (10 minutes to 6 hours) and avoidance of intubation and tracheotomy in several cases. These agents were well-tolerated in ACEI-IA. Conclusion: ACEI-IA is typically a self-limiting event. First-line therapies include ACEI discontinuation, observation, and supportive medications (eg, corticosteroids, antihistamines, and epinephrine). Symptom progression can be life-threatening and may require interventions such as tracheotomy and intubation. Off-label use of FFP and medications approved for hereditary angioedema have resulted in rapid resolution of symptoms and avoidance of intubation. Among these agents, icatibant has the most supporting evidence and has been incorporated into practice guidelines and algorithms as a second-line agent for serious life-threatening ACE-IA.
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Affiliation(s)
- Colleen M. Culley
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
- UPMC Pharmacy Service Line, Pittsburgh, PA, USA
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24
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Bezalel S, Mahlab-Guri K, Asher I, Werner B, Sthoeger ZM. Angiotensin-converting enzyme inhibitor-induced angioedema. Am J Med 2015; 128:120-5. [PMID: 25058867 DOI: 10.1016/j.amjmed.2014.07.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 07/13/2014] [Accepted: 07/14/2014] [Indexed: 01/13/2023]
Abstract
Angiotensin-converting enzyme inhibitors (ACE-I) are widely used, effective, and well-tolerated antihypertensive agents. The mechanisms by which those agents act can cause side effects such as decreased blood pressure, hyperkalemia, and impaired renal function. ACE-I can induce cough in 5%-35% and angioedema in up to 0.7% of treated patients. Because cough and angioedema are considered class adverse effects, switching treatment to other ACE-I agents is not recommended. Angioedema due to ACE-I has a low fatality rate, although deaths have been reported when the angioedema involves the airways. Here, we review the role of bradykinin in the development of angioedema in patients treated with ACE-I, as well as the incidence, risk factors, clinical presentation, and available treatments for ACE-I-induced angioedema. We also discuss the risk for recurrence of angioedema after switching from ACE-I to angiotensin receptor blockers treatment.
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Affiliation(s)
- Shira Bezalel
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel
| | - Keren Mahlab-Guri
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel
| | - Ilan Asher
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel
| | - Ben Werner
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel
| | - Zev Moshe Sthoeger
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel.
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25
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Charignon D, Ghannam A, Defendi F, Ponard D, Monnier N, López Trascasa M, Launay D, Caballero T, Djenouhat K, Fain O, Cichon S, Martin L, Drouet C. Hereditary angioedema with F12 mutation: factors modifying the clinical phenotype. Allergy 2014; 69:1659-65. [PMID: 25134986 DOI: 10.1111/all.12515] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) with normal C1 inhibitor (C1Inh) associated with the c.983C>A and c.983C>G mutations of the F12 gene (FXII-HAE) is a rare condition, and presents with highly variable clinical expression. On the basis of data gathered from a large carrier cohort, we assessed the modifiers affecting the clinical phenotype. METHODS We analyzed clinical and biological data recorded from 118 mutation carriers (80 symptomatic and 38 asymptomatic), 58 noncarrier relatives from 40 families, and 200 healthy donors. Disease severity was scored in relation to frequency and location of edema, as well as age at disease onset. To predict FXII-HAE disease severity, we analyzed the biological phenotype [C1Inh, C4, spontaneous amidase, angiotensin-I-converting enzyme (ACE), aminopeptidase P (APP), and carboxypeptidase N/M (CPN)] by means of logistic regression (Akaike information criterion) and odds ratio (OR). RESULTS Meaningful variables contributed to FXII-HAE, with the kinin catabolism enzymes ACE and CPN exhibiting a significant inverse relationship with disease severity (OR = 0.36, 95% CI 0.23-0.59, P < 0.001; OR = 0.58, 95% CI 0.36-0.91, P < 0.05, respectively). CPN activities were 37.5 (28.5-41.3) nmol/ml/min and 38.5 (32.8-45.6) for FXII-HAE asymptomatic and symptomatic carriers, respectively, and 37.9 (30.5-43.7) nmol/ml/min for noncarriers. Angiotensin-I-converting enzyme activities were 58 (44-76) and 49 (35-59) nmol/ml/min for FXII-HAE asymptomatic and symptomatic carriers, respectively, and 56 (49-66) nmol/ml/min for noncarriers. CONCLUSIONS The FXII-HAE is associated with modifiers, for example kinin catabolism enzymes, ACE and CPN, different from those recognized in HAE with C1Inh deficiency.
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Affiliation(s)
- D. Charignon
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
| | - A. Ghannam
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
| | - F. Defendi
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
| | - D. Ponard
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
| | - N. Monnier
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
| | - M. López Trascasa
- Institute for Health Research (IdiPaz); Hospital Universitario La Paz; Madrid Spain
- Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - D. Launay
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- Département de Médecine Interne; Université du Droit et de la Santé Lille 2; Lille France
| | - T. Caballero
- Institute for Health Research (IdiPaz); Hospital Universitario La Paz; Madrid Spain
- Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - K. Djenouhat
- Département d'Immunologie; Institut Pasteur; Alger Algeria
| | - O. Fain
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- Département de Médecine Interne; Université Paris XIII; Bondy France
| | - S. Cichon
- Institute für Humangenetics; Universität Bonn; Bonn Germany
- Departement Biomedizin; Universität Basel; Basel Switzerland
| | - L. Martin
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- Département de Dermatologie; L'UNAM Université; Hôpital d'Angers; Angers France
| | - C. Drouet
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
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26
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Cicardi M, Aberer W, Banerji A, Bas M, Bernstein JA, Bork K, Caballero T, Farkas H, Grumach A, Kaplan AP, Riedl MA, Triggiani M, Zanichelli A, Zuraw B. Classification, diagnosis, and approach to treatment for angioedema: consensus report from the Hereditary Angioedema International Working Group. Allergy 2014; 69:602-16. [PMID: 24673465 DOI: 10.1111/all.12380] [Citation(s) in RCA: 408] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 01/13/2023]
Abstract
Angioedema is defined as localized and self-limiting edema of the subcutaneous and submucosal tissue, due to a temporary increase in vascular permeability caused by the release of vasoactive mediator(s). When angioedema recurs without significant wheals, the patient should be diagnosed to have angioedema as a distinct disease. In the absence of accepted classification, different types of angioedema are not uniquely identified. For this reason, the European Academy of Allergy and Clinical Immunology gave its patronage to a consensus conference aimed at classifying angioedema. Four types of acquired and three types of hereditary angioedema were identified as separate forms from the analysis of the literature and were presented in detail at the meeting. Here, we summarize the analysis of the data and the resulting classification of angioedema.
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Affiliation(s)
- M. Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - W. Aberer
- Department of Dermatology; Medical University of Graz; Graz Austria
| | - A. Banerji
- Division of Rheumatology, Allergy and Immunology; Massachusetts General Hospital; Boston MA USA
| | - M. Bas
- Department of Otorhinolaryngology; Klinikum rechts der Isar; Technische Universität München; Munich Germany
| | - J. A. Bernstein
- Division of Immunology/Allergy Section; Department of Internal Medicine; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - K. Bork
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
| | - T. Caballero
- Department of Allergy; Hospital La Paz Institute for Health Research (IdiPaz); Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - H. Farkas
- 3rd Department of Internal Medicine; National Angioedema Center; Semmelweis University; Budapest Hungary
| | - A. Grumach
- Department of Clinical Medicine; Faculty of Medicine ABC; Sao Paulo Brazil
| | - A. P. Kaplan
- Medical University of South Carolina; Charleston SC
| | - M. A. Riedl
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
| | - M. Triggiani
- Department of Medicine; University of Salerno; Salerno Italy
| | - A. Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - B. Zuraw
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
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Lewis LM. Angioedema: Etiology, Pathophysiology, Current and Emerging Therapies. J Emerg Med 2013; 45:789-96. [DOI: 10.1016/j.jemermed.2013.03.045] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 12/02/2012] [Accepted: 03/24/2013] [Indexed: 01/30/2023]
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28
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Severe angioedema induced by angiotensin II receptor blocker. Int J Cardiol 2013; 168:e15-6. [DOI: 10.1016/j.ijcard.2013.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 05/04/2013] [Indexed: 11/18/2022]
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Mahmoudpour SH, Leusink M, van der Putten L, Terreehorst I, Asselbergs FW, de Boer A, Maitland-van der Zee AH. Pharmacogenetics of ACE inhibitor-induced angioedema and cough: a systematic review and meta-analysis. Pharmacogenomics 2013; 14:249-60. [PMID: 23394388 DOI: 10.2217/pgs.12.206] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIM Angioedema and cough are the two most important adverse effects of ACE inhibitors (ACEIs). Evidence exists that ACEI-related angioedema/cough is partly genetically determined and several genes have been identified to play a role in the development of ACEI-related adverse effects. MATERIALS & METHODS This study was performed in order to evaluate the evidence of these genetic associations and ACEIs' adverse effects. After removing duplicates and critical appraisal, 19 studies were considered to be eligible to review; 14 articles about cough and five articles about angioedema. A separate meta-analysis was performed for the most studied ACE insertion/deletion polymorphism (rs4646994) and its association with cough. RESULTS & CONCLUSION One gene region (XPNPEP2) was associated with ACEI-induced angioedema in three studies. In our meta-analysis we did not find a significant association between the ACE insertion/deletion polymorphism and ACEI cough.
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Affiliation(s)
- Seyed Hamidreza Mahmoudpour
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
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31
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Gang C, Lindsell CJ, Moellman J, Sublett W, Hart K, Collins S, Bernstein JA. Factors associated with hospitalization of patients with angiotensin-converting enzyme inhibitor-induced angioedema. Allergy Asthma Proc 2013; 34:267-73. [PMID: 23676576 DOI: 10.2500/aap.2013.34.3664] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Angiotensin-converting enzyme inhibitor (ACE-I)-induced angioedema can be life-threatening without emergent intervention. The putative mediator is believed to be bradykinin, similar to hereditary angioedema, so these patients respond poorly to corticosteroids and antihistamines. This study was designed to determine characteristics and clinical outcomes of patients presenting to an emergency department (ED) with ACE-I angioedema. This was a retrospective chart review of 100 patients presenting to the ED from 2007 to 2008 with an ICD-9 code of 995.1 (angioedema) or 995.2 (drug-induced angioedema). Two hundred fifty-two patients with these ICD-9 codes were identified and placed in random order, and the first 100 meeting inclusion criteria were included. Statistical analysis was primarily descriptive. All 100 patients had an ICD-9 code of 995.1 (angioedema). Patients presented in every month, with spring months (April-June) having the most presentations (32%). The median age was 59 years, 75% were African American, and 66% were admitted to the hospital. Two patients (2%) required endotracheal intubation. Lisinopril was the most commonly prescribed ACE-I (84%). The most common symptom was moderate lip and tongue swelling (89%) followed by mild difficulty breathing (12%). Tongue swelling was significantly associated with admission. Time from symptom onset to ED presentation was not associated with need for admission. Concomitant medications did not differ between admitted and discharged patients. ACE-I angioedema is associated with significant morbidity and health care use because many patients require hospitalization, suggesting an unmet need for novel therapies targeted to treat this condition.
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Affiliation(s)
- Cheng Gang
- Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, USA
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Association of B2
Receptor Polymorphisms and ACE Activity With ACE Inhibitor-Induced Angioedema in Black and Mixed-Race South Africans. J Clin Hypertens (Greenwich) 2013; 15:413-9. [DOI: 10.1111/jch.12104] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 02/08/2013] [Accepted: 02/10/2013] [Indexed: 11/26/2022]
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Hassen GW, Kalantari H, Parraga M, Chirurgi R, Meletiche C, Chan C, Ciarlo J, Gazi F, Lobaito C, Tadayon S, Yemane S, Velez C. Fresh Frozen Plasma for Progressive and Refractory Angiotensin-Converting Enzyme Inhibitor-induced Angioedema. J Emerg Med 2013; 44:764-72. [DOI: 10.1016/j.jemermed.2012.07.055] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 03/12/2012] [Accepted: 07/01/2012] [Indexed: 01/13/2023]
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Gonçalves-Zillo TO, Pugliese LS, Sales VMT, Mori MADS, Squaiella-Baptistão CC, Longo-Maugéri IM, Lopes JD, de Oliveira SM, Monteiro AC, Pesquero JB. Increased bone loss and amount of osteoclasts in kinin B1 receptor knockout mice. J Clin Periodontol 2013; 40:653-60. [PMID: 23534940 DOI: 10.1111/jcpe.12097] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 02/08/2013] [Accepted: 02/11/2013] [Indexed: 11/27/2022]
Abstract
AIM The pathophysiology of periodontal diseases involves aspects of immunity and bone remodelling. Considering the role of the kinin B1 receptor (Bdkrb1) in inflammation and healing, the purpose of this study was to evaluate the contribution of Bdkrb1 to the pathogenesis of periodontitis. MATERIAL AND METHODS We used a model of ligature-induced experimental periodontitis (LIEP) in mice lacking Bdkrb1 (Bdkrb1(-/-) ) to test the role of this receptor in bone loss and cytokine secretion by lymph nodes cells. Angiotensin-converting enzyme inhibitor (ACEi) was used as a pharmacological strategy to support the genetic model. Also, autonomous effect of Bdkrb1 deletion was evaluated in osteoclasts precursors from bone marrow. RESULTS Bdkrb1(-/-) mice exhibit increased bone loss and IL-17 secretion in response to LIEP when compared to wild type. LIEP does not modify TNF-α, IFN-γ and IL-10 levels in Bdkrb1(-/-) mice after 21 days. Bone marrow cells from Bdkrb1(-/-) displayed increased differentiation into functional osteoclasts with consistent artificial calcium phosphate degradation. Furthermore, treatment of mice with ACEi prevented bone destruction. CONCLUSION Bdkrb1 participates in the pathogenesis of LIEP bone loss possibly through mechanisms that involve modulation of the TH 17 response, thereby demonstrating its role in the development of periodontitis.
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del Río-Espínola A, Fernández-Cadenas I, Giralt D, Quiroga A, Gutiérrez-Agulló M, Quintana M, Fernández-Álvarez P, Domingues-Montanari S, Mendióroz M, Delgado P, Turck N, Ruíz A, Ribó M, Castellanos M, Obach V, Martínez S, Freijo MM, Jiménez-Conde J, Cuadrado-Godia E, Roquer J, Chacón P, Martí-Fábregas J, Sánchez JC, Montaner J. A predictive clinical-genetic model of tissue plasminogen activator response in acute ischemic stroke. Ann Neurol 2012; 72:716-29. [DOI: 10.1002/ana.23664] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 05/29/2012] [Accepted: 06/01/2012] [Indexed: 11/07/2022]
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Valsartan-Induced Angioedema in a Patient on Angiotensin-Converting Enzyme Inhibitor for Years. Am J Ther 2012; 19:e189-92. [DOI: 10.1097/mjt.0b013e3181f28f84] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Angioedema is a serious complication of renin-angiotensin system inhibitor therapy. The incidence is 0.1-0.7%. It consists of nonpitting edema and involves the face and lips. In severe cases, it extends to pharyngeal and laryngeal structures. RECENT FINDINGS Decreased degradation of bradykinin and its metabolites is thought to be a culprit. When the angiotensin-converting enzyme is inhibited, bradykinin metabolism is dependent on degradation by neutral endopeptidase, dipeptidyl peptidase IV, and aminopeptidase P. When these enzymes are inhibited, as in treatment of diabetes or in transplant recipients, the incidence of angioedema increases significantly. African-Americans, people over 65, women, and those with a history of smoking are especially at risk. A fiberoptic laryngeal examination should be performed in all patients. Patients with rapid progression of symptoms are at risk for airway compromise. Supportive treatment with steroids and antihistamines is not very effective. Recently, icatibant, a bradykinin receptor antagonist, has been used to successfully shorten the resolution of edema. SUMMARY Trauma of the airway, especially during difficult intubation, may precipitate severe angioedema. In cases with laryngeal involvement, fiberoptic intubation may be necessary. After the episode of angioedema, lifetime discontinuation of all renin-angiotensin inhibitors may be warranted.
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de Graaff LCG, van Essen M, Schipper EM, Boom H, Duschek EJJ. Unnecessary surgery for acute abdomen secondary to angiotensin-converting enzyme inhibitor use. Am J Emerg Med 2012; 30:1607-12. [PMID: 22867837 DOI: 10.1016/j.ajem.2011.10.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 10/29/2011] [Indexed: 11/17/2022] Open
Abstract
Acute abdominal pain is the reason for 5% to 10% of all emergency department visits. In 1 in every 9 patients, operated on for an acute abdomen, laparotomy is negative. In a minority of patients, the acute abdomen is caused by side effects of medication. We present a case of unnecessary abdominal surgery in a patient with acute abdominal pain caused by intestinal angioedema (AE), which was eventually due to angiotensin-converting enzyme inhibitor (ACE-i) use. We hope that this case report increases awareness of this underdiagnosed side effect. Emergency department physicians, surgeons, internists, and family physicians should always consider ACE-i in the differential diagnosis of unexplained abdominal pain. Since early withdrawal of the medication causing intestinal AE can prevent further complications and, in some cases, needless surgery, we propose an altered version of the known diagnostic algorithm, in which ACE-i and nonsteroidal anti-inflammatory drugs-induced AE is excluded at an early stage.
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Affiliation(s)
- Laura C G de Graaff
- Department of Internal Medicine, Reinier de Graaf Group of Hospitals, 2600GA Delft, The Netherlands.
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Zhou ZH, Chen T, Arora K, Hyams K, Kozlowski S. Complement C1 esterase inhibitor levels linked to infections and contaminated heparin-associated adverse events. PLoS One 2012; 7:e34978. [PMID: 22514695 PMCID: PMC3325920 DOI: 10.1371/journal.pone.0034978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 03/08/2012] [Indexed: 11/18/2022] Open
Abstract
Activation of kinin-kallikrein and complement pathways by oversulfated-chondroitin-sulfate (OSCS) has been linked with recent heparin-associated adverse clinical events. Given the fact that the majority of patients who received contaminated heparin did not experience an adverse event, it is of particular importance to determine the circumstances that increase the risk of a clinical reaction. In this study, we demonstrated by both the addition and affinity depletion of C1inh from normal human plasma, that the level of C1inh in the plasma has a great impact on the OSCS-induced kallikrein activity and its kinetics. OSCS-induced kallikrein activity was dramatically increased after C1inh was depleted, while the addition of C1inh completely attenuated kallikrein activity. In addition, actual clinical infection can lead to increased C1inh levels. Plasma from patients with sepsis had higher average levels of functional C1inh and decreased OSCS-induced kallikrein activity. Lastly, descriptive data on adverse event reports suggest cases likely to be associated with contaminated heparin are inversely correlated with infection. Our data suggest that low C1inh levels can be a risk factor and high levels can be protective. The identification of risk factors for contact system-mediated adverse events may allow for patient screening and clinical development of prophylaxis and treatments.
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Affiliation(s)
- Zhao-Hua Zhou
- Division of Monoclonal Antibodies, Office of Pharmaceutical Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States of America
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Korniyenko A, Alviar CL, Cordova JP, Messerli FH. Role of angiotensin-converting enzyme inhibitors in visceral angioedema. Int J Cardiol 2011; 148:377-9. [DOI: 10.1016/j.ijcard.2010.10.079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 10/23/2010] [Indexed: 01/13/2023]
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Jankovic S, Stefanovic S. Delayed angioedema during therapy with angiotensin-converting enzyme inhibitors. VOJNOSANIT PREGL 2011; 68:372-6. [DOI: 10.2298/vsp1104372j] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction. Angiotensin-converting enzyme inhibitors are leading cause of
drug-induced angioedema, with incidence of 0.1 to 0.2%. The angioedema is not
of immune nature; in predisposed individuals it is caused by accumulation of
vasoactive mediators due to reduced activity of angiotensinconverting enzyme.
Case report. We presented a 63-year old male patient suffering from
hypertension and chronic obstructive pulmonary disease, who had developed two
episodes of angioedema during a 5-year long therapy with enalapril. The first
episode happened after three, and the second after five years of the therapy.
On both occasions, the patient was admitted to the hospital and tracheotomy
was avoided in the last moment. Conclusion. Long-term therapy with
angiotensin-converting enzyme inhibitors could be associated with delayed
angioedema, especially in patients with inflammation of airways caused by
infection or chronic irritation.
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Affiliation(s)
- Slobodan Jankovic
- Medicinski fakultet, Kragujevac + Klinički centar Kragujevac, Služba za kliničku farmakologiju, Kragujevac
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Nzeako UC. Diagnosis and management of angioedema with abdominal involvement: A gastroenterology perspective. World J Gastroenterol 2010; 16:4913-21. [PMID: 20954277 PMCID: PMC2957599 DOI: 10.3748/wjg.v16.i39.4913] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Abdominal involvement in angioedema is often a challenge to diagnose. Acute onset abdominal pain is its most common presenting symptom, and misdiagnosis may lead to unnecessary surgical intervention. Familiarity with the types and presentations of angioedema can be invaluable to clinicians as they consider the differential diagnoses of a patient presenting with abdominal pain. Detailed personal and family histories, careful physical examination of the patient, combined with knowledge of angioedema types, can help clinicians perform their diagnostic evaluation. An accurate diagnosis is essential in order to provide appropriate treatment to patients with angioedema. Depending upon the diagnosis, treatment may be the avoidance of provoking factors (such as allergens or medications), inhibiting histamine-provoked reactions, or treating C1 esterase inhibitor deficiency.
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Bas M, Hoffmann TK, Tiemann B, Dao VTV, Bantis C, Balz V, Schultz-Coulon HJ, Stark T, Schuler P, Greve J, Ivens K, Bier H, Kojda G. Potential genetic risk factors in angiotensin-converting enzyme-inhibitor-induced angio-oedema. Br J Clin Pharmacol 2010; 69:179-86. [PMID: 20233181 DOI: 10.1111/j.1365-2125.2009.03567.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIMS The pathophysiology of angiotensin-converting enzyme inhibitor (ACEi)-induced angio-oedema remains unclear. We have investigated the impact of ACE insertion/deletion (I/D) polymorphism in combination with serum ACE activity as well as the bradykinin B2 receptor 2/3 and c.C181T polymorphisms. METHODS We analysed the ACE I/D as well as bradykinin B2 (2/3 and C181T) receptor polymorphisms in 65 patients with documented episodes of ACEi-induced angio-oedema and 65 patients matched for age and sex being under ACEi treatment without history of angio-oedema. Furthermore, we determined serum ACE activity in 47 of the 65 angio-oedema patients 3 months after the angio-oedema attack and compared these values with 51 healthy individuals (control II). RESULTS No risk association was identified between ACE I/D (I-allele: 0.42 vs. 0.41, D-allele: 0.58 vs. 0.59; P= 0.095) or bradykinin B2 receptor polymorphisms and the development of angio-oedema during ACEi treatment. We found a trend of lower serum ACE activity in ACE I/I genotypes in comparison with control II (I/I: 28 +/- 4.5 vs. 33 +/- 1.8 U l(-1); ID: 39 +/- 3.3 vs. 41 +/- 1 U l(-1); DD: 56 +/- 6.7 vs. 52 +/- 1.8 U l(-1); P= 0.9). CONCLUSIONS Our data suggest that polymorphism of ACE I/D and the bradykinin B2 receptor polymorphisms are not involved in the development of ACEi-induced angio-oedema when considered individually. Further studies should be carried out to clarify whether a combination of these polymorphisms might be a risk factor for ACEi-induced angio-oedema.
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Affiliation(s)
- Murat Bas
- Department of Otorhinolaryngology, Technische Universität München, München, Germany.
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Binkley KE. Factor XII mutations, estrogen-dependent inherited angioedema, and related conditions. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2010; 6:16. [PMID: 20667119 PMCID: PMC2920236 DOI: 10.1186/1710-1492-6-16] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 07/28/2010] [Indexed: 11/10/2022]
Abstract
The clinical, biochemical and genetic features of the conditions known as estrogen-dependent inherited angioedema, estrogen-associated angioedema, hereditary angioedema with normal C-1 inhibitor, type III angioedema, or factor XII angioedema are reviewed. Discussion emphasizes pathogenesis, diagnosis, and management.
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Affiliation(s)
- Karen E Binkley
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Alencar RC, Cobas RA, Gomes MB. Allergic reaction related to ramipril use: a case report. Diabetol Metab Syndr 2010; 2:4. [PMID: 20180980 PMCID: PMC2832622 DOI: 10.1186/1758-5996-2-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Accepted: 01/20/2010] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Angiotensin-converting enzyme (ACE) inhibitors are widely prescribed for patients with diabetes as a nephroprotector drug or to treat hypertension. Generally they are safe for clinical practice, but the relationship between these drugs and angioedema is known. The exact mechanism for ACE inhibitors-induced angioedema is not clear and it is still a matter of discussion. CASE REPORT We reported a case of a 23-year-old black female with an 11 year history of type 1 diabetes, regularly monitored in the department of diabetes, in use of 0,98 UI/kg/day of human insulin, which presented an allergic reaction 24 h after ramipril use. The drug had been prescribed to treat diabetic nephropathy. There was no previous history of drug induced or alimentary allergy. The patient was instructed to discontinue the use of ramipril and oral antihistaminic drug and topical corticosteroid were prescribed. Skin biopsies were performed and confirmed the clinical hypothesis of pharmacodermy. The evaluation of ACE polymorphism identified DD genotype. Six months after the withdrawal of ramipril the patient was prescribed the angiotensin-II receptor blocker (ARB) losartan as nephroprotector. She remained well without adverse reactions. CONCLUSIONS ACE inhibitors-induced angioedema is uncommon and the clinical presentation is variable with lips, tongue, oropharinge, and larynge as the most common locations. The presence of angioedema during treatment requires the immediate cessation of treatment due to the risk of possible severe complications. The case reported presented moderate symptoms, with the development of early onset edema in uncommon regions. ACE DD genotype had been associated with angioedema-ACE inhibitors induced. In patients who have experienced ACE inhibitor-related angioedema, ARB should be used cautiously used. However in the case of our patient, the prescription of losartan as nefroprotector did not result in any recurrent adverse effect.
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Affiliation(s)
- Renata C Alencar
- Department of Endocrinology and Metabology, Hospital Universitário Pedro Ernesto, Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - Roberta A Cobas
- Department of Endocrinology and Metabology, Hospital Universitário Pedro Ernesto, Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - Marília B Gomes
- Department of Endocrinology and Metabology, Hospital Universitário Pedro Ernesto, Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
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Abstract
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.
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Affiliation(s)
- Evangelo Frigas
- Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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Hoover T, Lippmann M, Grouzmann E, Marceau F, Herscu P. Angiotensin converting enzyme inhibitor induced angio-oedema: a review of the pathophysiology and risk factors. Clin Exp Allergy 2009; 40:50-61. [PMID: 19659669 DOI: 10.1111/j.1365-2222.2009.03323.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Angio-oedema (AE) is a known adverse effect of angiotensin converting enzyme inhibitor (ACE-I) therapy. Over the past several decades, evidence of failure to diagnose this important and potentially fatal reaction is commonly found in the literature. Because this reaction is often seen first in the primary care setting, a review was undertaken to analyse and document the keys to both diagnostic criteria as well as to investigate potential risk factors for ACE-I AE occurrence. A general review of published literature was conducted through Medline, EMBASE, and the Cochrane Database, targeting ACE-I-related AE pathomechanism, diagnosis, epidemiology, risk factors, and clinical decision making and treatment. The incidence and severity of AE appears to be on the rise and there is evidence of considerable delay in diagnosis contributing to significant morbidity and mortality for patients. The mechanism of AE due to ACE-I drugs is not fully understood, but some genomic and metabolomic information has been correlated. Additional epidemiologic data and clinical treatment outcome predictors have been evaluated, creating a basis for future work on the development of clinical prediction tools to aid in risk identification and diagnostic differentiation. Accurate recognition of AE by the primary care provider is essential to limit the rising morbidity associated with ACE-I treatment-related AE. Research findings on the phenotypic indicators relevant to this group of patients as well as basic research into the pathomechanism of AE are available, and should be used in the construction of better risk analysis and clinical diagnostic tools for ACE-I AE.
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Affiliation(s)
- T Hoover
- Herscu Laboratory, Clinical Research Division, Amherst, MA 01002, USA.
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ACE-I induced angioedema: a case report and review of literature. CASES JOURNAL 2009; 2:7181. [PMID: 19829931 PMCID: PMC2740143 DOI: 10.4076/1757-1626-2-7181] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 05/23/2009] [Indexed: 11/18/2022]
Abstract
Introduction Although rare, angioedema has been documented to occur following the administration of angiotensin-Converting Enzyme Inhibitors. Angiotensin-converting enzyme inhibitors are the leading cause of drug induced angioedema. Angiotensin-converting enzyme inhibitors induced angioedema is a class effect that can affect between 0.1% and 0.5% of patients taking the drug. It is rarely documented in Nigeria. Lisinopril is a commonly prescribed angiotensin-converting enzyme inhibitors-I which is considered to be generally safe and well tolerated. We report a case of angioedema following the use of lisinopril. Case presentation A 52-year-old man, known hypertensive, presented with severe breathlessness on exertion, paroxysmal nocturnal dyspnoea and bilateral pedal swelling of six weeks duration. There was no history of allergy or atopy. He was managed with lisinopril 5 mg o.d, frusemide 40 mg daily, aspirin 150 mg daily and digoxin 0.25 mg daily. He re-presented at the medical emergency unit of the hospital two days later with swellings involving the lips and the lower face of 10 hours duration. There was associated difficulty in swallowing but no stridor or hoarseness of voice. He did not have skin rashes or pruritus. There was no history of previous similar episodes. Physical examination revealed a middle aged man with swollen lips and lower part of the face. The pharynx was oedematous. The respiratory and cardiovascular system examinations revealed features of hypertensive heart disease in biventricular failure. Clinical assessment of hypertensive heart disease in failure with Lisinopril induced Angioedema was made. The Naranjo probability scale indicated that this adverse drug event was probable. Lisinopril was discontinued. After administration of corticosteroid and antihistamine, a complete resolution of the patient's symptoms was achieved. He was discharged to the medical outpatient unit of the hospital having recovered fully. Conclusion This case is presented for the purposes of documentation since it is a rare occurrence among Nigerians.
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Warkentin TE, Greinacher A. Heparin-induced anaphylactic and anaphylactoid reactions: two distinct but overlapping syndromes. Expert Opin Drug Saf 2009; 8:129-44. [PMID: 19309242 DOI: 10.1517/14740330902778180] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Heparin-induced anaphylactic and anaphylactoid reactions are of increasing clinical and scientific interest, particularly given the recent identification of a syndrome of heparin-induced anaphylaxis due to oversulfated chondroitin sulfate (OSCS), a contaminant in certain heparin preparations. However, heparin-induced anaphylactoid reactions also have been reported to be a consequence of immune-mediated heparin-induced thrombocytopenia (HIT). OBJECTIVE To summarize the clinical features and pathophysiology of two distinct disorders, HIT-associated anaphylactoid reactions as well as anaphylaxis resulting from OSCS-contaminated heparin. METHODS We review literature describing these two types of heparin-induced anaphylactic and anaphylactoid reactions, and seek potential pathophysiologic links between them. RESULTS Intravenous bolus heparin administered to patients with circulating 'HIT antibodies', usually as a result of recent heparin therapy, can produce anaphylactoid reactions, probably as a consequence of in vivo activation of platelets and, possibly, leukocytes. Affected patients often evince fever/chills, hypertension and/or acute respiratory compromise ('pseudo-pulmonary embolism'). In contrast, heparin-induced anaphylaxis is caused by activation of the contact system, with formation of vasoactive kinins (bradykinin, des-arg(9)-bradykinin). This latter syndrome has been linked in an epidemic form to administration of OSCS-contaminated heparin; these reactions feature prominent hypotension and laryngeal edema. Hemodialysis patients are at increased risk for both syndromes. There is evidence that OSCS-contaminated heparin itself increases the risk of HIT compared with non-contaminated heparin. CONCLUSION Two distinct syndromes of heparin-induced anaphylaxis and anaphylactoid reactions exist. These seem to share certain epidemiologic features, given that OSCS-contaminated heparin can produce anaphylaxis through contact system activation but also could increase risk of HIT and HIT-associated anaphylactoid reactions.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton Health Sciences, General Site, Hamilton, Ontario, Canada.
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