Characteristics of angioedema induced by ACE inhibitors - angiotensin-converting enzyme - Tips from

Date: Sept, 1991

Angioedema has been previously reported with all angiotensin-converting enzyme (ACE) inhibitors. However, the potential for a fatal outcome with this reaction has not been fully appreciated. Roberts and Wuerz report two cases in which ACE inhibitor-induced angioedema necessitated tracheal intubation because of life-threatening airway compromise. Both patients had tolerated ACE inhibitors for many months without ill effects, until angioedema of the upper airway suddenly developed. Neither patient responded to standard drug therapy. The authors also reviewed the literature to further characterize the specific clinical features of this side effect.

A total of 227 reports of ACE inhibitor-induced angioedema were found in the literature. The overall incidence has been estimated to be 0.1 to 0.2 percent. The etiology is nonimmunogenic and is thought to be related to accentuated bradykinin activity.

A number of unique clinical characteristics occur with this idiosyncratic reaction: angioedema may suddenly develop even though the drug has been well tolerated for months or years; symptoms may regress spontaneously while the patient continues taking the medication; the pathology has a predilection for the tongue and lips, making orotracheal and nasotracheal intubation difficult; symptoms may progress rapidly despite aggressive medical therapy, necessitating emergency airway procedures, and a rebound phenomenon following successful medical therapy has also been described.

The authors recommend aggressive medical treatment before angioedema becomes severe. Once even minor angioedema is attributed to an ACE inhibitor, an alternate class of antihypertensive medication should be chosen. Persons with a history of idiopathic angioedema or urticaria may be at increased risk and possibly should not be given ACE inhibitors. (Annals of Emergency Medicine, May 1991, vol. 20, p.555.)

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