Emergency Department Management of Patients with ACE-inhibitor Angioedema

Off-Label Use of Agents for Management of Serious or Life-threatening Angiotensin Converting Enzyme Inhibitor–Induced Angioedema

“…1 The overall incidence of ACEI-induced angioedema (ACEI-IA) ranges between 0.1% and 0.7%. 2 ACEI have been noted as an underlying cause of angioedema-related deaths, particularly in African Americans.…”

“…3 A higher prevalence of ACEI-IA has been reported in patients older than 65 years, female, of African American descent, with a smoking history, and with a history of ACEIinduced cough, with previous episodes of angioedema, heart failure, and atopy. 1,2,[4][5][6][7] Additional risk factors include aspirin, HMG-CoA reductase inhibitors, nonsteroidal antiinflammatory drugs, dipeptidyl peptidase IV (DPP-IV) inhibitors, and mammalian target of rapamycin inhibitors alone or in combination with ACEI. Angioedema symptoms may occur within one day or up to ten years or more of ACEI initiation.…”

“…8,9,14,15 The similarities in clinical presentation of bradykininmediated angioedema underscores the importance of careful collection and evaluation of medication histories, symptom onset and progression, and family and personal histories of angioedema to guide appropriate therapeutic management of the episode. 1,8,9,12 ACEI-IA should be suspected in anyone presenting with angioedema and a history of current or recent ACEI use. ACEI should be immediately discontinued; this generally leads to symptom resolution within 48 hours.…”

“…8,9,12,13 Mild cases of ACEI-IA can be observed in the ED or a general care unit until symptoms subside or resolve. 1,11 If laryngeal involvement is significant, intensive care monitoring following stabilization and emergent endotracheal intubation or cricothyroidotomy may be needed. 1,12 For cases not responding to ACEI discontinuation and standard therapies or when symptoms progress to be serious or life-threatening, additional therapeutic interventions are desired.…”

“…1,11 If laryngeal involvement is significant, intensive care monitoring following stabilization and emergent endotracheal intubation or cricothyroidotomy may be needed. 1,12 For cases not responding to ACEI discontinuation and standard therapies or when symptoms progress to be serious or life-threatening, additional therapeutic interventions are desired. Fresh frozen plasma (FFP) and pharmacologic agents, C1 esterase inhibitor concentrate, ecallantide, and icatibant, are Food and Drug Administration (FDA)-approved for use in acute HAE attacks and have been used in cases of ACEI-IA based on their antagonistic effect on bradykinin and/or the kallikrein-kinin system.…”