Letter: sprue‐like enteropathy associated with angiotensin II receptor blockers other than olmesartan

Abstract

We have observed five cases of sprue-like enteropathy during treatment with angiotensin II receptor blockers (ARBs) other than olmesartan. To the best of our knowledge, only seven cases 1,3-8 of enteropathy associated with sartans other than olmesartan have been described so far. In Table 1, we summarise the clinicopathological features of these cases including our series.The patients (eight females and four males) ranged in age from 52 to 85 years. They had been treated with ARBs other than olmesartan from 2 months to 13 years and the drugs involved were: irbe- In three cases, there was a collagenous colitis, 3 associated with IELs in two cases. A diffuse involvement of the gastrointestinal tract with collagenous gastritis, ileitis and colitis was documented in the case of Cyrany et al. 3 The possible involvement of almost the entire gut 1,2 is well known in olmesartan-associated enteropathy.Of note, in our series, all the patients underwent colonoscopy, whereas esophagogastroduodenoscopy was performed in two patients. This could explain why duodenal mucosa atrophy was identified only in two cases. In the same two cases, histology revealed also an acute eosinophilic colitis pattern. These cases represent the first report of eosinophilic colitis in patients taking ARBs other than olmesartan. As reported for olmesartan, 10 a milder histological presentation with slight increase in inflammatory cells of the colonic mucosa was present in one case of our series.In all patients, the symptoms ceased after drug withdrawal. In seven cases, the patients underwent follow-up biopsies which confirmed histological recovery 3-8 a few months after drug suspension.In conclusion, the clinicopathological findings in patients taking ARBs other than olmesartan are similar to those described in olmesartan-associated enteropathy.Therefore, we suggest the possibility of a class effect. Clinicians and pathologists should be aware of ARB-induced gastrointestinal injury because its identification has a drastic impact on the patient's health with no other intervention than ARB suspension. LETTERS TO THE EDITORS| 471

Angiotensin II receptor blockers and gastrointestinal adverse events of resembling sprue-like enteropathy: a systematic review

“…Similar histological findings together with sprue-like enteropathy were reported for the first time in a patient receiving telmisartan in 2014 [11], followed by 11 case reports of enteropathy after non-olmesartan ARB use [10–17]. These case reports raised the possibility that ARB-related enteropathy may be a class effect rather than an effect specific to olmesartan [13].…”

“…There were 248 cases resembling sprue-like enteropathy (age at diagnosis 45–89 years; 57.3% female) (Table 1). The ARBs listed in the case reports were olmesartan (233 cases; 94.0%), telmisartan (5 cases; 2.0%) [11–14], irbesartan (4 cases; 1.6%) [13, 16, 22], valsartan (3 cases; 1.2%) [13, 15], losartan (2 cases; 0.8%) and eprosartan (1 case; 0.4%) [17]. The periods between ARB initiation and onset of symptoms ranged from 2 weeks to 13 years [23–25].…”

Severe intestinal malabsorption associated with ACE inhibitor or angiotensin receptor blocker treatment. An observational cohort study in Germany and Italy

“…4,7-10 A large observational cohort study, based on the French health insurance claim database and using International Classification of Diseases, Tenth Revision (ICD-10) codes for intestinal malabsorption (IM) and coeliac disease diagnosis, highlighted an increased risk of hospitalization in patients treated with OM when compared with other ARBs and angiotensin converting enzyme inhibitors (ACE-i). 11 Otherwise, it is not appropriate to rule out the class-effect hypothesis 12 because recent case reports suggested an association between severe enteropathy and other ARBs, including valsartan, irbesartan, telmisartan, eprosartan, losartan, and candesartan. 10,[13][14][15][16][17][18][19][20] A large population-based study of ARB-treated patients managed by the general practitioners in Italy and Germany showed similar low proportions of unspecified IM diagnosis among the different drugs belonging to the same class.…”

Olmesartan - associated sprue-like enteropathy and colagenous colitis: A case report and review of literature

“…Twelve cases have been reported with other ARBs such as irbesartan, valsartan, losartan, eprosartan and telmisartan. [7,8,16,20] A cause-and-effect association of these other ARBs is not certain, however. A nationwide case-control study in Sweden failed to show an association of sprue-like enteropathy and use of either angiotensin converting enzyme inhibitors (ACEIs) or nonolmesartan ARBs.…”