Olmesartan-Induced Enteropathy: A Report of an Unusual Cause of Chronic Diarrhea

Abstract

Olmesartan, an angiotensin II receptor blocker indicated in the treatment of hypertension, has been associated with a seronegative sprue-like enteropathy that should be considered in the differential diagnosis of patients with unexplained chronic diarrhoea. It typically presents with severe chronic diarrhoea, considerable weight loss, and villous atrophy on biopsy and may be difficult to recognize because of its clinical and histological similarities to other clinical entities. Practically, discontinuation of the drug leads to dramatic recovery of the symptoms. We report a 76-year-old Caucasian female who was admitted to our hospital with complaints of chronic diarrhea and significant weight loss. Medical history was notable for hypertension being treated with olmesartan. Initially, investigation for all potential infectious causes and celiac disease was negative. Both upper and lower endoscopy was performed with duodenal biopsies revealing total villous atrophy and colonic biopsies showing lymphocytic colitis. In the presence of negative serology for celiac disease and after a thorough review of the patient's medications, olmesartan inducedenteropathy was the most possible diagnosis. Olmesartan was discontinued and the symptoms rapidly resolved. A follow-up done a few months later showed no recurrence of the symptoms. In olmesartanassociated enteropathy, discontinuation of olmesartan results in immediate clinical recovery. Although rare, it is considered an emerging and underdiagnosed enteropathy. This case report illustrates the need for a thorough medication history evaluation and regular review during workup. We aim to increase the awareness of olmesartan-induced enteropathy among clinicians and gastroenterologists. We hope it will add to the current literature and help to understand this rare phenomenon in order to avoid unnecessary testing.

Systematic review: Clinical phenotypes, histopathological features and prognosis of enteropathy due to angiotensin II receptor blockers

“…p < 0.05 were considered statistically significant. Ninety-four were case reports or case series of enteropathy due to ARBs (86 case reports or case series with less than five patients and eight case series with five or more patients 5,11,[99][100][101][102][103][104] ) corresponding to a total of 183 patients (101 F, mean age at diagnosis 69 ± 10 years) published between 2012 and 2023, with most cases being reported in Europe (93 cases) 11,13,17,18,20,21,23,24,26,27,[30][31][32][33][34]40,44,45,50,51,[55][56][57][61][62][63][64]67,68,70,73,75,77,80,[83][84][85][89][90][91]…”

“…VA was present in 164/183 (89%) patients. 5,11,13,14,[16][17][18]20,21,24,25,[27][28][29][30][31][32][33][34][35][36][37][38][39][74][75][76][77][78][79][80][81][82][83][84][85][86][87][88][90][91][92][93][94][95][96][97][98][99][100][101][102][103]…”

“…13,15,31,32,35,43,48,49,52,61,65,66,81,86 Among the 164 patients with VA, additional findings in the stomach or in the colon were present in 55 patients (30.1%). Of these 55 patients, 12 had pan-GI mucosal changes (gastric, small bowel and colonic involvement), 5,20,34,38,42,61,80,84,92,93 23 had evidence of gastric findings in addition to small bowel involvement 5,11,30,50,71,77,87,93,100,102 and 20 had colonic mucosal changes in addition to small bowel involvement. 5,16,21,26,29,36,48,52,60,62,70,91,93,[99][100]…”

“…Among the 41 patients with gastric mucosal changes at baseline, 5,11,20,23,30,34,38,42,50,61,71,77,80,84,87,92,93,100,102 follow-up gastric biopsies were performed in 19 patients after a median of 5 months (IQR 3-8). All these patients had a normal gastric biopsy at follow -up 5,11,38,61,77,80,92,93,102 with the exception of one. 102 Of the 39 patients with colon mucosal changes at baseline, 5,14,16,20,21,23,26,29,34,36,38,42,48,52,[60][61][62]70,80,84,[91]…”

Olmesartan medoxomil self-microemulsifying drug delivery system reverses apoptosis and improves cell adhesion in trinitrobenzene sulfonic acid-induced colitis in rats

“…Moreover, a case of sprue-like enteropathy and collagenous colitis was observed in a 73-year-old man with severe diarrhea and weight loss over the last two months (Kaneko et al., 2021 ). Olmesartan-induced enteropathy was also detected in a 76-year-old female complaining of chronic diarrhea and significant weight loss (Sotiropoulos et al., 2021 ).…”