Sprue-Like Enteropathy and Liver Injury: A Rare Emerging Association with Olmesartan

Abstract

Olmesartan-induced enteropathy is an underreported phenomenon, first described in 2012. While olmesartan’s antihypertensive properties were confirmed early on, its association with a sprue-like enteropathy was subsequently noted. Although this association has been reported with olmesartan, there have been few reports of this association with other angiotensin-receptor blockers. We present a case of a 79-year-old male who presented with diarrhea, weight loss, jaundice, and transaminitis. Further history revealed that he had been taking olmesartan 40 mg daily for hypertension. Workup of his diarrhea and jaundice included duodenal and liver biopsies revealed findings consistent with a sprue-like enteropathy and an autoimmune hepatitis-like pattern. On discontinuation of olmesartan, his 1-month follow-up revealed significant improvement in his clinical status as well as his liver function tests. Olmesartan is an effective antihypertensive medication; however, physicians must be mindful of its side effect of causing a sprue-like enteropathy and liver injury. Patients should be counseled on discontinuing olmesartan, and they should be started on an alternative therapy for hypertension.

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

“…The final diagnosis was reached after a median of 5 months, and an acute onset of symptoms leading to diagnosis was present in 10% of patients. Coeliac serology results were reported in 140/183 5,11,13,14,16–22,24,25,27–40,43–80,83,84,86,89–92,94–101 and were negative in the large majority of cases (138/140, 99%). In only two patients, IgA tissue transglutaminase antibodies were borderline and considered to be irrelevant by the authors 19,37 .…”

“…Overall, we included 97 papers in the present review. Ninety‐four were case reports or case series of enteropathy due to ARBs (86 case reports or case series with less than five patients 13–98 and eight case series with five or more patients 5,11,99–104 ) 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) 11,13,17,18,20,21,23,24,26,27,30–34,40,44,45,50,51,55–57,61–64,67,68,70,73,75,77,80,83–85,89–92,94–96,98,100,101,103,104 and North America (67 cases) 5,14,16,22,25,28,29,36–38,41–43,46,47,52–54,58,60,66,69,71,72,86,93,97,102 . Some cases were also reported in India (9),…”

“…Data on faecal calprotectin were reported for only 24/183 patients, 11,23,24,29,32,37,44,45,47,49,73,78,79,86 and it was increased in 14/24 (58%) 11,23,24,29,44,45,47,49,86 . Data on which other medications were being taken besides ARBs was reported explicitly for 57 patients, 13,14,16,18,20,25,26,30–33,36–42,44,45,47,50,51,54,57,58,61–64,66–68,70–75,77–79,82,84,86,87,91–93,95,97,103 with 9/57 reporting no other medication 14,18,20,30,40,61,67,68,82 and the remaining 48/57 taking mainly diuretics, statins or a second anti‐hypertensive medication. NSAID use was reported for five cases 36,42,54,64,71 and PPI in other six cases 26,38,51,73,77,97 …”

“…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.…”