Using a bradykinin blocker in ACE inhibitor-associated angioedema in the emergency department

No specific drugs are licensed for the treatment of ACE inhibitor (ACEI)-acquired angioedema (ACEI-AAE). Icatibant, an antagonist of the B2 receptor of bradykinin, is a potential treatment for this condition; however, its use in this setting is poorly documented. We report here clinical outcomes of 13 patients with ACEI-AAE treated with icatibant, in a real-life setting. Thirteen patients on ACEI seen in an Emergency Department (ED) with angioedema involving face, lips or the upper airways were analyzed. Angioedema due to known causes other than ACEI treatment was excluded. Initially, all patients received standard therapy (antihistamine, corticosteroids and epinephrine). Due to the lack of response and a worsening severity of symptoms, all patients received one subcutaneous injection of icatibant (30 mg/mL). Following icatibant treatment, all patients experienced improvement in the symptoms. The median time from onset of clinical symptoms to injection of icatibant was 3 h (IQR 2.5-5.5 h). Symptom relief was reported at 30 min (IQR 27.5-70 min). A complete resolution of symptoms was observed at 5 h (IQR 4-7 h). Ten patients had previously experienced angioedema attacks. The Median time to complete resolution of the previous attacks was higher (54 h; IQR 33-63 h), than after icatibant (p = 0.002) therapy. No patients required tracheal intubation or tracheotomy, and all patients were discharged within 24 h. No adverse events were reported. Before discharge, all patients were instructed to discontinue ACEI, and to take a different antihypertensive agent. This case series supports the efficacy of icatibant in improving symptoms of ACEI-AAE.

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“…These results are overall in line with those of previous anecdotal experiences [2,10,[16][17][18][19][20][21].…”

Section: Discussionsupporting

confidence: 94%

“…The use of icatibant in the therapy of ACEI-AAE has been described in a number of anecdotal experiences [2,10,[16][17][18][19][20][21]. Overall, icatibant appears to reduce time to first symptom improvement, and to complete symptom resolution of angioedema.…”

Section: Introductionmentioning

confidence: 93%

Treatment of ACEI-related angioedema with icatibant: a case series

et al. 2015

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“…Icatibant is currently only licenced for hereditary angioedema 13. Alteplase activates both the complement and bradykinin pathways so there is potential for icatibant use in patients suffering with post-thrombolysis OLA 14.…”

Section: Discussionmentioning

confidence: 99%

Orolingual angioedema to alteplase. Identify, counsel and monitor at risk patients

Timmis¹,

Epstein

Salim

2016

BMJ Case Reports

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Orolingual angioedema (OLA) is a known complication of intravenous alteplase used to treat ischaemic stroke. The incidence may be as high as 5.1%. ACE inhibitors are thought to increase the risk of developing this potentially life-threatening complication. This case report demonstrates how we may improve in the identification of risk factors in the history; the counselling of patients appropriately; in seeking alternative therapies such as mechanical thrombectomy; and in the monitoring of patients for signs of OLA once alteplase has been given.

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“…16,33 Case reports/series involving the management of ACEI-IA with icatibant are summarized in Table 3. [34][35][36][37][38][39][40][41][42][43][44][45] Icatibant successfully resolved symptoms in 25 of the 26 cases (96%). Treatment with standard therapy and icatibant did not improve symptoms in one case leading to intubation and ICU management with eventual resolution and discharge a few days after presentation.…”

Section: Icatibantmentioning

confidence: 97%

“…Summary of Select Published Case Reports/Series of Icatibant for ACEI-Induced Angioedema Treatment [34][35][36][37][38][39][40][41][42][43][44][45]. …”

mentioning

confidence: 99%

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

2015

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ACEI-IA is typically a self-limiting event. First-line therapies include ACEI discontinuation, observation, and supportive medications (eg, corticosteroids, antihistamines, and epinephrine). Symptom progression can be life-threatening and may require interventions such as tracheotomy and intubation. Off-label use of FFP and medications approved for hereditary angioedema have resulted in rapid resolution of symptoms and avoidance of intubation. Among these agents, icatibant has the most supporting evidence and has been incorporated into practice guidelines and algorithms as a second-line agent for serious life-threatening ACE-IA.

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Using a bradykinin blocker in ACE inhibitor-associated angioedema in the emergency department

Abstract: We report two cases of ACE inhibitor-associated angioedema and critical airway compromise, where the use of a selective bradykinin 2 receptor blocker resulted in rapid symptom resolution and prevented intubation to protect the airway.

Cited by 12 publications

References 13 publications

Treatment of ACEI-related angioedema with icatibant: a case series

Treatment of ACEI-related angioedema with icatibant: a case series

Orolingual angioedema to alteplase. Identify, counsel and monitor at risk patients

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

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