What is the emergency department treatment for lip swelling associated with Lisinopril (Angiotensin-Converting Enzyme Inhibitor)?

From the Guidelines

Emergency department treatment for lisinopril-induced lip swelling (angioedema) requires immediate discontinuation of lisinopril and all ACE inhibitors permanently. Initial management includes airway assessment, as severe cases may require intubation. Treatment typically involves IV antihistamines (diphenhydramine 25-50mg), corticosteroids (methylprednisolone 125mg), and H2 blockers (famotidine 20mg) 1. For severe cases, epinephrine (0.3-0.5mg IM) may be needed. In refractory cases, icatibant (30mg subcutaneously) or C1 esterase inhibitor concentrate may be considered, as these have been shown to be safe and efficacious for the treatment of acute angioedema attacks 1. Some key points to consider in the management of angioedema include:

• The importance of early treatment, as this can significantly reduce the duration and severity of symptoms 1
• The need for airway assessment and potential intubation in severe cases
• The use of symptomatic treatment, such as narcotic medications for pain control and antiemetics for nausea and vomiting, in addition to specific treatments for angioedema
• The importance of patient education and instruction to avoid all ACE inhibitors in the future and wear a medical alert bracelet This reaction occurs because ACE inhibitors prevent bradykinin breakdown, leading to increased vascular permeability and swelling, which is a bradykinin-mediated process that may not fully respond to typical allergy medications 1. Patients should be observed for 4-6 hours to ensure resolution of symptoms before discharge. Upon discharge, patients need clear instructions to avoid all ACE inhibitors in the future and wear a medical alert bracelet. It is also important to note that standard angioedema treatment modalities, such as epinephrine, corticosteroids, or antihistamines, do not have a significant effect on the swelling in patients with HAE, and that fresh frozen plasma has been used to treat acute angioedema attacks, but it can sometimes cause a sudden worsening of symptoms and carries the inherent risk of viral transmission 1.

From the FDA Drug Label

Angioedema of the face, extremities, lips, tongue, glottis and/or larynx, including some fatal reactions, have occurred in patients treated with angiotensin converting enzyme inhibitors, including lisinopril, at any time during treatment Patients with involvement of the tongue, glottis or larynx are likely to experience airway obstruction, especially those with a history of airway surgery. Lisinopril should be promptly discontinued and appropriate therapy and monitoring should be provided until complete and sustained resolution of signs and symptoms of angioedema has occurred

Emergency Department Treatment for Lip Swelling due to Lisinopril:

• Discontinue lisinopril promptly
• Provide appropriate therapy and monitoring until complete and sustained resolution of signs and symptoms of angioedema has occurred
• Be aware of the risk of airway obstruction, especially in patients with involvement of the tongue, glottis, or larynx 2, 2

From the Research

Emergency Department Treatment for Lip Swelling due to Lisinopril

• Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, can cause angioedema, a condition characterized by swelling of the lips, face, and airways 3, 4, 5.
• The incidence of angioedema associated with lisinopril is greater than that associated with other ACE inhibitors, such as captopril or enalapril 5.
• Patients presenting with lip swelling due to lisinopril may also experience swelling of the tongue, buccal mucosa, and face, but laryngeal edema and stridor are less common 3, 5.
• Treatment for ACE inhibitor-induced angioedema typically involves discontinuation of the offending medication and administration of diphenhydramine, ranitidine, and methylprednisolone 5, 6.
• In severe cases, C1 inhibitors may be used to alleviate inflammation and prevent intubation, and have been shown to decrease mechanical ventilation time 6.
• Fiberoptic laryngoscopy can be used to evaluate the airway in patients with suspected laryngeal edema, and may help identify patients at risk for airway compromise 3.
• Intubation may be necessary in cases where the airway is compromised, and anesthesia should be performed in a controlled setting, such as an operating room 4.