From the Guidelines
Lisinopril should not be continued in patients who develop angioedema, as it is a serious and potentially life-threatening adverse effect of ACE inhibitors. Angioedema is characterized by swelling of the face, lips, tongue, throat, or extremities, and can be fatal if not promptly treated. The mechanism involves bradykinin accumulation due to the inhibition of ACE, which normally degrades bradykinin 1. If angioedema occurs, lisinopril should be immediately and permanently discontinued, and the patient should never receive any ACE inhibitor again in the future.
Some key points to consider in the management of angioedema include:
- The risk of recurrent angioedema exists in patients who experienced angioedema in response to ACE-I therapy and then are switched to ARB therapy, although most patients can safely use ARBs without recurrence of angioedema 1
- Alternative medications for hypertension or heart failure might include angiotensin receptor blockers (ARBs), calcium channel blockers, diuretics, or beta-blockers, though ARBs should be used with caution as there is a small risk of cross-reactivity
- Patients who experience ACE inhibitor-induced angioedema should seek emergency medical attention immediately, especially if there is any throat or tongue swelling that could compromise the airway
In terms of treatment, the decision to switch to an ARB or to aliskiren when suspending an ACE-I because of angioedema should be considered in the context of a careful assessment of potential harm (recurrent angioedema) compared with benefit (therapeutic need for angiotensin/renin inhibition) and involve the patient in the decision-making process 1.
From the FDA Drug Label
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 Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor Lisinopril is contraindicated in patients with: -a history of angioedema or hypersensitivity related to previous treatment with an angiotensin converting enzyme inhibitor-hereditary or idiopathic angioedema
Lisinopril should not be continued with angioedema. The drug label explicitly states that lisinopril should be promptly discontinued in patients who experience angioedema, and it is also contraindicated in patients with a history of angioedema related to ACE inhibitor therapy 2 2.
From the Research
Angioedema and Lisinopril
- Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, can cause angioedema in some patients, with an incidence rate of 0.1-0.5% 3, 4.
- Angioedema is a potentially life-threatening adverse effect that can occur with ACE inhibitors, including lisinopril 5, 6.
- The exact cause of ACE inhibitor-induced angioedema is not fully understood, but it is thought to be related to the increased levels of bradykinin 4.
Continuing Lisinopril with Angioedema
- There is no clear evidence to support the continuation of lisinopril in patients who have experienced angioedema, as it may increase the risk of recurrence 4, 7.
- In fact, one study found that continued ACE inhibitor use was associated with a higher risk of angioedema recurrence, with an adjusted hazard ratio of 1.45 (95% CI, 1.19 to 1.78) 7.
- However, another study suggested that angiotensin II receptor blockers (AT2s) may be a safe alternative for patients with prior ACE inhibitor-related angioedema, with an adjusted hazard ratio of 0.39 (95% CI, 0.30 to 0.51) compared to other antihypertensives 7.