From the Guidelines
For suspected angioedema due to lisinopril, immediately discontinue the medication and switch to a non-ACE inhibitor antihypertensive, with Angiotensin Receptor Blockers (ARBs) being a preferred alternative due to their low risk of causing angioedema. When considering alternatives, the following options can be evaluated:
- Angiotensin receptor blockers (ARBs) like losartan (50-100 mg daily), valsartan (80-320 mg daily), or olmesartan (20-40 mg daily) are typically preferred as they rarely cause angioedema while providing similar cardiovascular benefits 1.
- Calcium channel blockers such as amlodipine (5-10 mg daily) or thiazide diuretics like hydrochlorothiazide (12.5-25 mg daily) are also good options, especially in combination therapy if needed for adequate blood pressure control. It's essential to note that while ARBs are a good alternative, there is a modest risk of recurrent angioedema, as reported in a study published in the Journal of Allergy and Clinical Immunology 1, which found that most patients who experienced ACE-I–induced angioedema can safely use ARBs without recurrence of angioedema. However, the risk of angioedema with aliskiren, a renin inhibitor, has also been reported, and patients with a history of angioedema during treatment with an ACE-I might be at increased risk if switched to aliskiren as an alternative antihypertensive agent 1. The decision to switch to an ARB or another alternative should be made after a careful assessment of potential harm compared with benefit and involve the patient in the decision-making process 1.
From the Research
Suspected Angioedema due to Lisinopril Use
- Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor, which has been associated with angioedema in some patients 2.
- The exact mechanism of ACE inhibitor-induced angioedema is not fully understood, but it is thought to be related to the inhibition of bradykinin degradation 2.
Recommended BP Medication Alternative
- Angiotensin II receptor blockers (AT2 blockers) may be a safe alternative for patients with suspected angioedema due to ACE inhibitor use 3.
- AT2 blockers do not increase bradykinin levels and have been shown to have a lower incidence of angioedema compared to ACE inhibitors 4, 3.
- A nationwide registry-based cohort study found that AT2 blockers do not increase the incidence of angioedema in patients with previous ACE inhibitor-related angioedema 3.
- Other antihypertensive medications, such as beta-adrenergic blockers, calcium channel blockers, and thiazides, may also be considered as alternatives 3.
Important Considerations
- Patients with a history of angioedema due to ACE inhibitor use should be closely monitored when switching to a new antihypertensive medication 4, 3.
- The incidence of angioedema recurrence is higher in patients who continue to use ACE inhibitors after an initial episode of angioedema 3.
- Medications that target the factors that cause ACE inhibitor-mediated angioedema, such as bradykinin antagonists, may be effective in treating ACE inhibitor-induced angioedema 5.