From the Guidelines
The management of ACEI-induced angioedema requires immediate discontinuation of the offending ACEI medication as the first and most crucial step. For acute episodes, treatment includes airway assessment and management, with intubation if necessary for severe cases involving the tongue, throat, or larynx. According to the most recent and highest quality study 1, discontinuation of the ACE-I is the cornerstone of therapy for these patients.
Key Considerations
- Medications typically administered for acute episodes may include antihistamines, corticosteroids, and epinephrine, although these may have limited effectiveness since ACEI angioedema is not histamine-mediated.
- In severe cases not responding to standard therapy, icatibant or C1 inhibitor concentrates may be considered, as described in the study 1.
- After resolution, patients should permanently avoid all ACEIs and be monitored for 24-48 hours to ensure complete resolution.
- Alternative antihypertensive medications such as angiotensin receptor blockers (ARBs), calcium channel blockers, or diuretics should be prescribed, though ARBs should be used cautiously as cross-reactivity can occur in about 10% of patients, as noted in the study 1.
Alternative Therapies
- 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, as suggested in the study 1.
- A modest risk of recurrent angioedema exists in patients who experienced angioedema in response to ACE-I therapy and then are switched to ARB therapy, with rates of subsequent angioedema ranging from 2% to 17% in a recent meta-analysis 1.
From the FDA Drug Label
Epinephrine alleviates pruritus, urticaria, and angioedema and may relieve gastrointestinal and genitourinary symptoms associated with anaphylaxis because of its relaxer effects on the smooth muscle of the stomach, intestine, uterus and urinary bladder Inject Adrenalin® intramuscularly or subcutaneously into the anterolateral aspect of the thigh, through clothing if necessary.
The management for angioedema caused by Angiotensin-Converting Enzyme Inhibitors (ACEI) use involves administering epinephrine intramuscularly, with the following dosages:
- Adults and Children 30 kg (66 lbs) or more: 0.3 to 0.5 mg (0.3 mL to 0.5 mL) of undiluted epinephrine, repeated every 5 to 10 minutes as necessary.
- Children less than 30 kg (66 lbs): 0.01 mg/kg (0.01 mL/kg) of undiluted epinephrine, up to a maximum of 0.3 mg (0.3 mL) per injection, repeated every 5 to 10 minutes as necessary 2 2.
From the Research
Management of ACEI-Induced Angioedema
The management of angioedema caused by Angiotensin-Converting Enzyme Inhibitors (ACEI) use involves several key considerations:
- Discontinuation of the ACEI is necessary to reduce the risk of recurrent episodes 3
- Airway management is the primary focus for the treatment of ACEI-induced angioedema (ACE-I-AE) 4
- In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment 4
- However, if the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions 4
Treatment Options
Several treatment options have been proposed for ACEI-induced angioedema, including:
- Fresh frozen plasma (FFP) for progressive and refractory cases 5
- Icatibant, an antagonist of the B2 receptor of bradykinin, which has shown efficacy in improving symptoms of ACEI-AAE 6
- Antihistamines, corticosteroids, and epinephrine, although these agents are often used by convention, they are generally unresponsive to ACEI associated angioedema 3
Alternative Therapies
For patients who experience ACEI-induced angioedema, alternative therapies such as angiotensin II receptor blockers may be considered: