From the Guidelines
The initial management for suspected angioedema should focus on airway assessment and stabilization, followed by administration of specific medications such as C1 esterase inhibitor concentrates, icatibant, or ecallantide, as these are the most effective treatments for hereditary or bradykinin-mediated angioedema, as recommended by the most recent guidelines 1. The management of angioedema involves a step-by-step approach to ensure the patient's airway, breathing, and circulation are stable.
- Evaluate the patient's airway, breathing, and circulation, with particular attention to signs of respiratory distress or airway compromise.
- For hereditary or bradykinin-mediated angioedema, standard treatments like antihistamines and corticosteroids are ineffective; instead, specific medications such as C1 esterase inhibitor concentrates, icatibant (30mg SC), or ecallantide (30mg SC) should be administered, as supported by recent studies 1.
- Throughout treatment, continuously monitor vital signs, oxygen saturation, and airway status, and be prepared for potential intubation or cricothyroidotomy if severe airway compromise occurs.
- Discontinuation of the ACE-I (or ARB) is the cornerstone of therapy for ACE-I (or ARB)–associated angioedema, although there might be a significant time lag between discontinuation of the drug and the propensity for angioedema, as noted in previous guidelines 1.
- The World Allergy Organization (WAO) guideline and emergency department (ED) guidelines emphasize the need to consider early intubation or tracheotomy in the case of upper airway angioedema, and guidelines also suggest that plasma may be used if first-line treatments are not available, depending on local availability and safety 1.
From the Research
Initial Management for Suspected Angioedema
To rule out angioedema, the following steps can be taken:
- Evaluate consciousness and vital signs to manage breathing and support circulation if necessary 2
- Rule out other forms of edema, such as anasarca, myxedema, superior vena cava syndrome, and acute dermatitis 2
- Differentiate between histaminergic and non-histaminergic angioedema by looking for concomitant urticaria and pruritus, which suggest a histaminergic origin 2
- Investigate exposure to allergens and drugs, such as ACE inhibitors and non-steroidal anti-inflammatory drugs, as well as a family history of similar symptoms 2
Diagnostic Approach
The initial diagnosis of angioedema is clinical, but laboratory tests can be used to confirm the diagnosis 2. The following factors can help differentiate between allergic and non-allergic angioedema:
- Presence of concomitant urticaria and pruritus 2
- Rapid course of the disease (minutes) in allergic histaminergic angioedema, versus a slower course (hours) in non-histaminergic angioedema 2
- Response to standard therapies, such as epinephrine, glucocorticoids, and antihistamines, which are effective in allergic angioedema but often ineffective in non-histaminergic angioedema 2, 3
Treatment Options
Treatment options for angioedema depend on the underlying cause:
- Allergic angioedema: epinephrine, glucocorticoids, and antihistamines 2, 3
- Non-histaminergic angioedema: C1-inhibitor concentrates, icatibant, and ecallantide 2, 4, 5
- ACE inhibitor-induced angioedema: discontinuation of the causative drug, and consideration of fresh frozen plasma if other treatments are not available 2, 6