What is the next best step in managing a 65-year-old man with angioedema, likely caused by lisinopril (angiotensin-converting enzyme inhibitor), presenting with tongue and upper lip swelling, tachycardia, hypotension, and mild respiratory stridor?

From the Guidelines

The next best step in managing this patient is to discontinue lisinopril, as it is the likely cause of the angioedema, and administer H1 antihistamines and corticosteroids to help manage symptoms, despite their limited efficacy in ACE-I associated angioedema, as stated in the study by 1. The patient has already received a dose of epinephrine, which is appropriate for acute management of angioedema with respiratory or cardiovascular compromise. However, the cornerstone of therapy for ACE-I associated angioedema is discontinuation of the offending drug, as noted in the study by 1. Some key points to consider in the management of this patient include:

• Discontinuation of lisinopril is crucial, as it is the most likely cause of the angioedema, as stated in the study by 1.
• Administration of H1 antihistamines and corticosteroids may help manage symptoms, although their efficacy in ACE-I associated angioedema is limited, as noted in the study by 1.
• Close monitoring in an intensive care setting is necessary, with preparation for possible intubation if respiratory distress worsens.
• The patient should permanently avoid all ACE inhibitors and consider alternative medications like angiotensin receptor blockers for hypertension management, though with caution as cross-reactivity can occur. It is also important to note that the study by 1 discusses the treatment of hereditary angioedema, which is a different condition from ACE-I associated angioedema, and its findings may not be directly applicable to this patient's case.

From the FDA Drug Label

1. 2 Angioedema and Anaphylactoid Reactions Angioedema 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

The next best step in managing this patient is to:

• Discontinue lisinopril as it is likely the cause of the angioedema, and
• Administer H1 antihistamine and corticosteroids to help alleviate the symptoms of angioedema 2.

From the Research

Next Best Step in Managing Angioedema

The patient presents with symptoms of angioedema, likely caused by lisinopril, including tongue and upper lip swelling, tachycardia, hypotension, and mild respiratory stridor. Considering the patient has already received epinephrine and is on intravenous fluids, the next steps should focus on further managing the angioedema and its complications.

Treatment Options

• Administer H1 antihistamine and corticosteroids: This is a common initial approach for angioedema, as it helps reduce inflammation and alleviate symptoms 3, 4.
• Discontinue lisinopril: Since lisinopril is likely the cause of the angioedema, discontinuing it is essential to prevent further episodes 3, 4.
• Administer fresh frozen plasma (FFP): FFP has been used in cases of refractory angioedema, particularly when conventional treatments fail, as it can help break down accumulated bradykinin 3, 5, 4, 6.
• Consider icatibant: Icatibant, a bradykinin receptor antagonist, has been shown to be effective in treating ACE inhibitor-associated angioedema, especially in cases involving the upper airway 7.

Current Situation

Given the patient's symptoms and the fact that they have already received epinephrine, the most appropriate next steps would involve administering H1 antihistamine and corticosteroids to reduce inflammation and considering the use of FFP or icatibant if the condition worsens or does not improve with initial treatment. Discontinuing lisinopril is also crucial to prevent further episodes of angioedema.

Decision

The best course of action now would be to Administer H1 antihistamine and corticosteroids as part of the initial management, alongside considering the discontinuation of lisinopril and monitoring the patient's condition closely for the potential need for more advanced treatments like FFP or icatibant if the angioedema does not respond to initial therapy or worsens.