What should be done if a patient develops angioedema while taking Lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor)?

From the Guidelines

Lisinopril should be discontinued immediately if a patient develops angioedema, and they should seek emergency medical attention right away. Angioedema associated with ACE inhibitors like Lisinopril is a potentially life-threatening reaction that can cause dangerous swelling of the face, lips, tongue, throat, and airways 1. Once in medical care, treatment typically includes airway management if needed, antihistamines, corticosteroids, and epinephrine depending on severity.

Key Considerations

• After an episode of ACE inhibitor-induced angioedema, the patient should never take Lisinopril or any other ACE inhibitor again, as recurrence is likely and could be more severe 1.
• Alternative medications such as angiotensin receptor blockers (ARBs) or calcium channel blockers may be prescribed instead for blood pressure control, with a modest risk of recurrent angioedema existing in patients who experienced angioedema in response to ACE-I therapy and then are switched to ARB therapy 1.
• The mechanism behind this reaction involves the accumulation of bradykinin due to ACE inhibition, which increases vascular permeability and leads to the characteristic swelling.
• Patients with a history of angioedema, especially those of African descent, have a higher risk of developing this reaction with ACE inhibitors 1.

Management and Prevention

• 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.
• A recent meta-analysis found a risk for recurrence of angioedema in patients who had ACE-I–induced angioedema and were switched to an ARB of 2% to 17% 1.

From the FDA Drug Label

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

If a patient develops angioedema while taking Lisinopril, the following steps should be taken:

• Discontinue Lisinopril promptly
• Provide appropriate therapy and monitoring
• Continue monitoring until complete and sustained resolution of signs and symptoms of angioedema has occurred 2

From the Research

Angioedema and Lisinopril

• Angioedema is a serious, potentially life-threatening adverse effect associated with the use of ACE inhibitors, including lisinopril 3, 4.
• The incidence of angioedema associated with lisinopril is estimated to be around 0.1-0.5% 5, 4.
• Patients who develop angioedema while taking lisinopril should be instructed to report immediately to an emergency room for medical attention if they experience any unexplained shortness of breath or swelling of the throat or tongue 3.

Treatment and Management

• Withdrawal of the ACE inhibitor is the only effective treatment for angioedema 5.
• High-dose steroids may be helpful, but if there is beginning dyspnoea or stridor, early endoscopically controlled intubation or emergency tracheostomy is essential to avoid hypoxaemia and death 5.
• Antihistamines and corticosteroids may be used to treat angioedema, but their effectiveness is limited 3, 5.

Alternative Therapies

• Angiotensin II receptor blockers were initially considered a safe alternative for patients who experienced angioedema following ACE inhibitor therapy, but recent case reports have documented angioedema following therapy with these agents 6, 7.
• Angiotensin receptor antagonists cannot be considered a safe alternative therapy in patients who have previously experienced ACE inhibitor-associated angioedema 7.

Clinical Considerations

• Clinicians need to be aware of the risk of angioedema when prescribing ACE inhibitors, including lisinopril, and should monitor patients closely for signs and symptoms of angioedema 3, 4.
• Patients who have experienced angioedema while taking ACE inhibitors should be cautious when using alternative therapies, including angiotensin II receptor blockers 6, 7.