What is the management of angioedema?

Management of Angioedema

The management of angioedema requires immediate assessment of airway compromise and treatment based on the specific type (histamine-mediated vs. bradykinin-mediated), with priority given to securing the airway in cases of oropharyngeal or laryngeal involvement. 1

Initial Assessment and Airway Management

Airway Evaluation

• Assess for signs of airway compromise: laryngeal involvement, oropharyngeal swelling, respiratory distress, voice changes, hoarseness, and stridor 1
• Do not directly visualize the airway as trauma from the procedure can worsen angioedema 2, 1
• All patients with oropharyngeal or laryngeal angioedema should be observed in a facility capable of emergency airway management 1
• Monitor oxygen saturation to maintain levels above 92% 1

Airway Intervention

• Consider early elective intubation if signs of impending airway closure develop 2, 1
• Be prepared for emergency tracheostomy if intubation fails 1
• High-risk features requiring closer monitoring include edema involving larynx, palate, floor of mouth, or oropharynx with rapid progression (within 30 minutes) 1

Treatment Based on Angioedema Type

Histamine-Mediated Angioedema (with urticaria)

• H1 antihistamines (e.g., diphenhydramine 50 mg IV) 1
• Corticosteroids (e.g., methylprednisolone 125 mg IV) 1
• Epinephrine for cases with respiratory involvement or significant symptoms 3

Bradykinin-Mediated Angioedema

ACE Inhibitor-Induced Angioedema

• Immediately discontinue the ACE inhibitor 1, 4, 5
• Switch to alternative antihypertensive medication, avoiding ARBs if possible due to potential cross-reactivity 1
• Consider calcium channel blockers, diuretics, or beta blockers as alternatives 1

Hereditary Angioedema (HAE) Treatment

• Icatibant 30 mg subcutaneously (may repeat at 6-hour intervals, not exceeding 3 injections in 24 hours) 1
• Plasma-derived C1 esterase inhibitor (20 IU/kg) 1
• Fresh frozen plasma (10-15 ml/kg) can be considered when first-line treatments are unavailable, though there is controversy about its use due to potential worsening of symptoms 2, 1

Symptomatic Management

Abdominal Attacks

• Pain medication (may require narcotics) for severe discomfort 2
• Antiemetics for nausea and vomiting 2
• Aggressive hydration for third-space sequestration of fluid 2
• Caution: Avoid long-term narcotic use to prevent addiction risk 2

Genitourinary Attacks

• Pain medication if discomfort is severe 2
• Catheterization if the patient cannot urinate 2

Long-term Prophylaxis for Recurrent Angioedema

• Options include plasma-derived C1INH replacement, lanadelumab, attenuated androgens, and antifibrinolytic agents 1
• Tranexamic acid (15-25 mg/kg twice or three times daily) as second-line prophylactic therapy 1
• Avoid estrogen-containing contraceptives in women with HAE 1
• Avoid ACE inhibitors in patients with any form of bradykinin-mediated angioedema 1

Special Considerations

High-Risk Populations

• African Americans, people over 65, women, and those with a history of smoking are at higher risk for ACE inhibitor-induced angioedema 1, 4
• In pregnancy, androgens are contraindicated; plasma-derived C1INH is preferred 1

Patient Education

• Provide education on early recognition of attacks 1
• Develop emergency action plans 1
• Recommend medical alert identification 1

Common Pitfalls and Caveats

1. Delayed Recognition: ACE inhibitor-induced angioedema can occur years after starting the medication, not just at initiation 5
2. Ineffective Treatments: Standard allergic reaction treatments (antihistamines, steroids) are often ineffective for bradykinin-mediated angioedema 6
3. Observation Duration: The observation period for oropharyngeal or laryngeal episodes should be individualized based on symptom progression 2
4. Medication Discontinuation: After an episode of ACE inhibitor-induced angioedema, lifetime discontinuation of all renin-angiotensin inhibitors may be warranted 4