What would you discharge a patient with angioedema on?

Discharge Medications for Angioedema

For patients with angioedema, discharge medications should include H1 antihistamines (preferably second-generation) for 2-3 days, H2 antihistamines for 2-3 days, and a short course of oral corticosteroids (prednisone) for 2-3 days. 1

Treatment Based on Angioedema Type

Histaminergic Angioedema (with urticaria)

• First-line: Second-generation non-sedating H1 antihistamines (cetirizine, desloratadine, fexofenadine, or loratadine) 2
  • Can be used at up to 4× standard dose for persistent cases
• Second-line: Add H2 antihistamine (ranitidine twice daily for 2-3 days) 1
• Third-line: Add oral corticosteroids (prednisone daily for 2-3 days) 1
• For refractory cases: Consider montelukast as add-on therapy 2

Bradykinin-Mediated Angioedema (without urticaria)

• ACE inhibitor-induced: Immediate discontinuation of the ACE inhibitor 2
• Hereditary or acquired C1-INH deficiency:
  • Icatibant 30 mg subcutaneously (can repeat after 6 hours if needed, maximum 3 doses/24 hours) 3
  • OR C1 inhibitor concentrate 1, 2
  • Fresh frozen plasma if C1 inhibitor is unavailable 2

Specific Discharge Instructions

For All Patients:

• Epinephrine auto-injector prescription for patients at risk of recurrent severe attacks, especially those with history of laryngeal involvement 1
• Medical identification jewelry or wallet card 1
• Follow-up appointment with primary care provider and consideration for allergist/immunologist referral 1

For Patients with Severe Angioedema:

• Airway management education - recognizing signs of airway compromise 1
• Anaphylaxis emergency action plan if applicable 1
• Training on proper epinephrine auto-injector use 1

Important Considerations

Medication Selection Based on Angioedema Type

• Standard antihistamines and corticosteroids are ineffective for bradykinin-mediated angioedema (hereditary, acquired, or ACE inhibitor-induced) 4
• Icatibant or C1-INH concentrate should be prescribed for patients with confirmed hereditary angioedema 1, 3
• Avoid ACE inhibitors in patients with any history of angioedema 5

Duration of Therapy

• For most histaminergic angioedema, a short course (2-3 days) of combination therapy is sufficient 1
• For recurrent or chronic angioedema, longer-term management with daily antihistamines may be necessary 2

Common Pitfalls to Avoid

1. Failing to identify and discontinue causative medications (especially ACE inhibitors) 2
2. Relying solely on antihistamines for bradykinin-mediated angioedema 4
3. Not providing an epinephrine auto-injector to patients with history of laryngeal involvement 1
4. Inadequate follow-up planning - all patients should have a follow-up appointment scheduled 1

By following this structured approach to discharge medications for angioedema, you can provide effective symptom relief while addressing the underlying mechanism of the patient's condition and preventing future episodes.