From the Guidelines
African American patients have a substantially higher risk of experiencing ACE-I–induced angioedema, with a risk 3-5 times higher than white subjects, and should be closely monitored when taking ACE inhibitors. The characteristics of Angioedema in African American patients include a higher prevalence of angioedema, particularly hereditary angioedema with normal C1 inhibitor levels and acquired angioedema related to ACE inhibitor use 1.
Key Factors
- African American subjects are at a higher risk of experiencing ACE-I–induced angioedema than white subjects 1
- Other factors that increase the risk of angioedema from ACE-Is include a history of smoking, increasing age, and female sex 1
- Diabetic patients have a lower risk than nondiabetic patients 1
- The management of ACE-I (or ARB)–associated angioedema is discontinuation of the ACE-I (or ARB) 1
Treatment and Prevention
- For acute management, first-line treatment includes epinephrine (0.3-0.5 mg IM for adults) for severe cases, antihistamines such as diphenhydramine (25-50 mg IV/PO) or cetirizine (10 mg daily), and corticosteroids like prednisone (40-60 mg daily for 3-5 days)
- For hereditary angioedema, specific treatments include C1 inhibitor concentrates (Berinert, Cinryze), icatibant (30 mg SC), or ecallantide (30 mg SC)
- When prescribing antihypertensives to African Americans with a history of angioedema, alternatives to ACE inhibitors such as angiotensin receptor blockers, calcium channel blockers, or thiazide diuretics should be considered
- Patients should be educated about angioedema symptoms and instructed to seek immediate medical attention if facial, lip, tongue, or throat swelling occurs 1
From the Research
Characteristics of Angioedema in African American Patients
- Angioedema is a nonpitting edema that can range from benign facial swelling to airway obstruction, requiring intubation or tracheotomy 2
- A study of 108 patients with angioedema found that 90.7% were African-American, and 75% were female 2
- The presentation of angioedema can be classified into three categories:
- Isolated facial swelling and oral cavity edema
- Floor of mouth and/or oropharyngeal edema
- Oropharyngeal edema with glottic and/or supraglottic involvement 2
- African-Americans may be at higher risk for angioedema, particularly those taking angiotensin-converting enzyme inhibitors (ACEIs) 3, 4, 5
- The pathogenesis of ACEI-induced angioedema is thought to be related to a reduced catabolism and accumulation of bradykinin, which is normally metabolized by ACE 3
- Genetic studies have shown that some single nucleotide polymorphisms at genes encoding relevant molecules for bradykinin metabolism and action may be involved in ACEI-induced angioedema, giving a basis for the ethnic predisposition 3
- Treatment of ACEI-induced angioedema is still a matter of debate, but discontinuation of the causative drug is recommended 6, 3, 4
- Common treatments for angioedema, such as antihistamines and glucocorticoids, have not been shown to be effective in ACEI-induced angioedema 6, 4