What is the relationship between angioedema and the use of lisinopril (Angiotensin-Converting Enzyme inhibitor) following anesthesia?

From the Guidelines

Lisinopril should be discontinued immediately in a patient who has developed angioedema, and this medication and all other ACE inhibitors should be permanently avoided in the future. The patient should be switched to an alternative antihypertensive medication from a different class, such as an angiotensin receptor blocker (ARB) like losartan or a calcium channel blocker like amlodipine. For acute management of angioedema, treatment includes airway assessment, epinephrine (0.3-0.5 mg IM) for severe cases, antihistamines (diphenhydramine 25-50 mg IV/PO), and corticosteroids (methylprednisolone 125 mg IV or prednisone 40-60 mg PO) 1.

Key Considerations

• The risk of angioedema with ACE inhibitors is estimated to be around 0.1% to 0.7% of patients, with African American subjects being at a substantially higher risk 1.
• The mechanism of ACE inhibitor-induced angioedema is thought to be related to the impaired degradation of bradykinin, leading to its accumulation and subsequent vasodilation and increased vascular permeability 1.
• While ARBs may be considered as alternative therapy for patients who have developed angioedema while taking an ACE inhibitor, there is a modest risk of recurrent angioedema with ARB therapy, and caution is advised when substituting an ARB in a patient who has had angioedema associated with use of an ACE inhibitor 1.

Management and Prevention

• Patients with a history of ACE inhibitor-induced angioedema should be clearly identified and this information should be prominently noted in their medical records and communicated to all anesthesia providers.
• Certain anesthetic agents can potentially exacerbate angioedema in susceptible individuals, and caution should be exercised when administering anesthesia to patients with a history of ACE inhibitor-induced angioedema.
• 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.

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.

The relationship between angioedema and the use of lisinopril following anesthesia is that angioedema can occur at any time during treatment with lisinopril, including after anesthesia.

• Key points:
  • Angioedema can cause airway obstruction, especially in patients with a history of airway surgery.
  • Lisinopril should be promptly discontinued if angioedema occurs.
  • Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor 2. However, the label does not explicitly address the relationship between angioedema and lisinopril use specifically following anesthesia.

From the Research

Relationship between Angioedema and Lisinopril Use following Anesthesia

• The use of lisinopril, an Angiotensin-Converting Enzyme (ACE) inhibitor, has been associated with an increased risk of angioedema, a potentially life-threatening condition characterized by rapid swelling of the skin and mucous membranes 3, 4, 5, 6, 7.
• Studies have reported that ACE inhibitors, including lisinopril, account for 8% of all cases of angioneurotic edema, with an overall incidence of 0.1 to 0.7% of patients on ACE inhibitors 3.
• Angioedema can occur at any time during ACE inhibitor therapy, even after years of treatment, and can be precipitated by factors such as surgery, anesthesia, and dehydration 4, 5, 6.
• The condition can manifest as upper airway edema, which can lead to airway obstruction and require intubation or tracheostomy 3, 4, 6.
• Discontinuation of the ACE inhibitor is the primary treatment for angioedema, and supportive therapy such as antihistamines and corticosteroids may also be used 3, 4, 7.
• Early recognition and diagnosis of angioedema are crucial to prevent serious complications and improve patient outcomes 3, 4, 5, 6, 7.

Incidence and Risk Factors

• The incidence of angioedema associated with lisinopril has been reported to be greater than that associated with other ACE inhibitors such as captopril or enalapril 7.
• Risk factors for angioedema include a history of ACE inhibitor use, surgery, anesthesia, and dehydration 4, 5, 6.
• Concomitant use of other medications that can cause angioedema, such as diuretics, may also increase the risk of developing angioedema 4, 5.

Clinical Presentation and Management

• Angioedema can present with symptoms such as swelling of the lips, tongue, face, and neck, as well as respiratory distress and stridor 3, 4, 6, 7.
• Clinical management of angioedema involves discontinuation of the ACE inhibitor, supportive therapy, and monitoring for airway compromise 3, 4, 6, 7.
• In severe cases, intubation or tracheostomy may be required to secure the airway 3, 4, 6.