Can I take Lisinopril (angiotensin-converting enzyme inhibitor) if I have a tree nut allergy?

Taking Lisinopril with a Tree Nut Allergy

Patients with tree nut allergies can safely take lisinopril as there is no contraindication between ACE inhibitors and nut allergies. 1

Safety of Lisinopril in Patients with Nut Allergies

• Lisinopril is contraindicated only in patients with a history of angioedema or hypersensitivity related to previous treatment with an ACE inhibitor or in those with hereditary or idiopathic angioedema 1
• The FDA label for lisinopril does not list nut allergies as a contraindication or precaution 1
• Tree nut allergies are IgE-mediated allergic reactions that are unrelated to the pharmacological mechanism of ACE inhibitors 2

Understanding Tree Nut Allergies

• Tree nut allergies affect up to 4.9% of the general population and can cause severe, potentially life-threatening reactions 2
• Most proteins implicated in tree nut allergic reactions belong to specific protein families (lipid transfer protein, 2S albumin, vicilin, legumin, and oleosin) that are not present in medications like lisinopril 2
• Tree nuts are clinically associated with severe immunoglobulin E-mediated systemic allergic reactions that are distinct from drug reactions 3

Important Considerations for Patients with Tree Nut Allergies

• Patients with tree nut allergies should always carry emergency medication, particularly epinephrine auto-injectors, regardless of what other medications they are taking 4, 5
• The American Academy of Pediatrics recommends prescribing two doses of epinephrine autoinjector for patients with nut allergies to carry at all times 5
• Patients with both tree nut allergies and asthma are at higher risk for severe allergic reactions and should be particularly vigilant 4

Potential Concerns with ACE Inhibitors

• While not related to nut allergies specifically, patients should be aware that ACE inhibitors like lisinopril can cause angioedema as a side effect in some patients 1
• Angioedema from ACE inhibitors is not allergic in nature but is due to the pharmacological effect of these medications on bradykinin metabolism 1
• ACE inhibitor-induced angioedema occurs in a small percentage of patients and is more common in Black patients than in non-Black patients 1

Management Recommendations

• Patients with tree nut allergies who are prescribed lisinopril should:
  • Continue to strictly avoid the specific nuts they are allergic to 6
  • Always carry emergency medication for their nut allergy, including epinephrine auto-injectors 4, 5
  • Be aware of the symptoms of angioedema (swelling of face, lips, tongue, throat) which, while unrelated to their nut allergy, is a possible side effect of lisinopril 1
  • Seek immediate medical attention if they experience symptoms of angioedema while taking lisinopril 1

Conclusion

• Tree nut allergies do not contraindicate the use of lisinopril 1
• The mechanisms of tree nut allergies (IgE-mediated) and potential ACE inhibitor side effects (bradykinin-mediated) are distinct 1, 2
• Patients should continue appropriate management of their tree nut allergy while taking lisinopril 5, 6