What medications are recommended for patients with angioedema upon discharge from the hospital?

Discharge Medications for Angioedema

Patients with angioedema being discharged from the hospital require specific medications based on the underlying etiology: for hereditary angioedema (HAE), prescribe on-demand acute treatment agents (C1-INH concentrate, icatibant, or ecallantide) plus consider long-term prophylaxis; for ACE inhibitor-induced angioedema, immediately discontinue the offending agent and avoid all ACE inhibitors permanently; for histaminergic angioedema, prescribe antihistamines and consider leukotriene modifiers.

Hereditary Angioedema (HAE) Discharge Prescriptions

Acute On-Demand Treatment (Essential for All HAE Patients)

Every HAE patient must have immediate access to acute attack medications at home:

• C1-esterase inhibitor (C1-INH) concentrate - plasma-derived, nanofiltered, or recombinant forms are all effective for acute attacks 1, 2
• Icatibant 30 mg subcutaneous injection - bradykinin B2 receptor antagonist; patients can self-administer at home; provides relief within approximately 0.75 hours with effects lasting at least 6 hours 1
• Ecallantide - kallikrein inhibitor alternative 3, 4

Critical caveat: Patients and caregivers must receive hands-on training for self-administration before discharge, with written instructions on when to use these medications and when to seek emergency care 1, 3.

Long-Term Prophylaxis (For Frequent Attacks)

Consider prophylactic therapy for patients experiencing frequent attacks:

• Berotralstat - oral kallikrein inhibitor that reduces attack frequency and improves quality of life 2
• Lanadelumab - subcutaneous monoclonal antibody that decreases both attack frequency and severity of breakthrough attacks 2
• Subcutaneous C1-INH - reduces attack frequency and severity 2
• Danazol - attenuated androgen that reduces attack frequency, though adverse event profile (weight gain, psychological changes, body hair) limits use 2

Evidence strength: All these agents except avoralstat demonstrate efficacy in reducing HAE attacks compared to placebo, with low rates of serious adverse events 2.

ACE Inhibitor-Induced Angioedema

Immediate Actions

• Permanently discontinue the ACE inhibitor - this is the single most important intervention 3, 5
• Do not prescribe antihistamines, corticosteroids, or epinephrine - ACE inhibitor-induced angioedema is bradykinin-mediated and resistant to these standard allergic treatments 3, 5

Alternative Antihypertensive Therapy

If the patient requires renin-angiotensin system blockade:

• Wait 6 weeks after ACE inhibitor discontinuation before considering an ARB 6, 7
• ARBs carry 2-17% risk of recurrent angioedema in patients with prior ACE inhibitor-induced angioedema 7
• Start ARB at low dose (e.g., losartan 25-50 mg daily) with close monitoring during the first weeks 7

Safer alternatives that avoid angioedema risk entirely:

• Calcium channel blockers 6, 7
• Thiazide diuretics 6, 7
• Beta-blockers 6, 7

Critical warning: Never use ARNIs (angiotensin receptor-neprilysin inhibitors) in patients with angioedema history, as they carry increased risk 7.

Histaminergic Angioedema (With or Without Urticaria)

First-Line Therapy

• High-dose H1-antihistamine - cetirizine 20 mg daily achieves complete suppression in 82% of patients 8
• Leukotriene modifier - montelukast 10 mg daily in combination with antihistamine provides superior control 8

Rationale: This form of angioedema is mediated by both histamine and leukotrienes, requiring dual blockade for optimal control 8.

Acute Rescue Medications

For breakthrough episodes:

• Epinephrine - for severe allergic angioedema with airway compromise 3
• Corticosteroids - adjunctive therapy for allergic angioedema 3
• Additional antihistamines - diphenhydramine for acute symptoms 5

Patient Education Requirements Before Discharge

All angioedema patients require comprehensive discharge instructions:

• Written and verbal instructions on medication type, purpose, dose, frequency, and side effects 9
• Emergency action plan detailing when to self-treat versus when to call 9-1-1 9
• Recognition of worsening symptoms - increasing swelling, difficulty breathing, tongue/throat involvement requires immediate emergency care 9
• Medication demonstration - for self-injectable medications like icatibant, ensure patient or caregiver can properly administer 1

Special Populations

Elderly Patients

• Icatibant shows increased systemic exposure in elderly patients but no dose adjustment required 1
• Monitor closely for adverse effects given altered pharmacokinetics 1

Hepatic/Renal Impairment

• Icatibant requires no dose adjustment in mild-to-moderate hepatic impairment (Child-Pugh 5-8) or renal impairment, as it is cleared non-renally 1

Common Pitfalls to Avoid

• Do not prescribe antihistamines for HAE or ACE inhibitor-induced angioedema - they are ineffective for bradykinin-mediated angioedema 3, 5
• Do not restart ACE inhibitors after ACE inhibitor-induced angioedema, even if the episode occurred months or years into therapy 5
• Do not assume angioedema is allergic without confirming presence of urticaria and pruritus 3
• Do not discharge HAE patients without on-demand acute treatment available at home 1, 2
• Do not use fresh frozen plasma if specific HAE treatments (C1-INH, icatibant, ecallantide) are available 3