From the Guidelines
The primary treatment for Angiotensin-Converting Enzyme (ACE) inhibitor-induced angioedema in the emergency department is discontinuation of the ACE inhibitor. This approach is based on the most recent and highest quality evidence available, as stated in the 2013 study published in the Journal of Allergy and Clinical Immunology 1. The management of ACE-I–associated angioedema is focused on discontinuing the offending medication, which is the cornerstone of therapy for these patients.
Key Considerations
- Discontinuation of the ACE-I is crucial, although there might be a significant time lag between discontinuation of the drug and the propensity for angioedema.
- During acute attacks, patients need to be observed in a controlled environment in case they require intubation.
- Treatment with antihistamines, corticosteroids, or epinephrine has not been shown to be efficacious for ACE-I–associated angioedema, as noted in the study 1.
- Efficacy of icatibant and fresh frozen plasma have been described for ACE-I–associated angioedema; however, no controlled studies have been reported, making these options less evidence-based.
Clinical Approach
- Immediately stop the ACE inhibitor and secure the airway if there is any compromise.
- Observe patients until symptoms resolve, typically 24-48 hours.
- Ensure patients understand never to take ACE inhibitors again and document the reaction clearly in their medical record.
- Recommend alternative antihypertensive medications, considering the potential for cross-reactivity with other medications, such as angiotensin receptor blockers, which can occur in about 10% of patients.
Given the lack of strong evidence supporting specific pharmacological interventions beyond discontinuation of the ACE inhibitor, the focus should remain on supportive care and monitoring, with consideration of icatibant or fresh frozen plasma in severe or refractory cases, as suggested by the available evidence 1.
From the Research
Treatment for Angiotensin-Converting Enzyme (ACE) Inhibitor-Induced Angioedema
- The primary focus for the treatment of ACE inhibitor-induced angioedema is airway management 2.
- In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment 2.
- If the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions 2.
- Any patient with suspected ACE inhibitor-induced angioedema should immediately discontinue that medication 2, 3.
Pharmacotherapy Options
- Corticosteroids and antihistamines are commonly used, but their efficacy is not well established 4, 3.
- Icatibant, a bradykinin B2 receptor antagonist, has shown promise in reducing symptoms of ACE inhibitor-induced angioedema 4, 5.
- Fresh frozen plasma (FFP) and C1 inhibitor concentrate may also be effective in reducing bradykinin production 5.
- Ecallantide, a plasma kallikrein inhibitor, has not been shown to offer significant benefits 4, 5.
Diagnostic Considerations
- A diagnostic score has been proposed to help differentiate between ACE inhibitor-induced angioedema and mast cell-mediated angioedema 6.
- Factors associated with ACE inhibitor-induced angioedema include the number of angioedema episodes, duration of angioedema, hospitalization in intensive care, and no recurrence of angioedema after stopping ACE inhibitors 6.