Are corticosteroids and antihistamines indicated in the treatment of angioedema?

From the Guidelines

Corticosteroids and antihistamines are indicated for certain types of angioedema, particularly histamine-mediated forms, but not for all types. For histamine-mediated angioedema (allergic or idiopathic), first-generation antihistamines like diphenhydramine (25-50mg every 6 hours) or second-generation antihistamines like cetirizine (10mg daily) can provide relief. Corticosteroids such as prednisone (40-60mg daily for 3-5 days) or methylprednisolone (60-125mg IV) are useful for more severe cases to reduce inflammation and swelling. However, these medications are ineffective for bradykinin-mediated angioedema, including hereditary angioedema and ACE inhibitor-induced angioedema. For these types, specific treatments like C1 inhibitor concentrates, icatibant, or ecallantide are required, as stated in the guidelines 1. When treating acute angioedema, it's crucial to first assess airway stability and administer epinephrine (0.3-0.5mg IM) if there's respiratory compromise, as recommended by the guidelines 1. The effectiveness of antihistamines and corticosteroids stems from their ability to block histamine receptors and reduce inflammatory mediator production, but they work too slowly to be effective for bradykinin-mediated swelling or life-threatening airway compromise. Some key points to consider when treating angioedema include:

• Assessing airway stability and administering epinephrine if necessary
• Using antihistamines and corticosteroids for histamine-mediated angioedema
• Using specific treatments like C1 inhibitor concentrates, icatibant, or ecallantide for bradykinin-mediated angioedema
• Considering the potential risks and benefits of treatment, as discussed in the guidelines 1. It's also important to note that the management of ACE-I (or ARB)–associated angioedema involves discontinuation of the ACE-I (or ARB) and may require specific treatments like icatibant or fresh frozen plasma, as stated in the guidelines 1. Overall, the treatment of angioedema requires a careful assessment of the underlying cause and the use of specific treatments to manage the condition effectively.

From the Research

Indications for Corticosteroids and Antihistamines in Angioedema

• Corticosteroids and antihistamines are commonly used in the treatment of angioedema, particularly in cases of allergic histaminergic angioedema 2.
• These medications are often effective in relieving symptoms and reducing the severity of the condition 2.
• However, in cases of non-histaminergic angioedema, such as bradykinin-mediated angioedema, corticosteroids and antihistamines may be less effective 3, 4.
• In fact, the use of epinephrine, which is often administered in conjunction with corticosteroids and antihistamines, may even be harmful in cases of non-histaminergic angioedema, as it can cause myocardial ischemia or dysrhythmia 4.
• The treatment of angioedema should be tailored to the specific underlying cause of the condition, and corticosteroids and antihistamines should only be used when appropriate 2, 5.

Specific Considerations for ACE Inhibitor-Induced Angioedema

• ACE inhibitor-induced angioedema is a type of non-histaminergic angioedema that is often resistant to treatment with corticosteroids and antihistamines 3, 4.
• In these cases, other medications such as C1-esterase inhibitor concentrates, icatibant, and ecallantide may be more effective in relieving symptoms 3.
• The use of corticosteroids and antihistamines in ACE inhibitor-induced angioedema is not recommended, as they are unlikely to be effective and may even cause harm 4.

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Treatment Options for Hereditary Angioedema

• Hereditary angioedema due to C1-esterase inhibitor deficiency is a rare autosomal dominant disease that requires specific treatment 6.
• The treatment of hereditary angioedema is based on three pillars: treatment of acute angioedema attacks, short-term prophylaxis, and long-term prophylaxis 6.
• Corticosteroids and antihistamines are not typically used in the treatment of hereditary angioedema, as they are not effective in relieving symptoms 6.
• Instead, medications such as purified plasma-derived human C1 esterase inhibitor concentrate, icatibant acetate, and ecallantide are used to treat acute angioedema attacks, while tranexamic acid, danazol, and lanadelumab are used for long-term prophylaxis 6.