From the Guidelines
The acute treatment for angioedema is best managed with on-demand medications such as plasma-derived C1INH, icatibant, or ecallantide, which have been shown to be safe and efficacious for the treatment of acute attacks 1.
Treatment Options
- Plasma-derived C1INH: effective in treating acute attacks of angioedema, but may not be available in all countries 1.
- Icatibant: a B2 bradykinin receptor antagonist, which has been shown to be safe and efficacious for the treatment of acute attacks of angioedema 1.
- Ecallantide: a plasma kallikrein inhibitor, which has been shown to be safe and efficacious for the treatment of acute attacks of angioedema 1.
Symptomatic Treatment
- Narcotic medications: may be required for control of pain during abdominal attacks 1.
- Antiemetics: may be required for nausea and vomiting 1.
- Aggressive hydration: may be helpful in managing third-space sequestration of fluid during abdominal attacks 1.
Avoided Treatments
- Epinephrine, corticosteroids, and antihistamines are not efficacious and not recommended for the treatment of HAE, as they do not affect the generation of bradykinin 1.
- Fresh frozen plasma may be effective in abrogating HAE attacks, but its use is controversial due to the risk of exacerbating some attacks and viral transmission 1.
- Tranexamic acid may potentially prolong the attack, but some patients may find it effective in reducing severity when used early in the attack 1.
- Attenuated androgens are unlikely to contribute to resolution of established attacks, but may be effective in aborting attacks when used immediately upon recognition of prodromal symptoms 1.
From the Research
Acute Treatment for Angioedema
The acute treatment for angioedema depends on the underlying cause and can be divided into two main forms: histamine-mediated and bradykinin-mediated angioedema.
- Histamine-mediated angioedema can be treated with:
- Bradykinin-mediated angioedema can be treated with:
- C1-INH protein replacement 2, 5, 3
- Kallikrein inhibitor 2
- Bradykinin receptor antagonists 2
- Icatibant (in hereditary angioedema or renin-angiotensin-aldosterone system blocker-induced angioedema) 5, 3
- C1-INH concentrate (in hereditary angioedema or acquired angioedema) 5
- Fresh frozen plasma (if other medications are not available) 3
Airway Management
Airway management is crucial in cases of angioedema, especially when the larynx or pharynx are involved.
- Recognition of impending airway obstruction and securing the airway is of highest priority 4, 2
- Airway intervention may require fiberoptic or video laryngoscopy, with preparation for cricothyrotomy 2
Disposition
Disposition of the patient depends on their airway and respiratory status, as well as the sites involved.