What is the next step in managing a 65-year-old female patient with angioedema, who has received intramuscular (IM) epinephrine (adrenaline) but continues to exhibit lip swelling?

From the Guidelines

For a 65-year-old female with persistent angioedema despite initial IM epinephrine, the most effective next step is to administer a specific HAE treatment, such as C1 esterase inhibitor concentrate, icatibant, or ecallantide, as these have been shown to be safe and efficacious for the treatment of acute HAE attacks 1. Given that epinephrine, corticosteroids, and antihistamines are not recommended for the treatment of HAE due to their lack of efficacy in reversing the swelling in patients with this condition 1, the focus should be on using medications that target the underlying pathophysiology of HAE, such as the bradykinin B2 receptor antagonist icatibant or the plasma kallikrein inhibitor ecallantide. Key considerations in managing this patient include:

• Identifying the cause of the angioedema, as this will guide specific treatment choices, such as discontinuing ACE inhibitors if applicable.
• Ensuring airway patency, especially if there is any involvement of the oropharynx or larynx, by positioning the patient upright, administering oxygen, and having intubation equipment ready.
• Providing symptomatic treatment for pain and nausea, which may include narcotic medications and antiemetics, but being cautious of the risk of narcotic addiction in patients with frequent attacks.
• Considering the use of fresh frozen plasma as an alternative, although it carries the risk of sudden worsening of symptoms and viral transmission 1. The primary goal is to manage the patient's symptoms effectively while minimizing the risk of complications, particularly airway compromise, which is a significant concern in HAE attacks involving the upper airways 1.

From the Research

Next Steps in Management

• The patient has already received epinephrine IM, which is the first-line treatment for anaphylaxis 2, 3, 4.
• Despite epinephrine administration, the patient's lip is still swollen, indicating that the reaction may not be fully controlled.
• Consider administering antihistamines, which have been shown to be beneficial in reducing the severity of anaphylactic reactions 3.
• Corticosteroids may also be considered, although the evidence for their use in anaphylaxis is not as strong 5, 4.
• It is essential to continue monitoring the patient's airway, breathing, and circulation, and to be prepared to administer additional doses of epinephrine or other medications as needed 2, 3, 4.

Adjunctive Therapies

• Antihistamines, such as diphenhydramine, may be administered to help alleviate symptoms such as urticaria and itching 3.
• Corticosteroids, such as prednisone, may be administered to help reduce inflammation and prevent biphasic reactions, although their effectiveness is still debated 5, 4.
• Beta-2 adrenergic agonists, such as albuterol, may be administered to help alleviate bronchospasm 4.
• Glucagon may be administered to help alleviate hypotension and bradycardia 4.

Ongoing Assessment and Management

• Continue to monitor the patient's vital signs and symptoms closely, and be prepared to escalate treatment as needed 2, 3, 4.
• Consider consulting with an allergist or other specialist for further guidance on management and treatment 2, 4.
• Ensure that the patient has access to epinephrine auto-injectors and knows how to use them properly 3, 4.