ACE Inhibitor-Induced Angioedema

Introduction to Angioedema

• Patients can develop ACE inhibitor-induced angioedema even after many years of continuous therapy, which is a well-documented phenomenon that can occur at any point during treatment, from the first month to after a decade or more of use, according to the Journal of Allergy and Clinical Immunology 1

Clinical Presentation and Diagnosis

• The American College of Allergy, Asthma, and Immunology characterizes ACE inhibitor-induced angioedema as asymmetric, non-pitting swelling that is NOT pruritic and occurs WITHOUT urticaria (hives) 2
• Swelling prominently involves the face and tongue but can also affect the bowel, extremities, and isolated laryngeal structures 1, 2
• Absence of skin rash, hives, or itching is characteristic 2

Treatment and Management

• The definitive management is immediate discontinuation of the ACE inhibitor 2
• ACE inhibitor angioedema does NOT reliably respond to epinephrine, antihistamines, or corticosteroids because it is bradykinin-mediated, not histamine-mediated 1, 2
• The swelling tendency can continue for at least 6 weeks after discontinuation of the ACE inhibitor 1, 2

Alternative Therapies

• Angiotensin Receptor Blockers (ARBs) are the preferred alternative for patients who cannot tolerate ACE inhibitors, although there is a small risk (2-17%) of cross-reactivity in patients who experienced angioedema with ACE inhibitors 3
• Calcium channel blockers or thiazide diuretics are excellent alternatives if ARBs are contraindicated or if the clinician wishes to avoid any cross-reactivity risk 3

Risk Factors and Prevention

• African American patients are at substantially higher risk than white patients for ACE inhibitor-induced angioedema 1
• Other risk factors include history of smoking, increasing age, and female sex 1
• Diabetic patients have a lower risk than nondiabetic patients 1