Lisinopril and angioedema
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Lisinopril and Angioedema: A Comprehensive Overview
Introduction to Lisinopril-Induced Angioedema
Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, is widely prescribed for hypertension and heart failure. However, it has been associated with a rare but serious adverse effect: angioedema. Angioedema involves the rapid swelling of the deeper layers of the skin, often affecting the face, lips, tongue, and throat, and can be life-threatening if it leads to airway obstruction.
Incidence and Risk Factors of Lisinopril-Induced Angioedema
The incidence of lisinopril-induced angioedema (LIA) is higher than previously reported. Studies indicate that the risk of LIA may be as high as 1.6%, significantly higher than the earlier estimates of 0.1% to 0.7% 810. This discrepancy is largely due to underreporting, as highlighted by research within the Veterans Health Administration (VHA), where local chart reviews revealed a substantial number of unreported cases 810.
Clinical Presentation and Severity
Lisinopril-induced angioedema typically presents with swelling of the lips, buccal mucosa, and face. In severe cases, it can progress to involve the throat, leading to respiratory distress and potentially fatal outcomes. A notable case involved a 66-year-old man who developed severe laryngeal edema, leading to total airway obstruction and death despite aggressive treatment . Another case reported life-threatening angioedema in a patient who had been on lisinopril for 11 years, underscoring that this adverse effect can occur even after long-term use .
Management and Treatment Options
The primary management of LIA involves immediate discontinuation of the drug and symptomatic treatment. Antihistamines like diphenhydramine are commonly used, and symptoms typically resolve within 1 to 2 days . In more severe cases, where initial interventions fail, C1 esterase inhibitor (C1-INH) has been shown to be effective. A case series demonstrated that patients treated with C1-INH for lisinopril-induced angioedema had complete resolution of symptoms and were discharged within 48 hours .
Special Considerations and Unique Presentations
Angioedema can also present in less common forms, such as isolated visceral angioedema, which affects the gastrointestinal tract. This rare presentation can cause symptoms like abdominal pain and nausea, as seen in a case involving a 62-year-old female with small bowel angioedema after prolonged lisinopril use 69.
Conclusion
Lisinopril-induced angioedema is a significant adverse effect that requires prompt recognition and management. The incidence is likely higher than previously reported, emphasizing the need for healthcare providers to be vigilant. Immediate discontinuation of lisinopril and appropriate symptomatic treatment are crucial, and in severe cases, C1-INH may be a viable option. Understanding the varied presentations of angioedema, including rare forms like visceral angioedema, is essential for timely diagnosis and treatment.
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