Lisinopril angioedema
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Lisinopril-Induced Angioedema: Incidence, Risks, and Management
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. This condition involves rapid swelling of the deeper layers of the skin, often around the eyes and lips, and sometimes the throat, which can be life-threatening.
Incidence and Risk Factors of Lisinopril-Induced Angioedema
Higher Incidence Than Previously Reported
Recent studies suggest that the incidence of lisinopril-induced angioedema (LIA) is higher than previously reported. Data from the Veterans Health Administration (VHA) indicate that the risk of LIA could be as high as 1.6%, significantly higher than the previously published rates of 0.1% to 0.7% 510. This discrepancy is attributed to underreporting, as local chart reviews revealed that many cases were not documented in national databases 510.
Demographic and Temporal Patterns
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found that 70% of angioedema cases occurred in patients taking lisinopril, with a higher prevalence among black participants and men . Notably, 6% of cases developed within a day of starting the medication, and 23% within the first week .
Clinical Presentation and Severity
Common Symptoms and Areas Affected
Patients with lisinopril-induced angioedema typically present with swelling of the lips, buccal mucosa, and face. In a review of nine cases, none exhibited laryngeal edema or stridor, and symptoms resolved within 1 to 2 days with diphenhydramine treatment and discontinuation of lisinopril . However, isolated uvular angioedema has also been reported, highlighting the diverse presentations of this condition .
Severe and Fatal Cases
While most cases are mild, severe and fatal instances have been documented. A case report described a 66-year-old man who developed severe laryngeal edema leading to total airway obstruction and death, despite aggressive treatment . Another report highlighted a life-threatening episode in a patient who had been on lisinopril for 11 years, underscoring that angioedema can occur even after long-term use .
Management and Treatment Options
Standard Interventions
The primary management strategy for lisinopril-induced angioedema involves discontinuing the drug and administering antihistamines, corticosteroids, and epinephrine in severe cases . Most patients respond well to these treatments, with symptoms resolving within a few days .
Use of C1 Esterase Inhibitor
For patients who do not respond to standard interventions, C1 esterase inhibitor (C1-INH) has shown promise. In a case series, four patients with persistent symptoms were successfully treated with a single dose of C1-INH, leading to symptom resolution and discharge within 48 hours . However, due to the high cost and low incidence of ACE inhibitor-induced angioedema, C1-INH should be reserved for severe cases at risk of airway compromise .
Conclusion
Lisinopril-induced angioedema is a significant adverse effect that requires prompt recognition and management. The incidence may be higher than previously thought, particularly in certain populations. Clinicians should be vigilant when prescribing lisinopril and educate patients about the signs and symptoms of angioedema, ensuring immediate medical attention if they occur. Advanced treatments like C1-INH can be considered for severe cases unresponsive to conventional therapies.
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