Learn about the nuances of ACE inhibitor-induced angioedema and how it differs from anaphylaxis. Discover why traditional treatments like antihistamines fall short and the importance of timely airway management. Explore innovative therapies such as bradykinin antagonists and the potential role of fresh frozen plasma. The episode dives into clinical presentations, emphasizing the common symptoms and urgent treatment strategies for patients experiencing swelling.
05:03
forum Ask episode
web_stories AI Snips
view_agenda Chapters
auto_awesome Transcript
info_circle Episode notes
insights INSIGHT
Different Pathways: Anaphylaxis Vs ACEI Angioedema
Anaphylaxis is mediated by histamine and mast cells, so epinephrine plus H1/H2 blockers target that pathway.
ACE inhibitor angioedema uses a different mediator, so histamine-directed therapies won't address it.
volunteer_activism ADVICE
Avoid Standard Anaphylaxis Drugs For ACEI Cases
Do not rely on epinephrine, steroids, or antihistamines for ACE inhibitor-induced angioedema because it is bradykinin-mediated.
Recognize that standard anaphylaxis meds will generally not improve ACEI angioedema.
volunteer_activism ADVICE
Prioritize Early Airway Management
Prioritize airway assessment and intubate early if there is impending airway compromise to avoid crash surgical airways.
Monitor progression closely because lip or tongue swelling can rapidly progress to airway obstruction.
Get the Snipd Podcast app to discover more snips from this episode
First line: epinephrine for vasoconstriction and bronchodilation
Second line: H1 and H2 antihistamines such as Benadryl and famotidine
ACE inhibitor-induced angioedema
Different pathway from anaphylaxis
ACE inhibitor-induced angioedema is mediated by bradykinins
Therefore, anaphylaxis medications are not beneficial in patients with ACE inhibitor-induced angioedema
Leading cause of drug-induced angioedema in the US
Patients most commonly present with swelling of the lips, tongue, or face
Treatment:
Airway management: varies depending on the severity and progression of the presentation
If awake nasointubation is required, LMX is a 5% lidocaine water-soluble solution that provides anesthesia to the oropharynx
Medications:
Icatibant is a synthetic bradykinin B2-receptor antagonist that can be used in acute treatment
Tranexamic acid (TXA) inhibits the plasmin-dependent formation of bradykinin, but the data on this treatment are mixed and limited
Fresh frozen plasma (FFP) is thought to degrade high levels of bradykinin with subsequent resolution of angioedema
Discontinue ACE inhibitor
References
Bork K, Wulff K, Hardt J, Witzke G, Staubach P. Hereditary angioedema caused by missense mutations in the factor XII gene: clinical features, trigger factors, and therapy. J Allergy Clin Immunol. 2009 Jul;124(1):129-34. doi: 10.1016/j.jaci.2009.03.038. Epub 2009 May 27. PMID: 19477491.
Bova M, Guilarte M, Sala-Cunill A, Borrelli P, Rizzelli GM, Zanichelli A. Treatment of ACEI-related angioedema with icatibant: a case series. Intern Emerg Med. 2015 Apr;10(3):345-50. doi: 10.1007/s11739-015-1205-9. Epub 2015 Feb 10. PMID: 25666515.
Karim MY, Masood A. Fresh-frozen plasma as a treatment for life-threatening ACE-inhibitor angioedema. J Allergy Clin Immunol. 2002 Feb;109(2):370-1. doi: 10.1067/mai.2002.121313. PMID: 11842313.
Pathak GN, Truong TM, Chakraborty A, Rao B, Monteleone C. Tranexamic acid for angiotensin-converting enzyme inhibitor-induced angioedema. Clin Exp Emerg Med. 2024 Mar;11(1):94-99. doi: 10.15441/ceem.23.051. Epub 2023 Aug 1. PMID: 37525579; PMCID: PMC11009700.
Simons FE. First-aid treatment of anaphylaxis to food: focus on epinephrine. J Allergy Clin Immunol. 2004 May;113(5):837-44. doi: 10.1016/j.jaci.2004.01.769. Erratum in: J Allergy Clin Immunol. 2004 Jun;113(6):1039. Dosage error in article text. PMID: 15131564.
Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4
Emergency Medical Minute