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Excellence In Physical Exam Series | ACE Inhibitor Angioedema

Jesse Nichos, DO and Mike Weinstock, MD
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ACE inhibitor angioedema has a range of presentations from mild lip swelling to airway closure – an exam starts with observing the patient for signs of respiratory distress and then obtaining a good view of the posterior pharynx looking for glottal edema and posterior pharyngeal edema.

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Angelina M., PA-C -

I was wondering why you wouldn't want to switch the patient to an ARB? I thought I heard that previously back when I was training but then I had a patient in the UC with this and I followed up on them and they were switched to an ARB, which I have since realized is common practice for our PCPs. After my initial encounter with this patient, I was double-checking with UTD and they state: "In patients with a history of ACE inhibitor-induced angioedema, we suggest not avoiding angiotensin-receptor blockers (ARBs) if an ARB has advantages over other agents for that patient (Grade 2C)." If the angioedema is from the bradykinin pathway then it would make sense that an ARB would be safe. Which resource recommends not starting an ARB and why? Thanks so much!

Mike W., MD -

Hi Angelina, here is the response from Jesse Nichols, DO. Thx for the comment!
M

Great question,
You’re right there is no absolute contraindication to switching to an ARB following an ACEi angioedema especially if the long term benefits outweigh the risks. The pathophysiology of ACEi angioedema is related to the bradykinin pathway. While ARBs do not have the same bradykinin pathway pathophysiology, there have been reports of angioedema and specifically visceral angioedema associated with ARBs. This by no means is an absolute contraindication to switching between the two medications especially if the long term benefits outweigh the risks. I have provided some literature resources as well as a reference:

Risk of angioedema with angiotensin receptor blockers in patients with prior angioedema associated with angiotensin-converting enzyme inhibitors: a meta-analysis
Haywire, Bret R. Et al.
Annals of Allergy, Asthma and Immunology, Volume 101, Issue 5, 495-499

Janet F. -

What is the management of someone with lip swelling/angioedema without respiratory compromise, tongue, pharyngeal swelling? How long do you observe them? If an Urgent Care an appropriate place for observation? Is the patient observed until the swelling has resolved?

Mike W., MD -

Hi Janet, thx for the question. Yes, this is tough and does need to be individualized. If I have a patient who has some swelling but it is not impeding the airway and I have observed the patient and reexamined and they are not worsening and I have confirmed w them that they will stop the ACE, I will feel comfortable discharging . The duration of observation can be individualized, but a recheck in 1 hour without any worsening of Sx would be reassuring to me. If there are minimal Sx then an UC would be appropriate for a recheck in an hour. Usually will take hours to days to resolve so it will be the rare case which completely resolved while they are in the UC.
Thx!
M
M

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Hippo Urgent Care RAP - October 2019 Written Summary 758 KB - PDF

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