A 64-Year-Old Man With Throat Swelling

Patricia Ayuk Noumedem, PharmD; Marissa Tabile; Ermias Shikur; Bini Mathews; Anthony L. Huynh; Tracy Kwaku

Disclosures

August 08, 2018

Angioedema is a potential adverse effect of many other drugs, including:

  • Bupropion

  • Vaccines

  • Selective serotonin reuptake inhibitors (SSRIs)

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Proton pump inhibitors

  • Statins

  • Radiocontrast agents

ACE-induced angioedema typically presents with swelling of extremities such as legs, hands, and feet, as well as facial swelling, including the tongue. Internally, ACE inhibitors can cause swelling of the pharynx and larynx, which can only be seen via CT scanning and MRI. Flexible fiberoptic laryngoscopy may be beneficial in patients with head and neck angioedema with any lingual involvement.[7] Notable symptoms include:[1,2]

  • Trouble breathing

  • Tightness in throat

  • Trouble swallowing

  • Nausea and vomiting

  • Cramps or stomach pain

  • Erythema

Intubation is indicated in severe cases in which the airway is obstructed. Discontinuation of the ACE inhibitor is required and may be sufficient in less severe cases. A ratings scale and discharge criteria have been proposed by Bonner and colleagues.[8]

Pharmacological treatments include:[2]

  • Subcutaneous epinephrine

  • Ecallantide

  • Icatibant

  • Fresh frozen plasma

Lisinopril, the drug responsible in this patient, is indicated in adults and pediatric patients (> 6 y) for the treatment of hypertension and also as an adjunct in the therapy of heart failure. It is also indicated for the treatment of acute myocardial infarction. ACE is responsible for the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor that also stimulates aldosterone secretion. ACE inhibitors therefore block the conversion of angiotensin I to angiotensin II, which leads to a decrease in vasoconstriction and aldosterone secretion. Lisinopril also exerts its effect by blocking the breakdown of bradykinin, which is a contributory factor to its vasodilatory effect and adverse effects of angioedema and cough.[1,2,4] Other side effects of lisinopril include dizziness, headache, rash, hypotension, angina, palpitations, and fatigue. Gastrointestinal side effects include nausea, vomiting, diarrhea, and constipation. Taste perversions may also be associated with its use. Hyperkalemia (especially in renal dysfunction) has been reported.[1,2]

Drug monitoring should be carried out upon initiation of treatment or dosage increase because of a propensity for renal dysfunction. Contraindications for the use of lisinopril include a history of angioedema, hereditary or idiopathic. Lisinopril is also contraindicated in patients with known hypersensitivity to the drug and in coadministration with aliskiren in patients with diabetes mellitus.[2]

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