1) Is treatment with all ACE inhibitors contraindicated in a patient with a history of ACE inhibito

Fråga: 1) Is treatment with all ACE inhibitors contraindicated in a patient with a history of ACE inhibitor induced angioedema as well as idiopathic angioedema? 2) Could angiotensin II-receptor blockers be safely given instead of an ACE inhibitor in the post-AMI regimen? An 84-year-old man who is on quinapril (Accupro), among many drugs, is admitted to the emergency room because of AMI (acute myocardial infarction). He also has angioedema which is judged to be caused by quinapril.

Sammanfattning: Angioedema is a well-known potentially life-threatening adverse effect to ACE inhibitor treatment and the risk of recurrence when treatment is continued is considerable. There seem to be a cross-reactivity with angiotensin II-receptor blockers. Neither ACE inhibitor nor angiotensin II-receptor blocker could be given safely in a patient who has a history of angioedema in association with ACE inhibitor treatment.

Svar: Angioedema edema is a well-known side effect to all ACE inhibitors registered in Sweden (1-5).

The overall incidence is around 0.1 to 0.2 per cent and the time of onset is usually during the first week of ACE inhibitor therapy (6). There are indications that the epidemiology of angioedema is changing in parallel with the increasing use of ACE inhibitors (7).

The mechanism of the angioedema is unclear. ACE inhibitor antibodies have not been demonstrated, and it is unlikely that the reaction is IgE mediated. Thus, it seems rather a biochemical phenomenon, with the bradykinin system involved more than the immunogenic (6).

A recent case report suggests that ACE inhibitor therapy should be discontinued immediately after late-onset angioedema to prevent further morbidity. They present an example of late-onset angioedema which was precipitated by taking a double dose of captopril incidentally (8).

A large study determined the characteristics of angioedema associated with the continued use of ACE inhibitors. A review of the medical records for patients who were taking ACE inhibitors and who had recurrent angioedema revealed that physicians attributed angioedema to a number of causes not related to ACE inhibitor use, even after multiple recurrences. Continuing use of ACE inhibitors in spite of angioedema results in a markedly increased rate of angioedema recurrence with serious morbidity (9).

Angioedema is also mentioned as a side effect for losartan in FASS and there are four cases reported to SADRAC (The Swedish Adverse Drug Reactions Advisory Committee). Recently, three new drugs in that group were registered in Sweden. In the side effect database of WHO there are until today 65 reports for losartan and 6 reports for valsartan respectively about angioedema.

The authors of another recent study suggest caution in using losartan in patients with known sensitivity to ACE-inhibitors manifested by angioedema. They report a case of a hemodialysis patient who previously had angioedema after ACE-inhibitor therapy and again had angioedema while taking losartan (10).