Is it possible to give candesartan to a patient that has reacted with angioedema on enalapril?

Fråga: Is it possible to give candesartan to a patient that has reacted with angioedema on enalapril?

Sammanfattning: There is a risk of developing angioedema on angiotensin receptor blockers in patients that have demonstrated this reaction during ACE inhibitor treatment, but it seems to be small with an upper 95% confidence limit of 6.6%.

Data are too limited to say if a difference exists between different ARBs.

Svar: This question has been dealt with in two previous Drugline documents (1,2). These have cited one reference (3) in different ways. The correct description is that the article by Cicardi et al (3) describes a cohort of 64 patients that had their antihypertensive treatment changed because of angioedema while treated with ACE-inhibitors. 26 of the patients were switched to angiotensin receptor blockers (ARB). Of these, five had angioedema that persisted after the switch, but in three of the patients the angioedema could be attributed to other factors than the ARB.

A systematic review and meta-analysis has been performed in order to estimate the risk of persisting angioedema after a switch from ACE-inhibitor to ARB (4). The authors found 254 unique citations, but most of them did not report original data or were case reports or case series and could not be used to calculate incidence rates. Only three publications (one randomized controlled trial (RCT) and two retrospective reviews) fulfilled the inclusion criteria. The risk could be calculated to be 9.4% (95% CI 1.6% - 17%) for angioedema persisting after the switch and 3.5% (95% CI 0%-9.2%) for angioedema that could not be ascribed to other causes than the ARB (4).

This meta-analysis was very recently updated (5) after the publication of an additional RCT were valsartan was substituted for ACE-inhibitors in patients developing angioedema. Including this RCT reduced the risk to 2.5% (95% CI 0%-6.6%) for persisting angioedema or 1.5% (95% CI 0%-5.1%) for angioedema not attributed to other causes than the ARB (5). Drugline no 21280 (year 2004) Drugline no 21774 (year 204) Cicardi M, Zingale LC, Bergamaschini L, Agostoni A. Angioedema associated with angiotensin-converting enzyme inhibitor use: outcome after switching to a different treatment. Arch Intern Med 2004;164(8):910-913 Haymore BR, Yoon J, Mikita CP, Klote MM, DeZee KJ. Risk of angioedema with angiotensin receptor blockers in patients with prior angioedema associated with angiotensin-converting enzyme inhibitors: a meta-analysis. Ann Allergy Asthma Immunol 2008;101(5):495-499 Haymore BR, DeZee KJ. Use of angiotensin receptor blockers after angioedema with an angiotensin-converting enzyme inhibitor. Ann Allergy Asthma Immunol 2009;103(1):83-84