Some angioedema patients can safely take ACEIs, study shows

While there is a connection between angioedema and the use of angiotensin-converting enzyme inhibitors (ACEIs), a class of medications commonly used to manage cardiovascular problems, certain people with the condition can safely use ACEIs.

That’s according to a Dutch study that examined primary care for people with angioedema in relation to their ACEI use. In a subset of participants who received ACEIs, nearly half started the treatment after the onset of angioedema or continued taking the medications throughout. Although ACEIs can trigger angioedema attacks for some people, continued use wasn’t systematically associated with signs of worse severity, the research team found.

“Given the absence of a diagnostic test to confirm ACEI causality, our findings suggest that a tailored approach to ACEI management, considering angioedema timing and severity, and cardiovascular benefit, may be worth considering in primary care,” the researchers wrote.

The study, “Angioedema in Primary Care: Disease Course and Its Relation to ACE Inhibitor Use,” was published in the International Journal of Dermatology.

In angioedema, swelling in the deep layers of the skin or mucous membranes can have several causes, including non-allergic reactions to certain medications. ACEIs are the most common cause of this type of drug-induced angioedema. They are commonly used to treat high blood pressure, heart conditions, and kidney disease.

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Data on individuals lacking

“While ACEIs are a well-known cause [of angioedema], their contribution in individual cases remains uncertain since there is no diagnostic test to confirm ACEI causality,” the team wrote. This raises questions about how primary care doctors should manage ACEI use among people with angioedema.

To investigate this, the team examined data from a general practitioner database of primary care usage. In the Netherlands, people with angioedema initially receive care from general practitioners rather than specialists, making primary care data suitable for this kind of analysis.

The researchers looked at 951 people diagnosed with angioedema between 2010 and 2020. More than half were women, with a mean age of 44. About half of the patients had only one primary care visit about their angioedema, while the other half had more extensive follow-up.

Of the 951 angioedema patients, 273 (29%) received prescriptions for ACEIs at some point. The researchers performed a series of analyses on a subset of 208 patients who developed angioedema and were prescribed ACEIs at least two years prior to data lock, the point when data collection for the study ended.

Within this subset, 36% of patients discontinued ACEIs directly after their first angioedema attack. Another 10% stopped taking ACEIs sometime between their first and last angioedema-related visits. Participants with delayed discontinuation tended to have more total visits, more angioedema-related prescriptions, and a longer follow-up time than those who discontinued ACEIs immediately. This may suggest these patients had more severe symptoms that ultimately led doctors to recommend against ACEI use.

Another 6% of participants started taking ACEIs after the onset of angioedema, but received their last ACEI prescription sometime between their first and last visits for angioedema, or after their last angioedema visit.

“Notably, [the remaining] 47% of ACEI users continued or initiated treatment despite angioedema, with minimal further angioedema-related care recorded,” the team wrote. This group included the 38% of participants who started taking ACEIs before the onset of angioedema and continued treatment throughout angioedema care, and the 9% who started on ACEIs after their last angioedema consultation.

Among participants who started ACEIs before developing angioedema and continued treatment thereafter, the median number of angioedema-related visits to a primary care provider was one. These people also had a median of less than one week of follow-up care. This suggests “that ACEI continuation did not increase angioedema-related healthcare use in these patients,” the team wrote.

People who started on ACEIs after their last angioedema visit also tended to have fewer consultations and a shorter follow-up period.

Together, the results suggest “that prior angioedema may not always be a contraindication for ACEI treatment,” the researchers wrote. They recommended that primary care physicians consider ACEI use on an individual basis, weighing the potential risks and benefits.