ED visits help most patients with drug-induced angioedema: Study
Over half of patients improve with emergency care, most safely discharged
More than half of individuals admitted to an emergency department, or ED, for drug-induced nonallergic angioedema — with nearly all of these patients experiencing swelling as a side effect of medications known as angiotensin-converting enzyme inhibitors, or ACEIs — showed improvement, with most staying briefly and few returning for care, according to the findings of a new study.
Medications like ACEIs and angiotensin receptor blockers, known as ARBs, are commonly used for treating high blood pressure and heart failure. In the U.S., however, these medicines are also the most frequent cause of drug-induced nonallergic angioedema.
In this study, a trio of U.S. researchers had mainly sought to “provide descriptive evidence regarding emergency department (ED) disposition of ACEI-induced angioedema patients … at a large, regional academic medical center.” As a secondary objective, the team wanted to “evaluate unique patterns” among such patients, particularly individuals requiring inpatient care.
“Our results indicated that at a large, tertiary care referral center, patients with ACEI-angioedema who did not exhibit severe symptoms were safely discharged home with low risk of early return visit to the ED,” the researchers wrote. “Further, among those admitted, patients in our study had a short inpatient stay and were safely discharged with no documented early return visit to the ED.”
The study, “Disposition of emergency department patients presenting with angiotensin-converting enzyme inhibitor-induced angioedema,” was published in the International Journal of Emergency Medicine.
Detailing ED care for patients with drug-induced angioedema
Similar to other types of angioedema, drug-induced nonallergic angioedema is marked by swelling that can affect any part of the body. When swelling occurs in the throat, it can be life-threatening and require emergency care.
Here, researchers from Tennessee and North Carolina reviewed the medical records of patients with drug-induced nonallergic angioedema to understand how they were treated in an emergency department and what factors affected their outcomes.
Data came from 94 patients in total: 90 in whom swelling occurred as a side effect of ACEIs, and four in whom it arose as a side effect of ARBs. Most patients were white men, with a median age of 60. They had been on ACEIs/ARBs for a median of three years before experiencing swelling symptoms. Swelling occurred in the lips in more than 50, or 87.5%. That was followed by swelling of the tongue for 43.6%, and of the face (23.4%) and throat (24.5%). Overall, these symptoms lasted a median of five hours before the patients’ admission to the emergency department.
Among the patients, 51 (54.3%) were admitted to the hospital for ongoing care and 43 (45.7%) were sent home. Those individuals with visible swelling in the throat or neck, or with throat-related symptoms such as difficulty speaking, were about three times more likely to be admitted to the hospital.
More than half (56.4%) improved during their stay in the emergency department, with most (60.4%) safely being sent home. Patients who were discharged were in the emergency department for a median of 4.2 hours — “with a minimum of 1.2 [hours], maximum of 9.2 [hours].” None of the 12 patients whose symptoms worsened were discharged.
One of the 43 patients sent home returned to the emergency department due to recurring symptoms, per the study.
“Those who were discharged from the ED with a median stay of [four hours] had no increased risk of return to the ED versus those who were admitted,” the researchers wrote.
Use of epinephrine tied to greater likelihood of hospital admission
The only ED treatment linked to a statistically significant increased likelihood of hospital admission versus discharge was the use of intramuscular, or into-the-muscle, epinephrine, the active agent in an EpiPen and related allergy treatments.
“All patients who received [intramuscular] epinephrine were noted by the ED physician to have worsening symptoms upon reassessment, prompting admission,” the researchers wrote, noting that “likely the use of [intramuscular] epinephrine is a marker for severity of presenting illness, rather than a cause for patient worsening.”
[Discharge] is appropriate in certain patients. … In particular, patients observed for at least [four hours], lacking any ‘severe symptoms,’ defined as difficulty breathing, speaking, drooling, or throat symptoms, can be safely discharged with a low risk of return to the ED.
Of the 51 patients admitted to the hospital, 32 stayed on the regular floor, for a median of 1.3 days. A total of 19 were admitted to the intensive care unit, where they stayed for a median of two days, with 10 requiring intubation to help them breathe. Patients who required intubation had a faster onset of symptoms and voice changes, with all failing to respond to intramuscular epinephrine and standard treatment with antihistamine medications.
The findings suggest that discharge “is appropriate in certain patients,” the researchers wrote. “In particular, patients observed for at least [four hours], lacking any ‘severe symptoms’, defined as difficulty breathing, speaking, drooling, or throat symptoms, can be safely discharged with a low risk of return to the [emergency department].”
Importantly, the researchers found inconsistencies in patient medical records regarding documented allergies to ACEIs/ARBs. Such allergies were recorded in 23.6% of the patients who were discharged and in 76.4% of those who were admitted to the emergency department.
“A significant number of patients discharged from the [emergency department] did not have their ACEI or ARB recorded as an allergy in their [electronic medical records],” the team wrote. “ED clinicians and pharmacists should take steps in their departments to prevent this potential source of patient harm.”
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