Man develops angioedema after taking spouse’s lisinopril
A man in the U.S. developed nonallergic angioedema on his tongue after he ran out of his blood-pressure medication and took his spouse’s lisinopril, another medication used to lower blood pressure, for two weeks.
The man had experienced a swelling episode from lisinopril (brand name Qbrelis, among others), an angiotensin-converting enzyme inhibitor (ACEI), four years earlier and was switched to the angiotensin II receptor blocker (ARB) irbesartan (brand name Avalide, and generics), which is considered a safer alternative for patients with a history of angioedema.
“Clinicians must educate patients about the risks associated with ACEIs and ensure clear documentation and communication to prevent inadvertent re-exposure,” researchers at Wright State University Boonshoft School of Medicine in Dayton, Ohio, wrote in a case study describing the incident.
The study, “Angiotensin-Converting Enzyme Inhibitor (ACEI)-Induced Angioedema After Re-exposure to Lisinopril: A Case Report and Clinical Review,” was published in Cureus.
Tongue swelling can be dangerous
ACEIs are common treatments for high blood pressure and heart disease. One rare but serious side effect of these medications is nonallergic angioedema. Like other types of angioedema, it is marked by swelling that can occur anywhere in the body.
“ACEI-induced angioedema can be challenging to diagnose due to several factors, including the lack of specific diagnostic tests, the delayed and unpredictable onset of symptoms, and the potential to misinterpret symptoms,” the researchers wrote.
When swelling occurs in the mouth, tongue, or throat, it can block the airway and make it difficult to breathe. Although this can become life-threatening, emergency care usually helps control symptoms within a few hours, with few patients returning for repeat episodes.
The 54-year-old man arrived at the emergency department with swelling on the left side of his tongue. The swelling had developed over four hours and made speaking difficult, but the man did not have shortness of breath, rash, or pain. There was no swelling on his lips, throat, or airway.
Four years earlier, about one year after starting treatment with lisinopril for high blood pressure, he had an episode of swelling in his right cheek. He was diagnosed with ACEI-induced angioedema and was switched to irbesartan.
Angioedema symptoms had not returned until he ran out of his prescription for irbesartan and took his spouse’s lisinopril.
Doctors initially treated the man with tranexamic acid, sometimes used off-label to treat angioedema in emergency situations. They also used corticosteroids to reduce inflammation, and epinephrine and antihistamines to block allergic responses. However, the researchers wrote, the man showed “minimal clinical improvement.” ACEI-induced angioedema is not driven by an allergic reaction and will typically not respond to medications used in allergic angioedema.
“Given the timing of symptom onset, prior history of angioedema, and exclusion of other potential causes,” the researchers wrote, the doctors assessed the likelihood of possible side effects caused by a specific medication and identified “a definite causal relationship between lisinopril and the angioedema.”
Although the man’s airway was not blocked, the doctors admitted him to the intensive care unit for close monitoring. Treatment with lisinopril was stopped. His swelling eased over the next day, and he could speak normally again. He was discharged home on irbesartan, with his blood pressure under control.
“In high-risk individuals or those with a history of angioedema, ARBs may offer a safer alternative, particularly for patients with underlying cardiovascular [heart and blood vessel] or renal [kidney] disease,” the researchers wrote.
It’s also important for patients to know not to restart treatment with ACEIs or other medications that have once caused an episode of angioedema, the team said.
“Clear patient education at diagnosis is essential to prevent inadvertent re-exposure, especially since patients may not recognize ACEIs by name or recall prior reactions,” the researchers wrote.
About the Author
