ACEI Angioedema and FFP Tom Grosheider Evidence in

ACE-I Angioedema and FFP Tom Grosheider Evidence in the ED April 10, 2013

Background n Angiotensin II AKA kinase II n Accumulation of kinins thought responsible for angioedema through opaque mechanism n Cough is most common side effect (up to 25% of patients) n Angioedema occurs in 0. 1%-0. 7% of patients

Conventional Treatment n Diphenhydramine, steroids, H 1 -blocker, and epinepherine if severe n Airway monitoring n Intubation n Discontinue treatment and it usually gets better in 24 -48 hours

FFP n Adopted from literature supporting its use in hereditary angioedema n In ACE-I AE, thought to be useful because it contains kinin II, which catalyzes the breakdown of bradykinin n Scant literature

Article 1 n Hassan, WH. , Kalantari, H. , Parraga, M. , Chirugi, R. , Meletiche, C. , Chan, C. , Ciarlo. , J, Gazi, F. , Lobaito, C. , Tadayon, S. , Yemane, S. , Velez, C. , “Fresh Frozen Plasma for Progressive and Refractory Angiotensin-Converting Enzyme Inhibitor. Induced Angioedema, ” The Journal of Emergency Medicine, Vol. 44, No. 4, pp 764 -772, 2013.

Article 1 n Case series of 7 patients treated for presumed ACE-I angioedema n Subset from a larger retrospective chart review delineating rate, causes, and ethnic differences from 2003 -2012 n Identified 7 patients with severe, refractory ACE-I AE who improved temporally with administration of FFP

Article 1 Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Age in years 49 64 58 62 51 73 45 Gender Female Male Female Male Ethnicity AA AA Hispanic AA AA AA Dose and type of ACEI 40 mg lisinopril 30 mg lisinopril Enalapril Lisinopril 10 mg enalapril Duration of use 1 year 3 years Unknown Comorbidities DM<comma> Asthma Hepatitis C<com ma> HIV FFP units 2 U 3 U 2 U 2 U 1 U C 1 esterase Normal Normal C 1 quantitative Normal C 2 Normal C 3 Normal C 4 Normal Angioedema course Progressive Progressive Disposition ICU ICU

Limitations n Case reports n No evidence of causality n Small sample size n Not everyone had a workup for HAE

Article 2 n Bolton, MR. , Dooley. Hash, S. , “Angiotensin -Converting Enzyme Inhibitor Angioedema, ” Journal of Emergency Medicine, Vol 43, No. 4, pp. e 261 -262, 2012.

Article 2 n Single case report of a 76 y/o gentleman with facial and tongue swelling n Refractory to steroids and benadryl n Got better with 2 u FFP n Also, he had a minor procedure requiring LMA earlier in the day and never had an HAE work-up

Article 3 n Warrier, M. , Copilevitz, C. , Dykewicz. , “Fresh Frozen Plasma in the Treatment of Resistant Angiotensin-converting Enzyme Inhibitor Angioedema, ” Annals of Allergy and Innunology, 9: 573 -575, 2004.

Article 3 n 43 y/o woman recently started on ramipril with AE n Resistant to steroids, benadryl, and sub-q epi x 2 n Improved with 2 u FFP

HUPism n ACE-I AE can be severe and lifethreatening n FFP is not without risks n FFP may be considered in severe, refractory cases of ACE-I AE, but the evidence is quite limited