Are steroids effective for treatment of ACEI-induced angioedema?

Question

A class of blood pressure medications called [angiotensin converting enzyme inhibitors][ace] (ACEI, e.g. lisinopril, benazepril, etc) sometimes have a side effect of [angioedema], usually manifesting as lip swelling. As described in that link, angioedema is also part of some types of allergic reactions. In those cases it is generally treated with steroids, antihistamines, and bronchodilators. However, ACEI angioedema is a bradykinin-mediated, a side effect of the drug’s mechanism of action rather than an IgE (immune system) mediated allergic reaction. Are steroids (glucocorticoids) helpful for treatment of ACEI angioedema?

Answer 1

ACE-inhibitor-induced angioedema is treated with corticosteroids, histamine 1 and 2 (H₁ and H₂) blockers, and/or intramuscular or subcutaneous epinephrine. However, there is no specific evidence supporting the use of these medications in the literature. While the kallikrein receptor blocker ecallantide and the bradykinin receptor antagonist icatibant have been approved by the FDA for the management of hereditary angioedema, there is not enough data available to support their use in ACEI-induced angioedema—only one randomized, controlled trial has been published for each agent.

A recent U.S. randomized clinical trial of icatibant showed that in participants with ACEI-induced angioedema, the medication led to a significantly faster resolution of edema compared with traditional treatment with corticosteroids and antihistamines. Another recent clinical trial in patients with ACEI-induced angioedema showed that the addition of ecallantide to standard therapy did not improve angioedema compared with placebo plus standard therapy. A successful reversal of life-threatening resistant angioedema with fresh-frozen plasma has been reported.

References

Temiño VM, Peebles RS Jr. The spectrum and treatment of angioedema. Am J Med. 2008;121(4):282-286.

Baş M, Greve J, Stelter K, et al. A randomized trial of icatibant in ACE-inhibitor-induced angioedema. N Engl J Med. 2015;372(5):418-425.

Rasmussen ER, Mey K, Bygum A. Angiotensin-converting enzyme inhibitor-induced angioedema—a dangerous new epidemic. Acta Derm Venereol. 2014;94(3):260-264.

Lewis LM, Graffeo C, Crosley P, et al. Ecallantide for the acute treatment of angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter, randomized, controlled trial. Ann Emerg Med. 2015; 65(2):204-213.

Answer 2

Since angioedema is an allergic reaction steroid would be administered based on the severity of the reaction. It is not a side effect it's an allergic reaction.