The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.
Letter to the Editor
In the review about drug treatment of elevated blood pressure (Aust Prescr 2010;33:108-12), angioedema is not mentioned as a comorbid condition. I believe it would be helpful to do so.
Angioedema occurring with ACE inhibitors was first reported in 1980,1and may account for 40% of angioedema presentations to hospital.2Onset may be delayed.3Epidemiological studies have confirmed a significant excess exposure to ACE inhibitors in patients with angioedema with an estimated attributable risk of 80% (CI*51–92).3An incidence of 0.68% over six months has been reported, so annual incidence may be greater than 1%.4Rates in people of African origin are even higher, at 1.62% over six months, so may be over 3% annually.4This is relevant in Australia, with recent immigration from Africa.
The importance of the relationship between ACE inhibitors and angioedema is underappreciated. In 2008 a patient reported a history of four episodes of angioedema, including admission to intensive care, followed by use of perindopril. He subsequently had further angioedema and the ACE inhibitor was stopped. In a recent audit of angioedema, four out of 25 patients on ACE inhibitors reported previous (sometimes multiple) episodes of angioedema.5In 2010 a 78-year-old woman on trandolapril was referred with her second episode of 'macroglossus of uncertain aetiology'. Unfortunately she developed airway obstruction and died nine days later.
There is a need for increased awareness of angioedema associated with ACE inhibitors, to reduce avoidable catastrophic outcomes. Including angioedema in tables of comorbid conditions to be considered when prescribing antihypertensives would assist with increasing awareness of this important association.
Royal Adelaide Hospital
- Wilkins JK, Hammond JJ, Kirkendall WM. The captopril-induced eruption. A possible mechanism: cutaneous kinin potentiation. Arch Dermatol 1980;116:902-5.
- Banerji A, Clark S, Blanda M, LoVecchio F, Snyder B, Camargo CA Jr. Multicenter study of patients with angiotensin-converting enzyme inhibitor-induced angioedema who present to the emergency department. Ann Allergy Asthma Immunol 2008;100:327-32.
- Gabb GM, Ryan P, Wing LM, Hutchinson KA. Epidemiological study of angioedema and ACE inhibitors. Aust N Z J Med 1996;26:777-82.
- Kostis JB, Packer M, Black HR, Schmieder R, Henry D, Levy E. Omapatrilat and enalapril in patients with hypertension: the Omapatrilat Cardiovascular Treatment vs Enalapril (OCTAVE) trial. Am J Hypertens 2004;17:103-11.
- Jones RL, Gabb GM. Angioedema and ACE inhibitors or angiotensin II receptor blockers, revisited. Pharmacoepidemiol Drug Saf 2010;19:S145.