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Can you prescribe ARB to a patient with ACE-inhibitor-related angioedema?

What is the cross-reactivity risk when prescribing ARB to a patient with ACE-inhibitor-related angioedema?

Less than 5 %, according to most sources.

A literature review of ACEi/ARB angioedema cross-reactivity, shows incidence of 3 to 8%. In a risk-benefit assessment, ARBs should be used cautiously in patients with a history of ACE inhibitor-induced angioedema.

According to a 2011 literature review, there is a conservative estimate of a 10% or less incidence of cross reactivity of angioedema in patients who receive an ARB after experiencing ACEI-associated angioedema. Angioedema related to ARBs is reported to be less severe and occurs earlier compared to angioedema that develops during ACEI therapy.

In a large trial published in The Lancet, telmisartan was well tolerated in patients unable to tolerate ACE inhibitors.

Can you prescribe ARB to a patient with ACE-inhibitor-related angioedema?

Yes, but only for populations that have demonstrated a clear benefit from angiotensin II antagonism, for example, patients with CHF and CKD.

The above recommendation has been adopted by the National Kidney Foundation guidelines and the American College of Cardiology and American Heart Association (ACC/AHA) consensus guidelines. Given the strong potential for harm with drug-induced angioedema, however, close monitoring is necessary to ensure that repeat angioedema does not occur with ARB.

Read more in Angioedema Due to Angiotensin Converting Enzyme Inhibitors at AllergyCases.org.

References

Cross-Reactivity of ACE Inhibitor–Induced Angioedema with ARBs. U.S. Pharmacist. Vol. No: 32:2 Posted: 2/20/2007.

The role of angiotensin receptor blockers in patients with angiotensin-converting enzyme inhibitor-induced angioedema. Ann Pharmacother. 2011 Apr;45(4):520-4. Epub 2011 Mar 22.

Valsartan-Induced Angioedema. The Annals of Pharmacotherapy: Vol. 37, No. 7, pp. 1024-1027, 2003.
Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial. Lancet. 2008 Sep 27;372(9644):1174-83. Epub 2008 Aug 29.
Angioedema with Different Blood Pressure Medications (Antihypertensives)

Visceral angioedema due to angiotensin-converting enzyme inhibitor therapy - diagnosed with abdominal CT. CCJM, 2011.

The first ACE inhibitor (captopril) was developed from viper venom by a Brazilian post-doc. The FASEB Journal, 2003;17:788-789.
Angioedema due to the renin inhibitor aliskiren. CCJM, 2011.
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