Icatibant in angiotensin-converting enzyme (ACE) inhibitor-associated angioedema

Abstract

Background: Angioedema occurs in up to 2% of those taking angiotensin-converting enzyme (ACE) inhibitors. Upper airway angioedema may potentially require endotracheal intubation or cricothyrotomy, and is usually unresponsive to adrenaline. The bradykinin receptor antagonist icatibant is proven to be effective in the treatment of acute attacks of hereditary angioedema, and has also been reported effective in the treatment of angioedema associated with ACE inhibitors. Aim: To describe the use of icatibant for ACE inhibitor-associated airway angioedema. Methods: We treated 13 consecutive emergency department (ED) patients, who had not improved with adrenaline and/or corticosteroids, with icatibant 30mg subcutaneously for ACE inhibitor-associated upper respiratory tract angioedema according to an agreed protocol. Results: Four patients were intubated in the ED either before or after receiving icatibant; three of these were extubated within 24h of treatment. Eight patients received early icatibant and did not require intubation. The time from onset of airway angioedema to ED presentation ranged from 1h to 3 days (median 4h); from ED presentation to receiving icatibant, from 30 minutes to 3 days (median 3h); and to onset of symptom improvement after icatibant, 15 minutes to 7h (median 2h). One patient received a second dose of icatibant. Conclusion: All patients improved after receiving icatibant, consistent with its bradykinin receptor blocking mechanism. Icatibant rapidly reversed symptoms, and appeared to avert the need for intubation or expedite extubation. Timely use of icatibant in ACE inhibitor-associated angioedema may avert the need for invasive airway procedures and intensive care unit admission.