Trip Answers

Question answered:22/02/08

The BNF notes in section 2.5.5.1:

 

“ACE inhibitors can cause profound hypotension (see Cautions) and renal impairment (see Renal effects above), and a persistent dry cough. They can also cause angioedema (onset may be delayed; higher incidence reported in Afro-Caribbean patients), rash (which may be associated with pruritus and urticaria), pancreatitis, and upper respiratory-tract symptoms such as sinusitis, rhinitis, and sore throat….” [1]

 

In the entry on angiotensin-II receptor antagonists, the BNF details adverse effects:

 

“Side-effects are usually mild. Symptomatic hypotension including dizziness may occur, particularly in patients with intravascular volume depletion (e.g. those taking high-dose diuretics). Hyperkalaemia occurs occasionally; angioedema has also been reported with some angiotensin-II receptor antagonists.” [2]

 

GPNotebook adds in its entry on swollen tongue and lip swelling in angioedema associated with ACE inhibitors:

 

• “this side effect occurs in approximately 1 % of users - but is much more common in the black population (circa 4%) (1)
• this side effect most commonly affects the face and mucous membranes, lips, tongue and larynx
• in general, symptoms are mild and short-lived
• most frequently implicated ACE inhibitors in the development of angioedema are captopril and lisinopril - may be a reflection of the widespread use of these drugs
• in general this side effect occur within hours, or, at most weeks, after starting ACE inhibitor therapy - it reverses within hours of stopping treatment with the ACE inhibitor.” [3]

 

The CKS guideline on hypertension states:

 

“What are the adverse effects of AIIRAs?
• Adverse effects with angiotensin-II receptor antagonists (AIIRAs) are similar to those seen with angiotensin-converting enzyme (ACE) inhibitors, although they tend to be milder. These include:
o Hypotension
o Hyperkalaemia
o Angioedema (requires immediate cessation of the drug)
• AIIRAs do not cause cough to the same extent as ACE inhibitors.” [4]

 

In previous years, we have answered two similar questions on this topic for which we provide links to below.

 

NLH Primary Care Q & A Service. Patient had angioedema secondary to Rx with Lisinopril - what are the risks of this recurring with other ACE's or A2RB's? September 2006 (http://www.tripanswers.org/Answer.aspx?QuestionId=4705)

 

NLH Primary Care Q & A Service. In patients with a significant sensitivity [angioneurotic oedema] to ACE inhibitors is there evidence to suggest that a class action effect might also extend into the angiotensin-II receptor antagonists and thus prohibit their use in these patients?” June 2006 (http://www.tripanswers.org/Answer.aspx?QuestionId=3208)

 

For the latest safety information on the management of patients with ACE inhibitor induced angioedema, we would recommend contacting the Medicines Information service.

 

References
1. BNF No. 54 September 2007. (http://www.bnf.org.uk/bnf/bnf/54/2578.htm?q=%22ace%22%22inhibitor%22)
2. BNF No. 54 September 2007. (http://www.bnf.org.uk/bnf/bnf/54/27510.htm)
3. GPNotebook. Swollen tongue and lip swelling in angioedema associated with ACE inhibitors. (http://www.gpnotebook.co.uk/simplepage.cfm?ID=x20030725161559447030
4. CKS. Hypertension. January 2007. (http://www.cks.library.nhs.uk/hypertension/)

---

DISCLAIMER: TRIPanswers is a collection of clinical questions and answers.  Each provider will have their own methodology in answering questions and these are likely not to be as rigorous as systematic review.  If you have any doubt as to the implications of this contact the Q&A Service Provider for further information. This document is presented for information purposes only. This document cannot and should not be used as a basis of diagnosis or choice of treatment, and is in no way intended to replace professional medical care or attention by a qualified practitioner. TRIPanswers and TRIP Database Ltd are not responsible or liable for, directly or indirectly, ANY form of damage whatsoever resulting from the use/misuse of information contained in or implied by this document.  Also, ensure you have read the terms and conditions for using the site.