Angioedema - Icatibant Rant

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Icatibant did not improve outcome compared to placebo for ACE-I associated angioedema.

Icatibant rant... (well, not really...it just rhymed)
Angiotensin converting enzyme inhibitor (ACE-I) associated angioedema rarely causes laryngeal edema and airway compromise.  There are few effective treatment options. Icatibant is a selective bradykinin B2 receptor antagonist and is used in hereditary angioedema.  This RCT of 121 patients with ACE-I angioedema found no difference in time to safe discharge compared to placebo.  This meant, "the earliest time that difficulty breathing and difficulty swallowing were absent (rating of 0 out of 4), and voice change and tongue swelling were mild or absent (0 or 1)."  Most patients received conventional treatment with antihistamines, steroids, and epinephrine in both placebo and treatment groups. We can do some serious savings on healthcare costs by not pulling out this expensive drug for ACE-I angioedema.  The basics for treating angioedema apply.  If there are throat or voice complaints, visualize the airway with nasopharyngoscopy.  Secure the airway if there is any concern for progression.  Consider FFP as a treatment option, though the evidence for it isn't great.  You can try epinephrine, steroids, and antihistamines as well, but they won't help ACE-I associated disease.  Read this free full-text SAEM Consensus Guideline on Treatment of Angioedema...it's good.

Another Spoonful
There's a veritable cornucopia of FOAM on this paper.  Here are two of the best.

  • I found this thanks to PharmERToxGuy on Twitter - see his take.  I mean, really, who doesn't regularly read the Journal of Allergy and Clinical Immunology Practice?
  • Anand Swaminathan does a play-by-play breakdown of the article on REBEL EM.

Source
Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema.  J Allergy Clin Immunol Pract. 2017 May 25. pii: S2213-2198(17)30172-1. doi: 10.1016/j.jaip.2017.03.003. [Epub ahead of print]

Peer reviewed by Thomas Davis.

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