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ACE-I Angioedema and FFP

ACE-I Angioedema and FFP. Tom Grosheider Evidence in the ED April 10, 2013. Background. Angiotensin II AKA kinase II Accumulation of kinins thought responsible for angioedema through opaque mechanism Cough is most common side effect (up to 25% of patients)

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ACE-I Angioedema and FFP

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  1. ACE-I Angioedema and FFP Tom Grosheider Evidence in the ED April 10, 2013

  2. Background • Angiotensin II AKA kinase II • Accumulation of kinins thought responsible for angioedema through opaque mechanism • Cough is most common side effect (up to 25% of patients) • Angioedema occurs in 0.1%-0.7% of patients

  3. Conventional Treatment • Diphenhydramine, steroids, H1-blocker, and epinepherine if severe • Airway monitoring • Intubation • Discontinue treatment and it usually gets better in 24-48 hours

  4. FFP • Adopted from literature supporting its use in hereditary angioedema • In ACE-I AE, thought to be useful because it contains kinin II, which catalyzes the breakdown of bradykinin • Scant literature

  5. Article 1 • Hassan, WH., Kalantari, H., Parraga, M., Chirugi, R., Meletiche, C., Chan, C., Ciarlo., J, Gazi, F., Lobaito, C., Tadayon, S., Yemane, S., Velez, C., “Fresh Frozen Plasma for Progressive and Refractory Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema,” The Journal of Emergency Medicine, Vol. 44, No. 4, pp 764-772, 2013.

  6. Article 1 • Case series of 7 patients treated for presumed ACE-I angioedema • Subset from a larger retrospective chart review delineating rate, causes, and ethnic differences from 2003-2012 • Identified 7 patients with severe, refractory ACE-I AE who improved temporally with administration of FFP

  7. Article 1

  8. Limitations • Case reports • No evidence of causality • Small sample size • Not everyone had a workup for HAE

  9. Article 2 • Bolton, MR., Dooley-Hash, S., “Angiotensin-Converting Enzyme Inhibitor Angioedema,” Journal of Emergency Medicine, Vol 43, No. 4, pp. e261-262, 2012.

  10. Article 2 • Single case report of a 76 y/o gentleman with facial and tongue swelling • Refractory to steroids and benadryl • Got better with 2u FFP • Also, he had had a minor procedure requiring LMA earlier in the day and never had an HAE work-up

  11. Article 3 • Warrier, M., Copilevitz, C., Dykewicz., “Fresh Frozen Plasma in the Treatment of Resistant Angiotensin-converting Enzyme Inhibitor Angioedema,” Annals of Allergy and Innunology, 9: 573-575, 2004.

  12. Article 3 • 43 y/o woman recently started on ramipril with AE • Resistant to steroids, benadryl, and sub-q epi x2 • Improved with 2u FFP

  13. HUPism • ACE-I AE can be severe and life-threatening • FFP is not without risks • FFP may be considered in severe, refractory cases of ACE-I AE, but the evidence is quite limited

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