Which medications are commonly associated with drug-induced angioedema, and how should I manage these cases?

Medications commonly associated with drug-induced angioedema include Angiotensin-converting enzyme (ACE) inhibitors ¹. Episodes of ACE inhibitor-related angioedema may persist for several months after stopping the drug ¹. Angiotensin-II receptor antagonists can also trigger episodes of angioedema ¹. Additionally, non-steroidal anti-inflammatory drugs (NSAIDs) can rarely cause severe angioedema as an allergic reaction ².

The recommended management for drug-induced angioedema involves several steps:

• Identification and Cessation: The primary step is to identify and stop the drug responsible for the angioedema ¹. For ACE inhibitor-related angioedema, treatment should be stopped immediately, and an alternative drug considered, while avoiding angiotensin-II receptor antagonists if possible ¹.
• Acute Management (Rapidly Developing Angioedema without Anaphylaxis): For rapidly developing angioedema without anaphylaxis, give slow intravenous (IV) or intramuscular (IM) chlorphenamine and hydrocortisone, and arrange emergency admission ¹.
• Management for Stable Angioedema without Anaphylaxis:
  • For mild symptoms, treatment may not be needed ¹.
  • If treatment is required, offer a non-sedating antihistamine (e.g., cetirizine, fexofenadine, or loratadine) for up to 6 weeks ¹.
  • For severe symptoms, a short course of an oral corticosteroid (e.g., prednisolone 40 mg daily for up to 7 days) should be given in addition to the non-sedating oral antihistamine ¹.
  • It is important to advise the person to seek immediate medical help (by dialling 999 or attending A&E) if symptoms progress rapidly or if symptoms of anaphylaxis develop ¹.
  • Review the person to assess their response to treatment ¹. If symptoms improve, consider the need for further antihistamine treatment based on the underlying cause and duration of symptoms ¹.
  • If symptoms are likely to be persistent or recurrent, prescribe daily antihistamine treatment for 3–6 months, then review ¹. For people with a long history of urticaria and angioedema, daily antihistamine treatment for 6–12 months with gradual withdrawal is advised ¹. If symptoms were short-lived and frequent recurrence is unlikely, treatment can be prescribed as required or prophylactically ¹.
  • If there is no improvement or symptoms worsen, consider hospital admission ¹.
  • Note that while antihistamines, corticosteroids, and adrenaline have traditionally been used for drug-induced angioedema, their efficacy remains unproven ¹.
• Referral: Refer the person to a dermatologist or immunologist if symptoms persist or reoccur 3 months after stopping an ACE inhibitor, or if the cause is unidentifiable or unavoidable ¹. Referral to a specialist drug allergy service is recommended for suspected anaphylactic reactions or severe non-immediate cutaneous reactions (e.g., Drug Reaction with Eosinophilia and Systemic Symptoms [DRESS], Stevens–Johnson Syndrome, Toxic Epidermal Necrolysis) ². People who have had a suspected allergic reaction to an NSAID with severe symptoms like anaphylaxis, severe angioedema, or an asthmatic reaction should also be referred to a specialist drug allergy service ².
• Information and Support: Discuss the suspected drug allergy with the person, provide structured written information, and ensure they are aware of drugs or drug classes to avoid ². Advise them to carry information about their drug allergy at all times ².