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Successful treatment of ACE inhibitor-induced angioedema with icatibant, a bradykinin B2 receptor antagonist

Clinical record

A 65-year-old woman of European ancestry presented to the emergency department (ED) of our tertiary hospital at 09:30 with isolated tongue swelling without rash, gastrointestinal symptoms or wheeze, which had progressed over the previous 4 hours and was non-responsive to adrenaline administered by her general practitioner at 08:15. She recalled a single episode of mild self-limiting tongue swelling several months earlier and had no family history of angioedema. The patient had well controlled hypertension managed with perindopril (5 mg daily) for the past 10 years. Other comorbidities included gastroesophageal reflux disease, hypercholesterolaemia and osteopaenia. She was an active smoker. Other medications included atorvastatin, calcium carbonate, dothiepin, esomeprazole and oestradiol valerate, and she denied over-the-counter medication use.

Despite treatment with intravenous dexamethasone (6 mg), intravenous glycopyrrolate (0.2 mg) and intramuscular promethazine (25 mg), the patient’s condition continued to deteriorate. Fibreoptic nasoendoscopy (FNE) revealed epiglottic and left arytenoid oedema. Her treating team planned awake fibreoptic intubation as a priority one case, with a surgical team on standby for emergency tracheostomy.

Icatibant, a competitive bradykinin B2 receptor (B2R) antagonist, was administered subcutaneously at a dose of 30 mg at 10:30, without….