4. :p
“I’ve got a patient over in
C18NO and he won’t stop
sticking his tongue out at
me.”
5. Angioedema
• Self limited, asymmetric, localised, non-pitting
swelling
• Results from increased vascular permeability
• Affects lips, eyes, tongue, respiratory and GI
mucosa
– Less connective tissue = Increased capacity to
swell
• Laryngeal oedema = 25-40% mortality
http://academiclifeinem.com/paucis-verbis-card-angioedema/
http://lifeinthefastlane.com/traumatic-angioedema/
6. Shane, did you say Urticaria or
Angioedema?
• Urticaria
– Epidermal and dermal oedema
– Redness and raised areas on skin
only
– Itchy. Rarely painful.
• Angioedema
http://www.virtualmedicalcentre.com/diseases/hives-urticaria/762
– Subcutaneous and mucosa
oedema
– Swelling below skin and mucosa
– Often painful. Sometimes itchy.
http://www.dermnetnz.org/reactions/angioedema.html
http://en.wikipedia.org/wiki/File:Angioedema2013.JPG
11. Non-allergic Drug Induced
Angioedema
• Commonly ACE inhibitors
– ACE inhibitors inhibit ACE
• ACE normally degrades bradykinin
• Bradykinin causes vasodilation and increases
vascular permeability
• Inhibition results in rapid accumulation of
fluid in the interstitial space
12. ACEi Induced Angioedema
• Approximately 2% of patients are affected
• Higher incidence in first month of use
•
•
•
•
•
•
Antihistamines won’t work
Adrenaline will* work for laryngeal oedema
FFP – Try two units
Icatibant – Bradykinin B2 receptor antagonist
Ecallantide – Kallikrein inhibitor
Recombinant C1-Inhibitor
http://www.ncbi.nlm.nih.gov/pubmed/15191027
13. ACEi induced angioedema
• “…cessation of the ACEI is necessary to reduce
the risk of recurrent episodes.”
– http://www.racgp.org.au/download/documents/A
FP/2011/December/201112andrew.pdf
• A2RB safety?
15. Hereditary Angioedema
•
•
•
•
Autosomal dominant
Type 1 = Reduced level and function of C1-INH
Type 2 = Normal level, poor function of C1-INH
Type 3 = Factor XII gene coding mutation
• Reduced C1 esterase inhibitor activity
excessive kallikrein excessive bradykinin
production
16. Hereditary Angioedema
• Not associated with urticaria
• Precipitants – Stress, trauma, hormonal
changes, exercise, alcohol
• Onset usually with puberty
• Gastrointestinal/Urological/Respiratory/Derm
atological symptoms
17. Hereditary Angioedema
• World Allergy Organisation guidelines:
– Test for C4, C1-INH protein, C1-INH function
– Treat with:
• Icatibant – Bradykinin B2 receptor antagonist
• Ecallantide – Kallikrein inhibitor
• Recombinant C1-Inhibitor
– Treat early if airway involvement +/- ETT/trache
– HAE 1/2 patients should carry “on demand” treatment
for two attacks
– Prophylaxis:
• Androgen (danazol, stanazolol) increase circulating C1-INH
http://emedicine.medscape.com/article/135208-overview
18. Acquired C1 inhibitor deficiency
• Associated with:
– B Cell Lymphoma
– C1 Inhibitor antibodies
http://www.dermnetnz.org/reactions/angioedema.html
• Diagnosed at advanced age
• No family history
• Treatment as for HAE
20. ABC’s of Angioedema
•
•
•
•
•
•
A is for Airway and Adrenaline
B is for Bradykinin
C is for C1 Esterase Inhibitor
D is for Drug induced – ACEi, gliptins
E is for EpiPen prescription
F is for FFP x2
Thanks for listening. I hope you’ve had a swell time.
