Icatibant in ACE‐I associated angioedema

J S Fok, C H Katelaris, A F Brown, W B Smith

Angioedema occurs in up to 2% of those taking angiotensin converting enzyme (ACE)-inhibitors. Upper airway angioedema may potentially require endotracheal intubation or cricothyrotomy, and is usually unresponsive to adrenaline. The bradykinin receptor antagonist icatibant is proven to be effective in the treatment of acute attacks of hereditary angioedema, and has also been reported effective in the treatment of angioedema associated with ACE-inhibitors. To describe the use of icatibant for ACE inhibitor-associated airway angioedema. We treated thirteen consecutive Emergency Department patients, who had not improved with adrenaline and/or corticosteroids, with icatibant 30 mg subcutaneously for ACE-inhibitor-associated upper respiratory tract angioedema according to an agreed protocol. Four patients were intubated in the Emergency Department either before or after receiving icatibant; 3 of these were extubated within 24 hours of treatment. Eight patients received early icatibant and did not require intubation. The time from onset of airway angioedema to ED presentation ranged from 1 hour to 3 days (median 4 hours); from ED presentation to receiving icatibant, from 30 minutes to 3 days (median 3 hours); and to onset of symptom improvement after icatibant, 15 minutes to 7 hours (median 2 hours). One patient received a second dose of icatibant. All patients improved after receiving icatibant, consistent with its bradykinin-receptor blocking mechanism. Icatibant rapidly reversed symptoms, and appeared to avert the need for intubation or expedite extubation. Timely use of icatibant in ACE-inhibitor associated angioedema may avert the need for invasive airway procedures and intensive care unit (ICU) admission.