arznei-telegramm 2008; 39: 98


Intestinal angioedema due to enalapril (XANEF, generics): A 49-year old woman suffers from severe cramplike pains in the middle and upper abdomen at two-week intervals with vomiting and diarrhoea. Several times, the attacks are so severe that the patient calls an emergency doctor. In the search for the cause, adhesions are found together with intolerance of certain substances and mild pancreatic insufficiency. The therapeutic measures ordered, including an operation to treat the adhesions, do not alleviate the symptoms significantly. It is only after there is a trial of discontinuation of the ACE inhibitor enalapril (XANEF, generics) on suspicion of intestinal angioedema that the patient who had lost a total of 10 kg in weight improves. At the time of the report eight weeks after discontinuing the medication she is asymptomatic and has already gained 1 kg (NETZWERK report 15.046). Angioedema caused by ACE inhibitors is manifested most often in the face and/or upper respiratory tract. However, intestinal angioedema has also been described in the literature for different ACE inhibitors (CHASE, M. P. et al.: J. Clin. Gastroenterol. 2000; 31: 254-7; SHAHZAD, G.: Mt. Sinai J. Med. 2006; 73: 1123-5). Patients with this rare form of angioedema are sometimes operated on unsuccessfully or suffer for years from recurrent abdominal pains before suspicion falls on the medication (BYRNE, T.J. et al.: Mayo Clin. Proc. 2000; 75: 1201-4; MULLINS, R. J. et al.: Med. J. Aust. 1996; 165: 319-21). The diagnosis is more difficult if gastrointestinal symptoms only occur some time after the start of treatment (ORR, K. K., MYERS, J. R.: Ann. Pharmacother. 2004; 38: 825-7). Angiotensin (AT)-II blockers such as losartan (LOZAAR) can also trigger angioedema. They are, therefore, not a safe alternative in patients with angioedema during treatment with ACE inhibitors. Repeated occurrence after switching from an ACE inhibitor to an AT-II blocker has also been described for intestinal angioedema (BUCCA, C.: Lancet 2004; 364: 1285). In patients who complain of abdominal pain, vomiting or diarrhoea and who take an ACE inhibitor or AT-II antagonist, medication-induced intestinal angioedema should be considered in the differential diagnosis.

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