PUID: 51 || PLAB 2 Mock 3 :: CounselingMedication19: ACEI induced Angioedema

Practice a case with the AI patient 🤖

Summary:

This scenario focuses on a patient presenting with facial swelling due to angioedema likely induced by the antihypertensive medication ramipril (an ACE inhibitor). The objective is to distinguish this from allergic reactions, provide appropriate emergency and long-term management, and demonstrate safe clinical judgment in potential airway compromise situations.

Key Points:

Clinical Presentation and Pathophysiology

• Angioedema:

  • Caused by increased bradykinin levels, not histamine.

  • Often linked to ACE inhibitors like ramipril.

  • Typically localized swelling (face, lips, tongue) without urticaria.

• Differential from Allergy:

  • Not mediated by histamine — antihistamines/adrenaline often ineffective.

  • Can occur even after prolonged use of the drug.

Red Flag Symptoms

• Airway compromise: difficulty breathing, swallowing, hoarseness.

• Signs of systemic involvement: dizziness (hypotension), rash, chest pain.

Important Considerations:

• Always treat facial angioedema as a potential emergency due to risk of airway obstruction.

• Angioedema, whether allergic or drug-induced, warrants hospital admission and monitoring.

• ACE-inhibitor induced angioedema requires discontinuation of the drug.

• Delayed phase reactions may occur, justifying prolonged observation (12-24 hours).

Diagnostic Approach:

1. Initial Assessment:

   • Confirm identity, obtain open history.

   • Clarify symptom onset, duration, triggers, past episodes.

2. Rule Out Allergy:

   • Ask about food, environmental, or drug allergies.

   • Assess for rash, itching, urticaria.

3. Medication History:

   • Directly ask about ACE inhibitors (e.g., ramipril).

4. Physical Exam:

   • Examine swelling location and severity.

   • Check vitals: BP, HR, SpO2 for instability.

5. Investigations:

   • Not urgent but may include CBC, U&E, C1 esterase inhibitor levels (later).

Management:

1. Immediate:

   • Stop ramipril.

   • Admit for observation (A&E or emergency setting).

   • Monitor airway closely.

   • Corticosteroids may be administered (though efficacy varies).

   • Antihistamines may be used but are often ineffective in bradykinin-mediated cases.

   • Arrange anesthesia support for potential intubation.

2. Referral:

   • ENT/anesthetics if airway involvement suspected.

3. Post-acute Care:

   • Switch to non-ACE antihypertensive (e.g., calcium channel blocker).

   • Provide patient information leaflet on angioedema.

   • Safety netting: advise seeking immediate care for future swelling episodes.

   • Schedule follow-up in 1–2 weeks.

Communication Skills:

• Use simple, non-medical terms to explain diagnosis (e.g., "deep swelling under the skin").

• Check patient understanding, use teach-back method.

• Empathize: reassure about hospital support and safety measures.

• Clearly explain hospital processes (monitoring, possible treatments).

• Include the patient in decision-making (shared care).

• Avoid jargon and stock phrases.

Ethical Considerations:

• Inform about medication risks (principle of autonomy and non-maleficence).

• Document and communicate clearly with the healthcare team (continuity of care).

• Act promptly to minimize risk (duty of care).

• Respect patient concerns and dignity (GMC Good Medical Practice, Domains 2 & 4).

Additional Resources:

• GMC’s "Good Medical Practice" guidelines (especially Domains 1 & 2).

• NICE guidelines on drug-induced angioedema.

• BNF on ACE inhibitor side effects and alternatives.

• Examiner Top Tips documents emphasizing structured consultation, differential diagnosis, and scenario adaptability.