PUID: 52 || PLAB 2 Mock :: Counseling Medication: Angioedema induced by ACEI:: 1st Attempt

Practice a case with the AI patient 🤖

Summary:

This PLAB 2 case scenario focuses on a patient presenting with facial swelling suspected to be angioedema caused by an ACE inhibitor. Candidates are assessed on their diagnostic acumen, emergency management protocols, and communication of a complex, non-allergic drug reaction.

Key Points:

Pharmacological Cause & Pathophysiology

• ACE Inhibitors (e.g., ramipril) can cause bradykinin-mediated angioedema.

• Angiotensin Receptor Blockers (ARBs) like telmisartan can also cause angioedema but less frequently.

• Mechanism: Impaired degradation of bradykinin leads to its accumulation, resulting in vascular permeability and localized swelling.

• Not histamine-mediated — thus, not a true allergic reaction.

Presentation and Assessment

• Commonly affects the face, lips, tongue, and airway.

• History is often subacute to chronic – weeks to years after starting ACE inhibitors.

• Swelling may be progressive and not associated with urticaria or itching.

• Assess for red flags: dyspnea, dysphagia, voice changes, chest pain, dizziness, rash.

Emergency Assessment

• Facial involvement = emergency due to risk of airway obstruction.

• First episodes can progress rapidly and unpredictably.

• Must admit immediately for monitoring and supportive care.

Important Considerations:

• Never restart ACE inhibitors if angioedema occurs.

• Swelling from bradykinin accumulation will not respond to antihistamines or steroids but these are still given empirically.

• Intubation may be needed; ENT or anesthetist consult should be sought in deteriorating cases.

• Patients often deny allergies or exposures — suspect the medication.

• Document the causative drug and advise permanent discontinuation.

Diagnostic Approach:

1. Detailed history: onset, progression, site, associated symptoms, medications.

2. Rule out other causes: allergic reactions, hereditary angioedema, etc.

3. Medication history: specifically ACE inhibitors or ARBs.

4. Vital signs and physical exam focusing on airway and swelling.

5. Urine dipstick to check renal function due to ACE inhibitor effect.

Management:

• Stop ACE inhibitor immediately.

• Admit to A&E for observation for 24–48 hours.

• Monitoring: vitals, respiratory status, progression of swelling.

• Medications:

  • Empirical antihistamines and corticosteroids (though ineffective for bradykinin-mediated cases, used as precaution).

  • Consider icatibant or C1 esterase inhibitor (if available).

• ENT/anesthetics on standby for airway compromise.

• Alternative antihypertensive: switch to calcium channel blocker or suitable ARB if tolerated.

• Follow-up: to assess control of BP and monitor recurrence.

Communication Skills:

• Use layman’s terms: “deep swelling under the skin” instead of “angioedema”.

• Avoid medical jargon; ensure patient understands seriousness.

• Reassure but emphasize the potential danger and need for observation.

• Check patient’s understanding throughout and encourage questions.

• Empathize: Acknowledge their fear and confusion around unexplained facial swelling.

Ethical Considerations:

• Ensure informed consent for all procedures and treatments.

• Respect patient autonomy while clearly conveying risks.

• Maintain confidentiality.

• Follow GMC guidelines for emergency care, prescribing, and communication.

Additional Resources:

• NICE Guidelines: Management of drug-induced angioedema.

• GMC Good Medical Practice: Emergency care and safe prescribing.

• PLAB 2 Examiner Top Tips: Relevance, time management, avoiding rehearsed phrases.

• Understanding Your Results: OSCE marking criteria for consultation, diagnosis, management, and communication.