Abstract
ABSTRACTAngioedema attacks are common causes of emergency care, and due to the potential for severity, it is important that professionals who work in these services know their causes and management. The mechanisms involved in angioedema without urticaria may be histamine- or bradykinin-mediated. The most common causes of histamine-mediated angioedema are foods, medications, insect sting and idiopathic. When the mediator is bradykinin, the triggers are angiotensin-converting enzyme inhibitors and factors related to acquired angioedema with deficiency of C1-inhibitor or hereditary angioedema, which are less common, but very important because of the possibility of fatal outcome. Hereditary angioedema is a rare disease characterized by attacks of edema that affect the subcutaneous tissue and mucous membranes of various organs, manifesting mainly by angioedema and abdominal pain. This type of angioedema does not respond to the usual treatment with epinephrine, antihistamines and corticosteroids. Thus, if not identified and treated appropriately, these patients have an estimated risk of mortality from laryngeal edema of 25% to 40%. Hereditary angioedema treatment has changed dramatically in recent years with the development of new and efficient drugs for attack management: plasma-derived C1 inhibitor, recombinant human C1-inhibitor, bradykinin B2 receptor antagonist (icatibant), and the kallikrein inhibitor (ecallantide). In Brazil, plasma-derived C1 inhibitor and icatibant have already been approved for use. Proper management of these patients in the emergency department avoids unnecessary surgery and, especially, fatal outcomes.
Highlights
Angioedema is characterized by non-inflammatory, localized, asymmetric, disfiguring, and self-limited swelling of the deep dermis, subcutaneous, and/or submucosal tissue, resulting from vasodilation and an increase in vascular permeability.(1)Due to potential severity, especially when angioedema affects the airways, the therapeutic approach in emergency department is often initiated soon after admission, before taking the medical history and possible identification of the etiology
These patients have a higher hospital admission rate than those treated for allergycaused angioedema.(8) In an Italian study, 0.37% of patients admitted to the emergency department during a six month period presented with angioedema of varyng causes.(9) In Canada, 0.1% of emergency care was due to angioedema of different etiologies, and more than one third of patients reported previous visits for the same cause.(10) No data is avaiable in Brazil on the number of visits to emergency department caused by angioedema attacks
In bradykinin-mediated angioedema, the most frequent triggers are angiotensin-converting enzyme inhibitors (ACEi) and factors related to hereditary angioedema (HAE) or acquired angioedema (AAE)
Summary
When the mediator is bradykinin, the triggers are angiotensinconverting enzyme inhibitors and factors related to acquired angioedema with deficiency of C1inhibitor or hereditary angioedema, which are less common, but very important because of the possibility of fatal outcome. Hereditary angioedema is a rare disease characterized by attacks of edema that affect the subcutaneous tissue and mucous membranes of various organs, manifesting mainly by angioedema and abdominal pain. This type of angioedema does not respond to the usual treatment with epinephrine, antihistamines and corticosteroids. In Brazil, plasma-derived C1 inhibitor and icatibant have already been approved for use Proper management of these patients in the emergency department avoids unnecessary surgery and, especially, fatal outcomes. The cause of death in one third of patients was asphyxia, those with no confirmed diagnosis being most at risk
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