Omesartan Induced Sprue-like Enteropathy

Abstract

Olmesartan is a commonly prescribed antihypertensive that blocks the angiotensin receptor. A serious side effect of sprue-like enteropathy has been documented. Severe chronic diarrhea with substantial weight loss can occur months and up to years after initiation of the drug. Histologically, it is indistinguishable from celiac disease, with villous blunting; however, celiac serology is negative. The infrequency in which it is encountered makes diagnosis difficult; nevertheless, this is a newly recognized and documented side effect seen across the country. A 67-year-old male presented to the hospital with chronic diarrhea. Bowel movements were described as loose, watery, non-bloody voluminous stools without abdominal pain. Stool output was 10-12 liters daily. On admission, workup included infectious, inflammatory, absorptive and autoimmune causes. Secretory causes were ruled out as levels of calcitonin, gastrin, vasoactive intestinal peptide and 5-hydroxyindoleacetic acid were nonremarkable with a negative octreoscan. Infectious causes were ruled out with negative stool studies and viral serologies. The patient's stay was complicated by acute kidney injury, severe protein malnutrition, and pneumatosis intestinalis. Esophagogastroduodenoscopy with duodenal biopsies showed marked villous blunting consistent with celiac disease; however, serology was negative. After extensive workup, it was concluded that the patient's olmesartan was a likely etiology, as studies have shown that the medication can cause sprue-like enteropathy. Olmesartan was discontinued at admission secondary to acute kidney injury, and diarrhea resolved after 4 weeks of hospitalization. This case illustrates the possibility for severe enteropathy with the use of olmesartan and the importance of a medication review in similar cases. Olmesartan induced sprue-like enteropathy can develop months to years after the initiation of therapy and can lead to prolonged hospital stays. One mechanism hypothesized is a cell-mediated immune response. Although very rare, enteropathy is a known adverse effect and prompt recognition is critical to resolve enteropathy, decrease unnecessary tests, and minimize hospital stay length.