REPLY
Adverse Effects of ACE Inhibitors
Zafar H. Israili and
W. Dallas Hall
15 February 1993 | Volume 118 Issue 4 | Pages 314-315
IN RESPONSE:
Dr. Edwards is correct that our statement may be misleading. The case reports he and Drs. Chu and Chow describe, as well as those in our review and recent ones [1-3], confirm that angioneurotic edema can occur even after prolonged therapy with ACE inhibitors. Because most cases occur within a week [4], we used the word "usually".
In some instances, the symptoms of angioedema may be very mild and subside without the patient's awareness. The symptoms may incorrectly be attributed to other causes such as food allergy, insect sting, or other drug reactions. Continued use of ACE inhibitors in such patients may result in the recurrence of severe angioneurotic edema.
Because of the unpredictable occurrence and severity of angioedema and the risk for serious life-threatening consequences, ACE inhibitors should not be given to patients who have had even a mild or easily reversed episode [5] or are prone to spontaneous angioedema.
Drs. Adams and Hazard point out a letter [6] not cited by us [1] describing the use of cromolyn inhalation therapy for persistent cough induced by ACE inhibitor therapy. The authors report that cromolyn resulted in the cessation of cough in three of six patients and reduction in cough severity in another two. No mention was made of dose or duration of cromolyn therapy in this uncontrolled study.
Cromolyn shares some common adverse effects (cough, wheezing, bronchospasm, angioedema, joint swelling, and urticaria) with ACE inhibitors. Thus, the use of cromolyn is not encouraged, especially in patients with compromised pulmonary function.
The use of ACE inhibitors is certainly desirable for many patients with congestive heart failure or diabetic nephropathy, and it may become necessary to continue or reinstate these drugs in patients who can tolerate the adverse effect of cough. A recent report has also shown that, in some patients, cough abates despite continued use of ACE inhibitors [7].
1. Israili ZH, Hall WD. Cough and angioneurotic edema associated with angiotensin-converting enzyme inhibitor therapy. Ann Intern Med. 1992; 117:234-42.
2. Bielory L, Lee SS, Holland CL, Jaker M. Long-acting ACE inhibitor-induced angioedema. Allergy Proc. 1992; 13:85-7.
3. Venable RJ. Angioedema after long-term enalapril use. J Fam Pract. 1992; 34:201-4.
4. Slater EE, Merrill DD, Guess HA, Roylance PJ, Cooper WD, et al. Clinical profile of angioedema associated with angiotensin converting-enzyme inhibition. JAMA. 1988; 260:967-70.
5. Chin HL, Buchan DA. Severe angioedema after long-term use of an angiotensin-converting enzyme inhibitor (Letter). Ann Intern Med. 1990; 112:312-3.
6. Aldis WL. Cromolyn for cough due to angiotensin-converting enzyme inhibitor therapy (Letter). Chest. 1991; 100:1741-2.
7. Reisen L, Schneeweiss A. Complete spontaneous remission of cough induced by ACE inhibitors during chronic therapy in hypertensive patients. J Hum Hypertens. 1992; 6:333-5.
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