enalapril and Drug-Hypersensitivity

Several studies have shown angiotensin-converting enzyme (ACE) inhibitors to confer significant mortality and morbidity benefits in heart failure. First-dose hypotension may necessitate interruption of such therapy. This is more likely to occur if the ACE inhibitor is administered early after coronary artery bypass grafting (CABG). The purpose of this study was to analyse the haemodynamic tolerance to early post-operative treatment with perindopril and enalapril in patients with impaired renal and ventricular function.. Eighty one consecutive CABG patients with a previous myocardial infarction, impaired pre-operative left ventricular ejection fraction (LVEF) on ventriculography and moderately impaired renal function (serum creatinine of 115-150 micromol/l) were randomised into three groups to receive oral placebo, perindopril (4 mg) or enalapril (5 mg) once daily. Groups were subdivided into those with mild ventricular dysfunction (LVEF = 35-65%, n = 20) and significant ventricular dysfunction (LVEF < 35%, n = 7). Exclusion criteria included oliguria (<0.5 ml/kg per h) or inotrope dependance at the point of entry on the first post-operative day. Intolerance to ACE inhibitor was defined as hypotension (<95 mmHg systolic blood pressure or a decrease exceeding 25 mmHg in systolic blood pressure) leading to oliguria (<0.5 ml/kg per h) which was unresponsive to intravenous furosemide (20 mg). In such cases ACE inhibitor treatment was discontinued and patients commenced on dopamine.. In the groups with mild ventricular dysfunction (LVEF = 35-65%) perindopril was discontinued in 1/20 and enalapril in 4/20 patients (P = n.s). However, in the groups with significant ventricular dysfunction (LVEF < 35%) perindopril was discontinued in 2/7 and enalapril in 7/7 patients (P = 0.02).. Our results suggest that after CABG, patients with moderately impaired renal function and significant ventricular dysfunction do not tolerate ACE inhibitors well when these were commenced on the first post-operative day. However, perindopril was associated with less haemodynamic deterioration than enalapril and consequently may be advantageous in this setting. rights reserved.

Topics: Administration, Oral; Angiotensin-Converting Enzyme Inhibitors; Coronary Artery Bypass; Drug Hypersensitivity; Enalapril; Feasibility Studies; Follow-Up Studies; Heart Failure; Hemodynamics; Humans; Indoles; Length of Stay; Middle Aged; Myocardial Infarction; Perindopril; Prognosis; Renal Insufficiency

Topics: Angioedema; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Aspirin; Drug Hypersensitivity; Enalapril; Female; Humans; Hypertension; Middle Aged; Propafenone; Urticaria

Topics: Aged; Airway Obstruction; Angioedema; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Diagnosis, Differential; Drug Combinations; Drug Hypersensitivity; Dyspnea; Enalapril; Heart Arrest; Humans; Hydrochlorothiazide; Male; Tongue Diseases

Captopril, enalapril, and lisinopril are angiotensin-converting enzyme (ACE) inhibitors widely prescribed for hypertension and heart failure. Cutaneous side effects of captopril include angio-edema, anaphylactoid reactions, maculopapular eruptions, pitiryasis rosea-like rash, toxic erythema, and exfoliative dermatitis. Some of the immunological captopril-induced cutaneous adverse reactions have been diagnosed in recent years by patch tests. A case of a cutaneous immune adverse reaction to captopril with tolerance to enalapril and lisinopril demonstrated both by patch tests and double-blind challenge tests is reported for the first time. A 71-year-old nonatopic woman suffered a generalized pruriginous maculopapular rash. Two months earlier, she had started oral treatment with captopril 50 mg t.i.d and glibenclamide 5 mg daily. After the rash appeared, she stopped both drugs and the reaction cleared. A skin biopsy from one of the lesions showed perivascular lymphocytic infiltrate of the upper dermis. Skin prick tests with captopril and glibenclamide and patch tests with enalapril, lisinopril, and glibenclamide at 1% and 10% pet., and with mercaptobenzothiazole (a sulfhydryl group-containing chemical at 1% pet were negative. Only patch tests with captopril at 1% and 10% concentrations were positive at 48 h. Oral double-blind challenge tests with glibenclamide, enalapril, lisinopril, and placebo showed good tolerance. The patient was advised to avoid only captopril. Because captopril is the only ACE inhibitor containing a sulfhydryl group and has occasionally been implicated in complex immunological diseases, this chemical group has been considered the culprit of allergic reactions to captopril. The lack of cross-reactivity between captopril, enalapril, and benazepril has been demonstrated in a few patients by patch tests. In our patient, patch tests identified captopril as the drug responsible for a probably immune adverse reaction not due to the sulfhydryl group. Patch tests are useful and safe in the diagnostic work-up of allergic drug reactions and in studies of cross-sensitivity among ACE inhibitors.

Topics: Aged; Angiotensin-Converting Enzyme Inhibitors; Captopril; Cross Reactions; Drug Hypersensitivity; Enalapril; Female; Glyburide; Humans; Lisinopril; Patch Tests; Skin Tests

Inhibitors of angiotensin converting enzyme (ACE) are suspected of inducing angioedemas in up to 0.2% of all patients. These angioedemas are mainly localized in the upper airways and therefore can cause severe airway obstruction and even death due to suffocation. We report the case of a 64-year-old man, who underwent emergency tracheotomy because of severe angioedema of the larynx, which was refractory to pharmacological treatment. We conclude that patients with ACE inhibitor-induced angioedemas should be observed by monitoring in an intensive care unit to ensure the possibility of early intubation, because conventional antiallergic-antiedematous therapy by histamine-receptor antagonists and corticosteroids is an insufficient, unreliable form of therapy in severe cases. Especially otolaryngologists should know about this uncommon potentially life-threatening side-effect of ACE inhibitors.

Topics: Angioedema; Clemastine; Clonidine; Combined Modality Therapy; Drug Hypersensitivity; Emergencies; Enalapril; Humans; Hypertension, Renal; Laryngeal Edema; Male; Middle Aged; Prednisolone; Ranitidine; Tracheotomy

Topics: Adult; Aged; Angioedema; Cheilitis; Dairy Products; Drug Hypersensitivity; Enalapril; Female; Food Hypersensitivity; Gingival Hyperplasia; Gingivitis; Granuloma; Humans; Hypersensitivity; Melkersson-Rosenthal Syndrome; Mouth Diseases; Pesticides; Spices

Topics: Adult; Angioedema; Angiotensin-Converting Enzyme Inhibitors; Captopril; Drug Hypersensitivity; Enalapril; Humans; Lisinopril; Male

Topics: Aged; Ampicillin; Angioedema; Drug Hypersensitivity; Enalapril; Female; Humans; Nitrofurantoin

Two cases of enalapril(Reniten)-induced angioedema are described. In both patients the time lag between the first manifestation of angio-edema and diagnosis was more than one year, during which several bouts of edema occurred. One patient developed life-threatening swelling of the tongue and the larynx followed by asystole and apnea. The second patient had recurrent edema of the tongue and dyspnea. In general, enalapril-induced edema is not thought to be based on immunological mechanisms. However, in both patients we found elevated titres of antinuclear antibodies, which were reversible upon cessation of enalapril medication. The possible pathomechanisms are discussed.

Topics: Angioedema; Antibodies, Antinuclear; Drug Hypersensitivity; Enalapril; Female; Humans; Middle Aged; Time Factors

Topics: Antihypertensive Agents; Captopril; Cross Reactions; Dipeptides; Drug Hypersensitivity; Enalapril; Eosinophilia; Humans; Hypertension, Renovascular; Male; Middle Aged; Proline