Administration of Tranexamic Acid as Treatment for Angiotensin Converting Enzyme Inhibitor-Induced Angioedema: A Case Report

<b>Background</b> Angiotensin converting enzyme inhibitor-induced angioedema is a major cause of angioedema-related hospitalizations each year. Common swelling predilection sites include the face, periorbital skin, lips, pharynx, larynx, and tongue. Involvement of airway structures could lead to airway obstruction and ultimately death if not treated promptly. A 62-year-old man presented to a rural clinic with a massively swollen tongue that obscured visualization of the retropharynx and mildly swollen lips. The patient stated that he had been taking lisinopril for many years and never had a swelling episode similar to this. The patient was initially administered epinephrine, antihistamine, steroids, and Tranexamic acid. A second dose of Tranexamic acid was administered 30 min later followed by close monitoring. Seven hours after the first administration, the patient had near-complete resolution of tongue swelling and was later discharged. Angioedema treatment is still variable and hospitals in different settings may be able to take advantage of available resources for treatment. Tranexamic acid is a cheap and widely available antifibrinolytic that may be used to treat angiotensin converting enzyme inhibitor-induced angioedema, especially if more specific therapeutics are unavailable.

AB0805 A SURVEY OF RHEUMATOLOGY PATIENTS’ SATISFACTION TO SWITCHING FROM ORIGINATOR TO BIOSIMILAR AGENTS

Background:The recent widespread switching of patients with inflammatory rheumatic conditions from originators to biosimilars has largely been driven by costs. The views of patients on switching are also important in the successful long term switching to biosimilars. We conducted a survey of patients views on patients satisfaction with the switch to biosimilar therapy.Objectives:To assess satisfaction and response after switching from originator (Humira or Enbrel) to biosimilar (Amgevita or Benepali respectively), and to describe efficacy, side effects and reactions to biosimilar.Methods:All patients diagnosed with an inflammatory arthritis and switched to biosimilar were identified using the Irish national HighTech electronic prescriptions system. Participants had been administered the biosimilar for > 3 months and were invited to take part via a telephone survey. This consisted of 4 questions (Question 1: satisfaction with the response to the new medication [Using 5 point Likert scale = 0: very dissatisfied; 1: dissatisfied; 2: neutral; 3 satisfied;4: very satisfied]; Question 2: overall satisfaction with biosimilar compared to originator if originator was 10 [satisfaction rating from 1 – 10 scale: 1,2: very dissatisfied; 3,4: dissatisfied; 5: neutral; 6,7,8: satisfied; 9,10: very satisfied]]; Question 3: adverse effects with biosimilars; Question 4: opinion on usage of new device [0: very difficult; 1: difficult; 2: same as previous device; 3: improvement compare to previous device).Results:Baseline characteristics of biosimilar switch patients with disease category were:Category(n)GenderMale (39), Female (56)Mean age (years)56Rheumatoid arthritis58Psoriatic arthritis18Ankylosing spondylitis16Reactive arthritis1Enteropathic arthritis1Juvenile idiopathic arthritis148 switched from Humira to Amgevita.The majority of the patients had positive view towards the effectiveness of the biosimilar: 36% very satisfied; 28% satisfied; 13% neutral; 10% dissatisfied; 13% very dissatisfied.45% of the patients gave score of 9 and 10 in the survey of overall satisfaction to biosimilar if originator was given a score of 10, followed by 32% of them gave a score from 6 to 8, 4% of the patients gave a score of 5 and 7% of them gave a score of 3 and 4. The rest of them gave a score of 1 and 2.12 participants switched back to originator (Humira, n=5; Enbrel, n=7) for the reasons of unable to use the device, anxiety, hemoptysis, nose bleeding, tongue swelling, neck pain, lethargy and generalized itchiness.The most common complaints were (12 patients) systemic side effects (tiredness, headache, nausea, skin rashes, hair loss, muscle ache, tongue swelling, mood swing, dizzy, nose bleed, erectile dysfunction, hypertension, hemoptysis and red sclera).17% of the patients find the biosimilars device easier to use compare to originator and 55% of the patients find both device are similar. 24% and 4% of them find the new device is difficult to very difficult to use respectively.Conclusion:69% of patients from Amgevita group and 60% of patients from Benepali group were satisfied with the change. Only 28% of the patients found the new device difficult to use. Overall conclusion from the study showed less than one quarter of the participants showed dissatifaction towards biosimilar and less than 12 % experienced systemic side effects and whether biosimilar could be a next cost effective biologic therapy to replace originator in future requires a longer duration of study.Disclosure of Interests:None declared

Case Report: Compromised Airway Following Anesthesia and Its Correlation With the Use of ACE Inhibitors—An Unexpected Clinical Event and Review of Literature

Angiotensin-converting enzyme inhibitors associated angioedema involving the upper aerodigestive tract is indisputably a hazardous airway condition which is clinically poorly recognized and frequently underestimated. We describe and present case of a 70-year old man on ramipril who developed massive tongue swelling post-operatively after unremarkable laryngeal mask anaesthesia which was fortuitously managed conservatively. High index of suspicion, timely recognition and knowledge of pathophysiology and the clinical course should guide airway and further supportive management in these patients.

Extending our understanding of exenatide: a rare case of angio-oedema

Exenatide is a subcutaneous injectable glucagon-like peptide 1 receptor agonist that has been approved by the Federal Drug Administration for the treatment of type 2 diabetes mellitus. While side effects such as nausea, vomiting and local hypersensitivity reactions are more commonly described, angio-oedema has never been previously reported in the literature. We present the case of a 67-year-old woman who presented to the emergency department with acute-onset tongue swelling, difficulty breathing, dizziness and diffuse itching which began shortly after receiving her first dose of intramuscular extended release (ER) exenatide. This case aims to raise awareness of the potential adverse effect of angio-oedema secondary to exenatide ER and serves as a reminder to clinicians to discuss possible adverse effects of medications and early recognition of symptoms which would prompt further medical attention.

Recurrent macroglossia requiring tracheostomy after haemorrhagic basal ganglia stroke

A 50-year-old African American woman with hypertension, congestive heart failure, chronic kidney disease and prior cerebral vascular accident was transferred from an outside hospital after being found unresponsive and subsequently intubated for severe orolingual swelling. Imaging showed left thalamic haemorrhagic stroke, and the lingual swelling was clinically concerning for angio-oedema, with which a lingual biopsy was consistent. Work-up was negative for hereditary or acquired angio-oedema, and imaging was negative for structural causes. Of note, the patient had an episode of severe orolingual swelling 3 months prior to this presentation after suffering left thalamic haemorrhage which self-resolved after approximately 2 months. In both episodes lingual swelling predated receipt of tissue plasminogen activator and she had discontinued ACE inhibitor therapy since her first episode of tongue swelling. Despite medical and supportive management, tongue swelling progressed during admission and the decision was made to allow the patient’s tongue swelling to self-resolve.

Infusion-related angioedema associated with infliximab-abda: Case report

Purpose A case of infusion-related angioedema associated with the use of an infliximab biosimilar (infliximab-abda) is reported in order to bring awareness that this adverse effect is still highly possible in biosimilars, similar to the reference infliximab biologic. Summary A 37-year-old white male with a past medical history significant for ileocolonic fistulizing Crohn’s disease, depression, and gastroesophageal reflux disease (GERD) presented to an emergency department with shortness of breath, urticaria, and tongue swelling that had developed shortly after initiation of an infusion of infliximab-abda. The patient had no documented allergies at the time of presentation. The patient was taking oral budesonide 9 mg daily and oral azathioprine 50 mg daily for treatment of Crohn’s disease. Other medications included oral omeprazole 40 mg every morning for GERD and oral sertraline 100 mg daily for depression. The patient’s tongue swelling worsened, and he was intubated for airway protection. The patient received supportive care treatment for angioedema with intravenous (IV) dexamethasone 8 mg every 8 hours, IV diphenhydramine 50 mg every 8 hours, and IV famotidine 20 mg every 12 hours. He was extubated approximately 43 hours later and observed overnight in a medical intensive care unit. He was transferred to a general medicine unit the next day for further care. The total hospital length of stay was 4 days. Conclusion A 37-year-old man developed infusion-related angioedema with use of infliximab-abda. Discontinuation of the biosimilar product along with supportive care brought about resolution of angioedema. There are no prior published reports of infusion-related angioedema reactions secondary to infliximab-abda use.

Angioedema, ACE inhibitor and COVID-19

SARS-CoV-2, the virus responsible for COVID-19, binds to the ACE2 receptors. ACE2 is thought to counterbalance ACE in the renin-angiotensin system. While presently it is advised that patients should continue to use ACE inhibitors or angiotensin receptor blockers, questions still remain as to whether adverse effects are potentiated by the virus. Here, we report a case of a 57-year-old man, unknowingly with COVID-19, who presented to the emergency department with tongue swelling, shortness of breath and difficulty in speaking following 4 months taking benazepril, an ACE inhibitor. Finally, we also describe possible pathways that exist for SARS-CoV-2 to interact with the mechanism behind angioedema.