eMedicine Specialties > Allergy and Immunology > Urticaria and Angioedema

Angioedema: Follow-up

Author: Huamin Henry Li, MD, PhD,, Director of Immunology, Institute for Asthma and Allergy
Contributor Information and Disclosures

Updated: Dec 21, 2009

Follow-up

Further Inpatient Care

  • Laryngeal involvement should be closely monitored. When intubation is required, admission to an intensive care unit is often needed. Anesthesiologists, critical care specialists or pulmonologists, otolaryngologists, and respiratory therapists are helpful for the management team.
  • Tracheotomy may be needed for extreme cases. A surgeon should be consulted in this regard.
  • Pain control can be a significant part of managing severe angioedema attacks.

Further Outpatient Care

  • Most patients require regular office visits to monitor their response to treatment and to assess ongoing or new episodes of angioedema.
  • Allergy and immunology specialists should be consulted (eg, to identify potential allergies, medication reactions, changes in certain body enzymes).

Inpatient & Outpatient Medications

  • Inpatient care for angioedema is usually not necessary; however, moderate to severe angioedema is often seen in the emergency department.
    • Epinephrine should be used when laryngeal angioedema is suspected. Supportive care should also be provided regardless of the etiology.
    • For histamine-mediated angioedema, a combination of antihistamine(s) and an H2 blocker is most frequently used. Corticosteroids are often considered, based on the severity of the swelling.
    • For bradykinin-mediated angioedema (eg, HAE), C1 INH concentrate infusion (Berinert P, 20 IU/kg) can be used. Fresh frozen plasma (1-2 units) and Amicar may also be considered for these patients.
    • For angioedema with unclear etiology (eg, idiopathic), start with antihistamine(s) and an H2 blocker. Corticosteroids may be considered if symptoms are severe.
  • Outpatient treatment should avoid long-term corticosteroid use.
    • For histamine-mediated angioedema, antihistamine(s) with or without H2 antagonists are first-line treatment. Immunomodulators should be considered when angioedema does not respond to antihistamines and H2 antagonists.
    • For nonhistamine-mediated angioedema such as HAE, androgen derivatives are often the first choice for prophylaxis. For patients who cannot tolerate androgen derivatives, antifibrinolytic agents may be considered. C1 INH concentrate should be used in patients with HAE who have frequent swelling attacks and are not able to tolerate androgen derivatives or antifibrinolytics.
    • For idiopathic angioedema, the response to treatment varies tremendously among individuals. Many patients may need multiple attempts to find the right combination of medicine to control their symptoms. Antihistamines and H2 antagonists are still most commonly prescribed for this condition. Leukotriene antagonists (montelukast and zafirlukast), 5-lipoxygenase inhibitor (zileuton), and immunomodulators (eg, cyclosporine) have been used in these patients. Corticosteroid is reserved for very recalcitrant cases. Antifibrinolytics have been tried in some patients with success. Androgen derivatives and progesterone-only oral contraceptives may also be considered for these patients.

Complications

  • Airway obstruction can be life-threatening. Throat pain or discomfort, dysphonia, and dysphasia may indicate laryngeal involvement.
  • Airway swelling can make intubation difficult. The risk is increased for vocal cord damage during intubation.
  • Other complications, such as severe abdominal pain, bowel obstruction, acute pancreatitis, and skin rupture have been described.

Prognosis

  • Angioedema induced by allergies or medications usually resolves once the triggers are identified and avoided.
  • Chronic idiopathic angioedema runs a variable course, which may be a few weeks to a few years. In a small percentage of patients, symptoms may persist for more than 10 years.
  • HAE often requires lifelong treatment.
  • The outcome of AAE depends on the treatment of underlying lymphoproliferative or autoimmune disorders.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to intervene early by securing the airway in patients with laryngeal involvement
  • Failure to consider angioedema in a patient presenting with severe abdominal pain
  • Failure to prescribe an epinephrine automatic injector in high-risk patients (eg, food allergies, venom hypersensitivity) and to document patient education regarding storage and use
  • Failure to diagnose the cause of angioedema where a method of prevention can be identified
  • Failure to avoid prescribing a drug to which the patient is known to be sensitive or a similar, cross-reacting drug (Angioedema caused by nonsteroid anti-inflammatory drugs or ACE inhibitors is related to the drug class; switching to a different drug in same class does not help.)
  • Failure to administer epinephrine expediently instead of less-effective medications

Special Concerns

  • Trauma, surgical procedure, and stress are common nonspecific triggers for angioedema attacks.
  • Genetic screening for ACE polymorphism may help identify at risk population for ACE inhibitor–induced angioedema (AIIA).
  • Patients with AIIA may have a risk of developing angioedema when switching to an angiotensin II receptor blocker (ARB) in 0-9.2% of cases.20
  • In recalcitrant cases, consider possible misdiagnosis and other concurrent medical problems.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Maurice Reid, MD; Brian Euerle, MD, FACEP; and Mary Elizabeth Bollinger, DO, to the development and writing of this article.



More on Angioedema

Overview: Angioedema
Differential Diagnoses & Workup: Angioedema
Treatment & Medication: Angioedema
Follow-up: Angioedema
Multimedia: Angioedema
References
Further Reading
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Further Reading

Kaplan AP. Urticaria and Angioedema. In: Adkinson Jr NF, Bochner BS, Busse WW, Holgate ST, Lemanske Jr RF, and Simons FER, eds. Middleton’s Allergy Principles and Practice. 7th ed. St. Louis, Mo: Mosby; 2009:1063-82.

Banerji A, Sheffer AL. The spectrum of chronic angioedema. Allergy Asthma Proc. 2009 Jan-Feb;30(1):11-6. Review.

Grigoriadou S, Longhurst HJ. Clinical Immunology Review Series: An approach to the patient with angio-oedema. Clin Exp Immunol. 2009 Mar;155(3):367-77.

Zuraw BL. Clinical practice. Hereditary angioedema. N Engl J Med. 2008 Sep 4;359(10):1027-36. Review.

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Keywords

angioedema, AE, angioneurotic edema, urticaria, swelling, hereditary angioedema, HAE, acquired angioedema, AAE, angiotensin converting enzyme inhibitor, ACEI, ACEI induced angioedema, AIIA, NSAID, allergic reaction

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Contributor Information and Disclosures

Author

Huamin Henry Li, MD, PhD,, Director of Immunology, Institute for Asthma and Allergy
Huamin Henry Li, MD, PhD, is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology, and MedChi
Disclosure: Dyax Consulting fee Consulting; Shire/Jerini Consulting fee Consulting; CSL Behring Consulting fee Consulting; Lev Pharma Consulting fee Consulting; Sanofi-Advantis Honoraria Speaking and teaching

Medical Editor

Stephen C Dreskin, MD, PhD, Professor of Medicine, Departments of Internal Medicine, Director of Allergy, Asthma, and Immunology Practice, University of Colorado Health Sciences Center
Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology
Disclosure: Genentech Consulting fee Consulting; American Health Insurance Plans Consulting fee Consulting; Johns Hopkins School of Public Health Consulting fee Consulting; Array BioPharma Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Samuel R Marney, Jr, MD, Director, Associate Professor, Department of Internal Medicine, Division of Allergy and Immunology, Vanderbilt University School of Medicine
Samuel R Marney, Jr, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, and Tennessee Medical Association
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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