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World Allergy Organization
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Ask The Expert

January 31, 2014

ACE Inhibitors

Question

Should we routinely cease ACE inhibitors in someone with food, drug or venom anaphylaxis? What about angiotensin-receptor blockers (sartans)?

Answers

From the Editors: There are many times in our clinical allergy practice that we encounter patients who are taking an ACE inhibitor or an ACE receptor blocker. Some of these patients have also had anaphylaxis to a food or to a stinging insect or have severe allergic rhinitis. We often advise skin testing to pertinent inhalants, foods, or sting insects for these patients. And some of these patients will need allergy injections. Do we refuse to test, test but refuse to give allergy injections, stop the medication, or switch from an ACE inhibitor to an ACE receptor blocker? Our experts, Dr. Mario Sánchez-Borges and Dr. Roland Solensky offer us advice on how to reach the best clinical decision.

By Dr. Mario Sánchez-Borges

More than 40 million people worldwide currently receive Angiotensin converting enzyme inhibitors (ACEIs). Angioedema (AE) induced by these drugs occurs in 0.1 to 0.7 %, while in our Allergy Clinics the prevalence is 0.37 % of all consulting patients [1], with about 66% of those showing life-threatening episodes. This adverse reaction is a drug class effect common to all ACEIs.

Inhibition of ACE, decreased bradykinin catabolism, decreased aminopeptidase P activity and dipeptidyl peptidase P in the substance P degradation pathway, and a polymorphism of XPNPEP2 (the -2399 A variant) have been associated with the pathogenesis of ACEI-induced AE.

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By Dr. Roland Solensky

The concern of using ACE inhibitors (and to lesser extent, angiotensin II receptor blockers) in patients allergic to foods, drugs or venom, is that they may interfere with the endogenous compensatory mechanism during anaphylactic reactions, resulting in more severe or prolonged symptoms. (1) The only published data on whether this occurs in the clinical setting is in patients with hymenoptera venom allergy, and the studies are conflicting. A prospective study on venom immunotherapy found that patients taking ACE inhibitors had a significantly increased risk of severe anaphylaxis compared to those not taking ACE inhibitors (odds ratio 2.27, p = 0.019). (2) A retrospective cohort study did not find an association between use of ACE inhibitors and anaphylactic reactions to venom immunotherapy. (3) There are no clinical data that I am aware of evaluating the use of ACE inhibitors in patients with food allergy and drug allergy.

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