ACE inhibitors: upper respiratory symptoms

Abstract

Cough and angioedema are well-known adverse reactions of ACE inhibitors. However, other adverse effects of upper airways such as postnasal drainage, rhinitis and nasal blockage, are less frequently recognised. These might share the same pathophysiological mechanism: bradykinin accumulation. We present two patients with ACE inhibitor-induced upper respiratory symptoms that improved after the discontinuation of ACE-inhibitors and substitution with angiotensin II receptor blockers. The incidence of these adverse events is not accurately known, since these are not required to be reported, but it is estimated to be low. This presents challenges to the physician and demonstrates the importance of keeping it as a differential diagnosis. Most physicians are aware of ACE inhibitor-induced cough but not of ACE inhibitor-induced nasal blockage, rhinitis or postnasal drainage. Identifying these can avoid unnecessary diagnostic tests and inappropriate treatment.

Rhinitis 2020: A practice parameter update

“…147 No mechanism has been clearly identified because there are many drugs that can produce nasal symptoms, such as calcium channel blockers, angiotensin-converting enzyme inhibitors, gabapentin, and psychotropics (eg, risperidone and chlorpromazine). 147,148 The effect of exogenous estrogens and oral contraceptives on nasal physiology is uncertain although it has been suggested that oral contraceptives may reduce allergen-provoked nasal congestion during ovulation but increase sneezing at the end of the menstrual cycle. [149][150][151] Overuse of topical decongestants can result in rhinitis medicamentosa, a form of drug-induced rhinitis, which is further discussed in the intranasal decongestants section.…”

“…In addition to AR, because of the concomitant use of multiple medications in the elderly, drug-induced rhinitis is not infrequent. Alpha-1 adrenergic antagonists used for benign prostatic hyperplasia, 566 angiotensin-converting enzyme inhibitors, 148,[567][568][569] and possibly beta-adrenergic inhibitors 570 and phosphodiesterase inhibitors 571 can induce symptoms of rhinitis. (See earlier section on drug-induced rhinitis.…”

Perindopril-induced angioedema of the lips and tongue: a case report

“…In the present case, our patient was a chronic user of ACE inhibitors and had no comorbidity. On the other hand, patients with severe edema, particularly in the upper airway, may require either mechanical ventilation or an invasive procedure such as tracheotomy, intubation, or cricothyroidotomy [ 18 , 19 ]. However, in this patient the administration of antihistamines and corticosteroids brought about a resolution.…”

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