Olmesartan induced enteropathy affecting the entire gastrointestinal tract: a case report

Abstract

Olmesartan, a well-known and powerful antihypertensive drug, was first described to cause enteropathy in 2012. A possible mechanism may be inhibition of the intestinal immune suppressive effect of transforming growth factor-beta (TGF-β), with a consequential increase of intestinal T-cell inflammation. We present the case of a 60-year-old woman who developed large volume, watery diarrhoea with 8kg weight loss only two weeks after starting olmesartan 20mg daily with a secondary mild acute kidney insufficiency and hypokalaemia. Coeliac serology was negative. Endoscopy revealed no macroscopic lesions. Histology showed increased gastric, duodenal, ileal and colonic intraepithelial lymphocytes with partial duodenal villous atrophy, hence affecting the entire gastrointestinal tract. After cessation of olmesartan, symptoms improved within a week; therefore a diagnosis of olmesartan induced enteropathy was made. Extra immunohistochemical stains to further investigate the underlying pathophysiology were inconclusive.

Systematic review: Clinical phenotypes, histopathological features and prognosis of enteropathy due to angiotensin II receptor blockers

“…p < 0.05 were considered statistically significant. Ninety-four were case reports or case series of enteropathy due to ARBs (86 case reports or case series with less than five patients and eight case series with five or more patients 5,11,[99][100][101][102][103][104] ) corresponding to a total of 183 patients (101 F, mean age at diagnosis 69 ± 10 years) published between 2012 and 2023, with most cases being reported in Europe (93 cases) 11,13,17,18,20,21,23,24,26,27,[30][31][32][33][34]40,44,45,50,51,[55][56][57][61][62][63][64]67,68,70,73,75,77,80,[83][84][85][89][90][91]…”

“…The final diagnosis was reached after a median of 5 months, and an acute onset of symptoms leading to diagnosis was present in 10% of patients. Coeliac serology results were reported in 140/183 5,11,13,14,[16][17][18][19][20][21][22]24,25,[27][28][29][30][31][32][33][34][35][36][37][38][39][40]83,84,86,[89][90][91][92][94][95][96][97][98][99][100][101] and were negative in the large majority of cases (138/140, 99%). In only two patients, IgA tissue transglutaminase antibodies were borderline and considered to be irrelevant by the authors.…”

“…VA was present in 164/183 (89%) patients. 5,11,13,14,[16][17][18]20,21,24,25,[27][28][29][30][31][32][33][34][35][36][37][38][39][74][75][76][77][78][79][80][81][82][83][84][85][86][87][88][90][91][92][93][94][95][96][97][98][99][100][101][102][103]…”

“…13,15,31,32,35,43,48,49,52,61,65,66,81,86 Among the 164 patients with VA, additional findings in the stomach or in the colon were present in 55 patients (30.1%). Of these 55 patients, 12 had pan-GI mucosal changes (gastric, small bowel and colonic involvement), 5,20,34,38,42,61,80,84,92,93 23 had evidence of gastric findings in addition to small bowel involvement 5,11,30,50,71,77,87,93,100,102 and 20 had colonic mucosal changes in addition to small bowel involvement. 5,16,21,26,29,36,48,52,60,62,70,91,93,[99][100]…”

“…Among the 41 patients with gastric mucosal changes at baseline, 5,11,20,23,30,34,38,42,50,61,71,77,80,84,87,92,93,100,102 follow-up gastric biopsies were performed in 19 patients after a median of 5 months (IQR 3-8). All these patients had a normal gastric biopsy at follow -up 5,11,38,61,77,80,92,93,102 with the exception of one.…”