Knowledge of the side effects of angiotensin-converting-enzyme (ACE) inhibitors is a matter of current discussion. Further to the recent Readers’ Comment by Roberts et al, some adverse drug reactions (ADRs) caused by ACE inhibitors are likely to be found by allergists, but ADRs to angiotensin II receptors blockers (ARBs) may also be found. The number of symptoms associated with these ADRs might allow them to be considered a new “syndrome.”
We present a series of 45 cases of ACE inhibitor or ARB side effect syndrome treated in the allergy service at Hospital Central de la Defensa (Madrid, Spain). Patients were treated from March 2009 to April 2012 by otolaryngology and ophthalmology services or emergency department or primary care physicians. The main complaint was persistent moderate to severe rhinitis, without response to symptomatic treatment with corticosteroids and antihistamines. Characteristics of patients, symptoms, involved drugs, and evolution are listed in Table 1 . Careful medical histories and physical examinations showed that all patients had other symptoms associated with rhinitis, matching the definition of a syndrome: 1 or various symptoms that can appear in time, continuously or sometimes intermittently. In this case, the symptoms were cough, conjunctivitis, angioedema, the sensation of a foreign body in the pharynx, itching, aphonia, and photophobia. All patients were studied according to the Allergic Rhinitis and Its Impact on Asthma guidelines. In all patients, allergic, infectious, occupational, hormonal, atrophic, emotional, nutritional, eosinophilic, and other causes were discarded.
| Variable | Value |
|---|---|
| Women | 32 (71.1%) |
| Men | 13 (28.9%) |
| Mean age (years) | 66 (range 37–85) |
| Symptomatology | |
| Rhinitis | 45 (100%) |
| Cough | 27 (60%) |
| Conjunctivitis | 17 (37.7%) |
| Angioedema | 16 (35.6%) |
| Sensation of foreign body in pharynx | 6 (13.3%) |
| Itching | 5 (11.1%) |
| Aphonia | 3 (6.7%) |
| Photophobia | 2 (4.4%) |
| Suspected medication | |
| ACE inhibitors | 24 (53.3%) |
| Enalapril | 20 (44.4%) |
| Lisinopril | 3 (6.7%) |
| Captopril | 1 (2.2%) |
| ARBs | 21 (46.7%) |
| Valsartan | 9 (20%) |
| Losartan | 7 (15.6%) |
| Telmisartan | 2 (4.4%) |
| Olmesartan | 1 (2.2%) |
| Irbesartan | 1 (2.2%) |
| Candesartan | 1 (2.2%) |
| Evolution/development | |
| ACE inhibitor/ARB withdrawn | 45 (100%) |
| Clinical improvement | 45 (100%) |
| Time to achieve improvement (days) | 48.4 ± 19.1 |
| Reexposure, similar symptomatology | 17 (38%) |
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