A patient on lisinopril develops nonpruritic lip edema after a meal; no urticaria. What is the best next step?

A patient on lisinopril develops nonpruritic lip edema after a meal; no urticaria. What is the best next step?

• A. Administer epinephrine
• B. Start high-dose steroids
• C. Discontinue lisinopril
• D. Reassurance and observe

Answer: (C)

ACE inhibitor–induced angioedema causes nonpruritic swelling of the lips or face without urticaria, driven by excess bradykinin rather than histamine. Because this is not a histamine-mediated allergic reaction, epinephrine and steroids are unlikely to rapidly reverse it. The best next step is to discontinue the ACE inhibitor to remove the trigger and allow the edema to resolve, with careful airway monitoring for possible progression. If needed later, an alternative antihypertensive with a lower risk of angioedema can be used.

ACE inhibitor–induced angioedema causes nonpruritic swelling of the lips or face without urticaria, driven by excess bradykinin rather than histamine. Because this is not a histamine-mediated allergic reaction, epinephrine and steroids are unlikely to rapidly reverse it. The best next step is to discontinue the ACE inhibitor to remove the trigger and allow the edema to resolve, with careful airway monitoring for possible progression. If needed later, an alternative antihypertensive with a lower risk of angioedema can be used.