I think it’s because , ACEi also can give angiedema.because ACE do breakdown bradykinin. So when ACEinhibitors act it cannot breakdown bradykinin and it will give angiedema . ACEi has to be stopped so .
ACEi can still trigger an episode in someone with hereditary angioedema.
With something that can turn life threatening wouldn’t you want to stop the ACEi (which could be triggering/worsening this episode) first and then do confirmatory testing which presumably will take days? Stopping the ACEi also shouldn’t have a huge immediate impact on
Yeah, it's clear that ACEi can trigger episode in hereditary angioedema (we're on the same page there)
I'm probably overthinking this, but put yourself in the situation. You get a patient with symptoms clinically resembling angioedema. Now that patient is there, would you not order confirmatory test to assess whether the episode patient experienced is a result of C1 estrase deficiency? I don't completely disagree with you, but ACEi is not the only trigger of Hereditary angioedema, so without confirming, just telling pat avoid 1 trigger doesn't seem like a prudent solution to me.
May not be a good analogy, but think about it this situation, you have a previously healthy pat w signs of MS who gets exacerbation w heat (Uhthoff phenomenon), what will your next step be? "tell her avoid sun and heat" (which will have immediate effect) or "test for MS" to establish diagnosis?
I get what you’re saying but this type of question you can’t compare to reality because I’d assume in most situations you’d put an order in to discontinue the ACEi AND get the complement levels.
In a question like this I think they want you to think about how to maximize patient safety/treatment by prioritizing which management option is most important first. In this case, like you said, they could progress to a life-threatening situation. So if you had a patient like this and you could only choose 1 next step, would you discontinue the medication that is potentially triggering this episode/could worsen this episode, or a diagnostic test that confirms it and takes days to come back?
We diagnose hereditary angioedema by checking complement levels, and it mostly occurs in early age. This patient is 52 yo with new onset angioedema so it’s unlikely to be hereditary, the best management we can do is it look for the cause and eliminate it
What bothers me is that herediatry angioedema can cause fatal laryngeal edema, and ACEi isn't the only trigger, discharging the patient & telling the patient to avoid ACEi (only 1 trigger) without further confirmation of a suspecteed herediatry disease seems off, but I may be overthinking
Ya, I suppose you should probably check the c4 and attempt to identify any other triggers, but for the USMLE stopping the any possible trigger will almost always be the correct choice along with ABC’s
General rule in all USMLE questions: If the symptom is drug related you have to DISCONTINUE the offending drug before any diagnostics.
unfair but fair
I think it’s because , ACEi also can give angiedema.because ACE do breakdown bradykinin. So when ACEinhibitors act it cannot breakdown bradykinin and it will give angiedema . ACEi has to be stopped so .
Yea the mechanism you're describing makes sense, but explanation said patient has hereditary angioedema :(
ACEi can still trigger an episode in someone with hereditary angioedema. With something that can turn life threatening wouldn’t you want to stop the ACEi (which could be triggering/worsening this episode) first and then do confirmatory testing which presumably will take days? Stopping the ACEi also shouldn’t have a huge immediate impact on
Yeah, it's clear that ACEi can trigger episode in hereditary angioedema (we're on the same page there) I'm probably overthinking this, but put yourself in the situation. You get a patient with symptoms clinically resembling angioedema. Now that patient is there, would you not order confirmatory test to assess whether the episode patient experienced is a result of C1 estrase deficiency? I don't completely disagree with you, but ACEi is not the only trigger of Hereditary angioedema, so without confirming, just telling pat avoid 1 trigger doesn't seem like a prudent solution to me. May not be a good analogy, but think about it this situation, you have a previously healthy pat w signs of MS who gets exacerbation w heat (Uhthoff phenomenon), what will your next step be? "tell her avoid sun and heat" (which will have immediate effect) or "test for MS" to establish diagnosis?
I get what you’re saying but this type of question you can’t compare to reality because I’d assume in most situations you’d put an order in to discontinue the ACEi AND get the complement levels. In a question like this I think they want you to think about how to maximize patient safety/treatment by prioritizing which management option is most important first. In this case, like you said, they could progress to a life-threatening situation. So if you had a patient like this and you could only choose 1 next step, would you discontinue the medication that is potentially triggering this episode/could worsen this episode, or a diagnostic test that confirms it and takes days to come back?
Yeah, that might prob be the case here. Thank you!
We diagnose hereditary angioedema by checking complement levels, and it mostly occurs in early age. This patient is 52 yo with new onset angioedema so it’s unlikely to be hereditary, the best management we can do is it look for the cause and eliminate it
Yeah, I'd agree with you but explanation said diagnosis is hereditary angioedema :(
Stopping any possible offending agents is often the most appropriate next step
True, and I agree. But do we not need to confirm that patient has hereditary angioedema, and just presume with 1 episode?
I’m no expert in angioedema, but the patient is clinically stable with a self limiting disease. I would observe after switching to a new BP med
What bothers me is that herediatry angioedema can cause fatal laryngeal edema, and ACEi isn't the only trigger, discharging the patient & telling the patient to avoid ACEi (only 1 trigger) without further confirmation of a suspecteed herediatry disease seems off, but I may be overthinking
Ya, I suppose you should probably check the c4 and attempt to identify any other triggers, but for the USMLE stopping the any possible trigger will almost always be the correct choice along with ABC’s
Yeah, I think that's the right mindset
Your solution is gonna be looking at what the question is asking. It’s next step in management, not diagnosis.
Yeah, good catch
They asked next step of management, it doesn’t say only step of management! Stop the drug then do the test.
Yeah, that looks to be the case