Letter to the Editor
Enteropathy associated with chronic use of olmesartan
Enteropatía asociada al uso crónico de olmesartán
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To date, a total of 46 ADR cases have been reported but we have found no related article in the Spanish bibliography<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2–6</span></a> (bibliographic search on PubMed using keywords: olmesartan, sprue, enteropathy, villous atrophy and sprue-like enteropathy, for the last 10 years). Below, we present the case of a patient who developed an enteropathy secondary to the chronic intake of this drug.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 73-year old male who attended to the Emergency Department with chronic diarrhoea, asthenia, and weight loss of 15 kg. In his pathological history the following stood out: high blood pressure of more than 10 years evolution, treated with olmesartan (20 mg/day) for the last 8 years, and prostate adenocarcinoma, currently healed after undergoing a prostatectomy in 2006. It is worth mentioning that 10 months before visiting our centre, the patient was diagnosed with coeliac disease by means of a duodenal biopsy (duodenal mucous membrane with flattened villi, glandular crypts hyperplasia and marked intraepithelial lymphocytosis); since then, he had been following a strict gluten-free diet. Since the patient was not responding to treatment, he underwent a breath test, ruling out bacterial overgrowth, but was diagnosed with lactose and fructose intolerance. In spite of being on a diet that restricted foods containing these components, his clinical state worsened progressively, so he decided to consult us.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A physical examination showed that he had high blood pressure (BP 90/60 mmHg) and, therefore, the administration of olmesartan was suspended, with no other relevant finding observed. The laboratory tests indicated Na<span class="elsevierStyleSup">+</span> 141 mEq/l, K<span class="elsevierStyleSup">+</span> 1.5 mEq/l, Ca<span class="elsevierStyleSup">2+</span> 5.2 mg/dl, Mg<span class="elsevierStyleSup">2+</span> 0.5 mg/dl, total proteins 6.3 g/dl; the haemogram and the other baseline biochemical analyses were normal.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The immunological and genetic study (HLA-DQ2 and HLA-DQ8) ruled out coeliac disease (anti-tissue transglutaminase antibodies 0.8 U/ml [< 4.0 U/ml], DQB1*05:02:01, DQB1*05:03:01). The immunoglobulin dosage was normal. The microbiological faeces exam and HIV serology were both negative. The thoracic and abdominal CT scan did not reveal relevant disorders, and the barium swallow exam showed a progressive ileum contrast dilution, with a radiological pattern indicating intestinal malabsorption. Examination was completed by a fibergastroscopy and fibercolonoscopy, neither of which identified macroscopic changes. The histology and immunohistochemical studies showed flattened villi, crypts hyperplasia and marked intraepithelial lymphocytary infiltration (positive CD3 and CD5). There were no signs of microscopic colitis, lymphoproliferative disorder or PAS-positive markers.</p><p id="par0025" class="elsevierStylePara elsevierViewall">During hospitalisation, while receiving no specific medical treatment, the number of depositions decreased progressively until the clinical condition resolved after 3 weeks. Based on the suspicion of enteropathy secondary to olmesartan, the patient was instructed to follow a regular, unrestricted diet, which he tolerated correctly.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Once the patient improved clinically, he was discharged from the hospital. In subsequent outpatient follow-up visits (2 months later), we found that the patient had regained 10 kg, with no new episodes of diarrhoea.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The most frequent aetiology seen within chronic diarrhoea syndrome associated with villi atrophy is coeliac disease<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7,8</span></a>. Some of the less frequent causes are: variable common immunodeficiency, autoimmune enteropathy, bacterial overgrowth, infections (e.g. giardiasis, Whipple's disease, and tuberculosis), intestinal lymphoma, collagenous sprue, Crohn's disease, tropical sprue, and drugs<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Our review of the cases reported to date revealed that most patients had been previously diagnosed with coeliac disease non-responsive to a gluten-free diet, or refractory coeliac disease<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,8</span></a>. No relation between the length of exposure to olmesartan and enteropathy has been described<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a>. The intestinal epithelium damage could be related to the immune-mediated cellular response secondary to an imbalance between anti-inflammatory and pro-inflammatory factors<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a>. The most frequent symptoms are diarrhoea and weight-loss; other possible symptoms are: fatigue, nausea and abdominal pain<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a>. Although the histopathological findings are not specific, it is worth mentioning that most patients present the symptoms described in the anatomopathological study undergone by our patient (villi atrophy with variable inflammation)<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2–7</span></a>. The gluten-free diet and treatments for other types of enteropathy (glucocorticoids, antidiarrhoeal, pancreatic enzymes, antibiotics, etc.) tend to be ineffective<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a>. It has been observed that once olmesartan is suspended, there is a remission of symptoms and histological disorders<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2–7</span></a>. Intestinal biopsy has not been repeated for this patient.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In view of the abovementioned, we conclude that the clinical condition presented by our patient was secondary to the intake of olmesartan. According to the Naranjo algorithm, causality is considered probable (7 points). This adverse reaction has been notified to the Spanish Agency of Medicines and Medical Devices.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Téllez A, Pellicé M, Llobell A, Milisenda JC. Enteropatía asociada al uso crónico de olmesartán. Med Clin (Barc). 2015;144:139–140.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "FDA Drug Safety Communication: FDA approves label changes to include intestinal problems (sprue-like enteropathy) linked to blood pressure medicine olmesartan medoxomil" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "U.S. Food and Drug Administration" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2013" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Five cases of sprue-like enteropathy in patients treated by olmesartan" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. Théophile" 1 => "X.R. David" 2 => "G. Miremont-Salamé" 3 => "F. Haramburu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.dld.2013.12.014" "Revista" => array:6 [ "tituloSerie" => "Dig Liver Dis" "fecha" => "2014" "volumen" => "46" "paginaInicial" => "465" "paginaFinal" => "469" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24472297" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0055" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Olmesartan-associated sprue-like enteropathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.P. Stanich" 1 => "M. Yearsley" 2 => "M.M. Meyer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MCG.0b013e31829a27e6" "Revista" => array:6 [ "tituloSerie" => "J Clin Gastroenterol" "fecha" => "2013" "volumen" => "47" "paginaInicial" => "894" "paginaFinal" => "895" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23751857" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0060" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe spruelike enteropathy associated with olmesartan" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Rubio-Tapia" 1 => "M.L. Herman" 2 => "J.F. Ludvigsson" 3 => "D.G. Kelly" 4 => "T.F. Mangan" 5 => "T.T. Wu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.mayocp.2012.06.003" "Revista" => array:6 [ "tituloSerie" => "Mayo Clin Proc" "fecha" => "2012" "volumen" => "87" "paginaInicial" => "732" "paginaFinal" => "738" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22728033" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0065" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Angiotensin-II inhibitor (olmesartan)-induced collagenous sprue with resolution following discontinuation of drug" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.A. Nielsen" 1 => "A. Steephen" 2 => "M. Lewin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3748/wjg.v19.i40.6928" "Revista" => array:6 [ "tituloSerie" => "World J Gastroenterol" "fecha" => "2013" "volumen" => "19" "paginaInicial" => "6928" "paginaFinal" => "6930" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24187471" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0070" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spruelike enteropathy associated with olmesartan: An unusual case of severe diarrhea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.E. Dreifuss" 1 => "Y. Tomizawa" 2 => "N.J. Farber" 3 => "J.M. Davison" 4 => "A.E. Sohnen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2013/618071" "Revista" => array:5 [ "tituloSerie" => "Case Rep Gastrointest Med" "fecha" => "2013" "volumen" => "2013" "paginaInicial" => "618071" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23573432" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0075" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Villous atrophy and negative celiac serology: a diagnostic and therapeutic dilemma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. DeGaetani" 1 => "C.A. Tennyson" 2 => "B. Lebwohl" 3 => "S.K. Lewis" 4 => "H. Abu Daya" 5 => "C. Arguelles-Grande" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/ajg.2013.45" "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "2013" "volumen" => "108" "paginaInicial" => "647" "paginaFinal" => "653" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23644957" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0080" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ACG clinical guidelines: diagnosis and management of celiac disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Rubio-Tapia" 1 => "I.D. Hill" 2 => "C.P. Kelly" 3 => "A.H. Calderwood" 4 => "J.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2017 October | 6 | 1 | 7 |
| 2017 September | 10 | 2 | 12 |
| 2017 August | 15 | 9 | 24 |
| 2017 July | 9 | 3 | 12 |
| 2017 June | 11 | 8 | 19 |
| 2017 May | 12 | 11 | 23 |
| 2017 April | 10 | 11 | 21 |
| 2017 March | 9 | 37 | 46 |
| 2017 February | 8 | 4 | 12 |
| 2017 January | 0 | 1 | 1 |
| 2015 November | 1 | 0 | 1 |
