Letter to the Editor
Enteropathy by olmesartan
Enteropatía por olmesartán
Luis Téllez Villajos
, Laura Crespo Pérez, Ana Cano Ruiz, Víctor Moreira Vicente
Corresponding author
Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2015;144:139-40" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 178 "formatos" => array:2 [ "HTML" => 91 "PDF" => 87 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Enteropathy associated with chronic use of olmesartan" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "139" "paginaFinal" => "140" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enteropatía asociada al uso crónico de olmesartán" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Adrián Téllez, Martina Pellicé, Arturo Llobell, José César Milisenda" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Adrián" "apellidos" => "Téllez" ] 1 => array:2 [ "nombre" => "Martina" "apellidos" => "Pellicé" ] 2 => array:2 [ "nombre" => "Arturo" "apellidos" => "Llobell" ] 3 => array:2 [ "nombre" => "José César" "apellidos" => "Milisenda" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775314003431" "doi" => "10.1016/j.medcli.2014.03.031" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775314003431?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020615000443?idApp=UINPBA00004N" "url" => "/23870206/0000014400000003/v1_201510132016/S2387020615000443/v1_201510132016/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Enteropathy by olmesartan" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "140" "paginaFinal" => "141" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Luis Téllez Villajos, Laura Crespo Pérez, Ana Cano Ruiz, Víctor Moreira Vicente" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Luis" "apellidos" => "Téllez Villajos" "email" => array:1 [ 0 => "luistevilla@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Laura" "apellidos" => "Crespo Pérez" ] 2 => array:2 [ "nombre" => "Ana" "apellidos" => "Cano Ruiz" ] 3 => array:2 [ "nombre" => "Víctor" "apellidos" => "Moreira Vicente" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enteropatía por olmesartán" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Olmesartan medoxomil is a drug belonging to the angiotensin <span class="elsevierStyleSmallCaps">ii</span> type 1 receptor antagonist, which was approved in 2002 as a treatment for arterial hypertension. Although diarrhoea is a very frequent adverse effect in patients undergoing chronic drug treatment, the mechanisms by which it develops are mostly unknown. Enteropathy with villous atrophy has been previously associated with certain drugs, such as some immunosuppressants<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a>. In June 2012, Rubio-Tapia et al. reported 22 cases of enteropathy with villous atrophy in patients who were being treated with olmesartan medoxomil<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> and later, in May 2013, DeGaetani et al. described the case of a series of patients with intestinal villous atrophy with absence of coeliac disease, in which some of the patients, with no defined aetiology, either had been or were being treated with olmesartan<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a>. To date, there are few documented cases in the medical literature associating this drug with the onset of severe diarrhoea with significant weight loss, and most of these have histological analyses of the duodenum showing villous atrophy<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2–5</span></a>. As a result, in July 2013, the U.S. Food and Drug Administration issued an alert listing enteropathy as a severe side effect caused by olmesartan<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a>. In the following paragraphs, we describe a case diagnosed at our centre that presented severe diarrhoea with associated malnutrition.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 78-year old male who, in March 2013, consulted about diarrhoea of about one month evolution. His pathological history included longstanding, essential arterial hypertension that had been treated, for 8 years with 40 mg olmesartan administered on a daily basis. The patient had diarrhoea with 4 to 5 daily depositions, which were abundant and watery, but did not present blood, pus or mucous. Diarrhoea episodes intensified after meals and did not subside during night sleep. He had lost 10 kg over the previous 2 months and presented incapacitating asthenia. He had not travelled abroad or been in contact with people presenting similar symptoms. Physical examination indicated that his weight was 53.8 kg, with a BMI of 21. No lesions were detected on his skin or oral cavity. His blood test levels indicated: creatinine 4.2 mg/dl (0.5-1.1 mg/dl), potassium 2.7 mM/l (3.5-4.5 mM/l), pH 7.2 (7.35-7.45) and bicarbonate 13.8 mM/dl. Laboratory tests also indicated total proteins of 4.4 g/dl (6.4-8.3), retinol binding protein 2.95 mg/dl (3.0-6.0), albumin 2.57 g/dl (3.3-5.2), prealbumin 13.3 mg/dl (20.0-40.0), phosphorus 1.6 mg/dl (2.7-4.5), calcium 7.4 mg/dl (8.7-10.3), iron 23 ug/dl (65-175), with magnesium, folic acid and vitamin B<span class="elsevierStyleInf">12</span>, all within normal ranges. The haemogram showed anaemia, with Hb 9.8 g/dl (12-18). We ordered a complete microbiological study including the following: a total of 3 stool cultures, which showed regular flora for the sample, toxin and culture for <span class="elsevierStyleItalic">Clostridium difficile</span>, which were negative; no parasites were detected in the faeces. The serology for rotavirus and HIV, as well the serum DNA test for cytomegalovirus (CMV) were all negative; IgG through indirect immunofluorescence for <span class="elsevierStyleItalic">Leishmania</span>, negative; 3 determinations through immunochromatography for <span class="elsevierStyleItalic">Giardia Lamblia</span>, negative. Elastase and faecal calprotectin determination were within normal ranges. Alfa-1-antitrypsin clearance was 15.6 mg/g (<24), which, in the presence of diarrhoea, was not considered pathological. The patient underwent a colonoscopy, showing no signs of macroscopic disease, except for 2 small tubular adenomas with low grade dysplasia. His thyroid hormones, TSH, and blood sugar levels were within normal ranges, autoantibodies (ANA and anti-DNA) and tumour markers (CEA and CA 19-9) were all normal, and the complete serology for coeliac disease (IgA and IgG anti-transglutaminase and antiendomysial antibodies) was negative. The colon biopsies reported lymphocyte infiltration of the mucosa. The upper digestive endoscopy showed no macroscopic lesion and no <span class="elsevierStyleItalic">Helicobacter pylori</span> was detected in gastric antrum biopsies. Both the X-ray study of the small intestine with barium contrast and the computed tomography of the abdomen with intravenous contrast were normal. The hydrogen breath test with glucose did not find bacterial overgrowth. Histological analysis of the duodenum confirmed the presence of subtotal villous atrophy, crypt hyperplasia, intraepithelial lymphocytes increase and lamina propria plasmacytosis, all of these findings being compatible with type <span class="elsevierStyleSmallCaps">iii</span>A coeliac disease in the modified Marsh classification<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a>. The immunophenotypic study conducted on the intraepithelial lymphocytes of the patient's duodenal mucosa confirmed an increased percentage of lymphocytes of up to 24.9% (8%-12%) with respect to the total epithelium, whereas the TCR lymphocyte percentage was within the normal range, and the CD3- CD103+ lymphocyte percentage was 1.8% (>20%), thus indicating an absence off coeliac disease. However, and despite presenting histological and serological findings not conclusive of coeliac disease, the patient was put on a gluten-free diet but showed no improvement after a month. Consequently, the patient underwent further tests for IgA and IgG anti-enterocyte and anti-goblet cells and the results obtained were normal. The patient's HLA was DQB1*03 DQB1*13, ruling out coeliac disease. Given the lack of response to a gluten-free diet, the progressive weight loss of up to 20 kg, and the significant impact on blood test levels, the patient was instructed to resume a regular diet and to suspend treatment with olmesartan. Three weeks after having suspended the treatment, the patient remained asymptomatic, and blood test levels normalised. Six months later, the patient remains completely asymptomatic from a digestive viewpoint, without anaemia, and with a weight gain of 5 kg; he had an upper digestive endoscopy performed with duodenal biopsies that confirmed a normal pattern of intestinal villous, and an intraepithelial lymphocyte immunophenotypic study, all of them within normal ranges.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In conclusion, enteropathy induced by olmesartan is an infrequent entity, probably not widely known and, therefore, underdiagnosed. As confirmed by the case presented here, which was diagnosed at our centre, and from our review of the medical literature published to date, the patient had chronic diarrhoea that developed months or even years after initiating olmesartan treatment, associated with significant weight loss and fundamental histological changes in the duodenum, with villous atrophy, in the colon and digestive organs. Drug discontinuation results in a clinical improvement, seen in weeks, and histological normalisation of the intestinal mucosa, although the latter is not necessary to confirm the diagnosis. In light of the above, it is crucial to include chronic treatment with olmesartan in the differential diagnosis of unexplained chronic diarrhoea and intestinal villous atrophy refractory to a gluten-free diet.</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 Villajos L, Crespo Pérez L, Cano Ruiz A, Moreira Vicente V. Enteropatía por olmesartán. Med Clin (Barc). 2015;144:140–141.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Villous atrophy induced by mycophenolate mofetil in renal-transplant patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Kamar" 1 => "P. Faure" 2 => "E. Dupuis" 3 => "O. Cointault" 4 => "K. Joseph-Hein" 5 => "D. Durand" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00147-004-0745-0" "Revista" => array:6 [ "tituloSerie" => "Transpl Int" "fecha" => "2004" "volumen" => "17" "paginaInicial" => "463" "paginaFinal" => "467" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15322747" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "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:1 [ "Revista" => array:5 [ "tituloSerie" => "May Clin Proc" "fecha" => "2012" "volumen" => "87" "paginaInicial" => "732" "paginaFinal" => "738" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "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" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "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" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "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" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "U. S. Food and Drug Administration. Drug Safety and Availability. FDA Drug Safety Communication: FDA approves label changes to include intestinal problems (sprue-like enteropathy) linked to blood pressure medicine olmesartan medoxomil. Available from: <a href="http://www.fda.gov/Drugs/DrugSafety/ucm359477.htm">http://www.fda.gov/Drugs/DrugSafety/ucm359477.htm</a>." ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Institute technical review on the diagnosis and management of celiac disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Rostom" 1 => "J.A. Murray" 2 => "M.F. Kagnoff" 3 => "American Gastroenterological Association (AGA)" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.gastro.2006.10.004" "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "2006" "volumen" => "131" "paginaInicial" => "1981" "paginaFinal" => "2002" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17087937" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014400000003/v1_201510132016/S2387020615000571/v1_201510132016/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014400000003/v1_201510132016/S2387020615000571/v1_201510132016/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020615000571?idApp=UINPBA00004N" ]
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