2025 Southeastern Residency Conference

Title: Angioedema Resolution: Evaluation of Low Dose and High Dose Steroids
Authors: Cristina V. Martinez, Evan C. Hardbeck, Nicholas Filk, Neha Naik, Maria C. CreelBulos, Jasleen K. Bolina 


Background: According to the Centers for Disease Control, angioedema affects approximately 110,000 patients annually in the United States. Angioedema is characterized by self-limited swelling of the mucosal tissues in the face and larynx. It can become life-threatening if airway obstruction occurs, requiring prompt emergency care. Angioedema can be classified as either hereditary or acquired. In hereditary cases, swelling occurs due to a bradykinin response, whereas in acquired cases, it is triggered by a histamine response. Bradykinin-mediated angioedema is initially treated with a C1- esterase inhibitor, while histamine-mediated angioedema is managed with corticosteroids, antihistamines, and epinephrine. While corticosteroids are commonly used to treat angioedema there is a notable gap in current literature on optimal dosing strategies. This retrospective review aims to evaluate steroid use in angioedema patients by comparing low dose and high dose regimens to elucidate current practices, trends, and outcomes in symptom resolution.


Methods: This multicenter, retrospective, observational study included patients aged 18 years or older, diagnosed with angioedema, who received more than one dose of corticosteroids over a two-year period. Patients were excluded from the study if they were known to be pregnant or incarcerated. Patients were stratified into four groups based on their initial steroid agent and the secondary steroid treatment to which they were transitioned. Groups 1 and 2 received an initial high dose of steroids followed by a low dose in Group 2 or remained on high dose in Group 1. Groups 3 and 4 received an initial low dose followed by a high dose in Group 3 or remained on a low dose in Group 4. High dose was defined as an equivalent dose of hydrocortisone equal or greater to 250 mg. The primary objective of this study was resolution of angioedema, defined as discontinuation or de-escalation of steroid therapy, de-escalation of oxygen therapy, or documentation of resolution of symptoms. Secondary objectives included adjuvant angioedema treatments used, oxygen requirements over two days, incidence of intubation, hospital length of stay, ICU length of stay, and adverse effects including infection and hyperglycemia post steroid initiation.


Results: A total of 66 patients were categorized into four groups based on initial and subsequent steroid doses. The median time to angioedema resolution in the high dose to high dose group (Group 1) and the high dose to low dose group (Group 2) was 2 days. The low dose to high dose group (Group 3) had the shortest resolution time, with a median time of one day. In the low dose to low dose group (Group 4), the median time to resolution was 2.5 days. Group 1 included all patients who required intubation, accounting for 15% of the total study population. ICU length of stays was longest at 3 days in Group 1 followed by 2.5 and 1.5 days in Group 2 and 4 respectively. Additionally, patients in the higher dose regimen groups experienced higher rates of hyperglycemia and infection when compared to regimens with lower doses.


Conclusion: This study highlights the gap in current guidance for the use of corticosteroid dosing strategies for angioedema. While high dose regimens are commonly used, practitioners should assess patient specific factors due to increased risk of adverse effects with higher dosing regimens. Transitioning to lower doses may provide a safer and equally effective alternative. This area of practice calls for future research to develop standardized guidelines to optimize corticosteroid use in angioedema treatment, ensuring both efficacy and safety for patients.