Lisinopril and ACE inhibitors and allergen immunotherapy

I am not sure of the intent of this question. I assume you are asking if it would be advisable to hold lisinopril (ACE inhibitor) for 24 hours before allergen immunotherapy as a safety precaution. The practice parameter for allergen immunotherapy summarizes the literature as follows (1):

“Two retrospective studies found no increased frequency of systemic reactions in patients taking ACE inhibitors receiving VIT or inhalant immunotherapy. However, a few case reports and a prospective study of 962 patients who received VIT found that ACE inhibitors were associated with more severe reactions from VIT. This update recommends that ACE inhibitor discontinuation be considered for patients receiving VIT. However, concurrent administration of VIT and an ACE inhibitor is warranted in selected cases in which there is no equally efficacious alternative and the risk/benefit assessment is favorable.”

There are no data supporting value in discontinuing ACE inhibitors, angiotensin blocking therapy or beta blocking therapy immediately prior to an allergen injection, although this is a relatively common practice. There are risks in holding cardiovascular therapy, particularly with beta blockers. ACE inhibitor dose delay, if the blood pressure is well controlled, probably is not a major risk. There are no published data showing an increased risk of anaphylaxis with angiotensin receptor blockers (ARBs).

In summary, I would not recommend holding lisinopril for 24 hours before an allergen injection. I might consider holding a beta blocker therapy if the treatment was for hypertension or tremor and the conditions were well controlled. I would not delay a beta blocker therapy if the patient was receiving for an arrythmia. The practice parameters suggest that ACE inhibitors not be used concomitantly with immunotherapy if possible, but I generally will provide immunotherapy with a solid indication without changing cardiovascular medication unless the patient is at a higher risk of anaphylaxis, asthma for example. You may want to ask the primary care physician about changing the ACE inhibitor to an ARB. All of this information should be shared with your patient in a shared decision-making discussion.

1. Cox, Linda, et al. "Allergen immunotherapy: a practice parameter third update." Journal of Allergy and Clinical Immunology 127.1 (2011): S1-S55.

I hope this information is of help to you and your practice.
All my best.
Dennis K. Ledford, MD, FAAAAI