Letters to the Editor

Additional Side Effects of ACE Inhibitors

TO THE EDITOR: I would like to suggest two additions to the American Family Physician patient information handout on angiotensin-converting enzyme (ACE) inhibitors.¹ First, angioedema is a rare but potentially fatal complication of ACE inhibitor use. All persons who use ACE inhibitors should be informed of this side effect, which may occur more commonly in blacks. Second, more emphasis should be placed on exercising caution with the use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs may cause serious, potentially life-threatening hyperkalemia, especially in older patients who are the patients most likely to use both of these classes of drugs. It is important for physicians to educate their patients who are receiving ACE inhibitors about avoidance of over-the-counter NSAIDs.

JOHN W. GRAVES, M.D.
Division of Hypertension
Mayo Clinic
200 1st SW
Rochester, MN 55905

REFERENCE

1. Bicket DP. Using ACE inhibitors appropriately [Information from your family physician]. Am Fam Physician 2002;66:473-4.

Food Challenge vs. Skin Antigen Testing

TO THE EDITOR: I enjoyed reading the recent review article, "Allergy Testing."¹ The article provided useful and timely information, especially with the increasing incidence of asthma and other atopic diseases in the United States. However, the article did not fully describe the relevance and benefits of testing for food allergies.

Some evidence supports Dr. Li's statements that "percutaneous skin testing ... is less reliable for evaluating food allergy than for evaluating reaction to airborne allergens" and that "a double-blind food challenge should be considered when more clinical certainty is needed in diagnosing a serious food allergy." However, evidence also suggests that hypoallergenic diets are clinically useful for patients with atopic disease. In one study,² 91 percent of 322 children placed on a hypoallergenic diet had significant improvements in asthma or allergic rhinitis; food challenges reproduced symptoms 51 percent of the time, but skin tests with food allergens rarely correlated with these results. In another trial,³ 41 adults with severe asthma were randomized to either an antigen-free elemental diet or a control diet (both composed of blended food) under double-blind conditions. Patients treated with the elemental diet had significant improvement in their asthma scores.

These data support the hypothesis that food allergy is a significant component of atopic disease in some patients and also that challenge testing is superior to skin antigen testing. The diagnosis and treatment of both food and respiratory allergies is clinically useful, and we should be aware of any modalities that may benefit our patients.

MARK DERAMO, M.D.
UPMC St. Margaret & McKeesport Family Practice
Lawrenceville Family Health Center
3937 Butler St.
Pittsburgh, PA 15215

REFERENCES

1. Li JT. Allergy testing. Am Fam Physician 2002;66: 621-4.
2. Ogle KA, Bullock JD. Children with allergic rhinitis and/or bronchial asthma treated with elimination diet: a five-year follow-up. Ann Allergy 1980;44: 273.
3. Hoj L, Osterballe O, Bundgaard A, Weeke B, Weiss M. A double-blind controlled trial of elemental diet in severe, perennial asthma. Allergy 1981;36:257-62.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.