Toxic megacolon and radiological FU

Q: A 23-year-old male is admitted to the ICU with a flare-up of his ulcerative colitis. CT scan in ED is consistent with Toxic Megacolon. Surgical service wrote for serial KUBs. What's the importance of serial KUBs in Toxic Megacolon?

Answer: May determine the course of toxic megacolon

Although CT is preferred over KUB in toxic megacolon, it's not practical to perform it every few hours. Instead, following clinical signs of toxicity with serial KUBs may help to determine the course of the disease. A progressive increase in small bowel gas on abdominal films may help determine whether toxic megacolon is worsening or improving. As the name implies, signs of clinical toxicity highly correlate with severity of toxic megacolon, such as fever, heart rate, neutrophilic leukocytosis, anemia, dehydration, mental status change, electrolyte abnormalities, and hypotension.

Also, an increase in small-bowel gas on abdominal films, or a changing pattern such as multiple air-fluid levels, may be helpful. If serial KUBs indicate treatment failure along with clinical signs, CT should be considered. Ultrasound has also been used successfully alongside serial KUBs.

#GI

#radiology

#surgical-critical-carew

References:

1. . Hokama A, Ohira T, Kishimoto K, et al. Impending megacolon: small bowel distension as a predictor of toxic megacolon in ulcerative colitis. Intern Emerg Med 2012; 7:487.

2. Arienti V, Campieri M, Boriani L, et al. Management of severe ulcerative colitis with the help of high resolution ultrasonography. Am J Gastroenterol 1996; 91:2163.

3. Moulin V, Dellon P, Laurent O, et al. Toxic megacolon in patients with severe acute colitis: computed tomographic features. Clin Imaging 2011; 35:431.

routes of succinylcholine

Q: 54-year-old male with severe vasculopathy started having seizures in the ICU and lost his IV access. After intramuscular benzodiazepine, the patient started losing his respiratory drive and started desaturating, though he continued to seize. Intubation is called, but due to seizure, may require Succinylcholine. Without IV access, it is OK to administer succinylcholine intramuscularly (IM).

A) True

B) False

Answer: A

Succinylcholine is a depolarizing neuromuscular blockade (NMB) with the fastest onset and shortest duration of all NMBs. Although Succinylcholine is designed and preferred to be given intravenously for Rapid Sequence Induction and Intubation (RSII), if the situation absolutely arises, it can be given IM at a higher dose of 3 to 4 mg/kg, though it may take up to 3-4 minutes for full effect, first reported almost 7 decades ago. 

It can be given intraosseously too and has been found to be comparable to the IV route (reference # 3)

Another less-known use of Succinylcholine is continuous infusion, mostly used in electroconvulsive therapy when a brief period of neuromuscular blockade is required, titrated to twitch depression.

#procedures

#pharmacology

References:

1. GLOWACKI ET, AUSTIN S, GREIFENSTEIN FE. Intramuscular doses of succinylcholine as an adjunct in anesthesia. Anesth Analg. 1958 Jul-Aug;37(4):211-6. PMID: 13583596.

2. VANDERVEEN JL, SNEDDON EA, SCHMIDT SJ. INTRAMUSCULAR SUCCINYLCHOLINE IN ADULTS. A CONTROLLED STUDY. Anesthesiology. 1963 Nov-Dec;24:765-9. doi: 10.1097/00000542-196311000-00003. PMID: 14071406.

2. Moore GP, Pace SA, Busby W. Comparison of intraosseous, intramuscular, and intravenous administration of succinylcholine. Pediatr Emerg Care. 1989 Dec;5(4):209-10. doi: 10.1097/00006565-198912000-00001. PMID: 2602189.

pericardiocentesis in PH patients

Q: Patients with which Pulmonary Hypertension Group (PH) have the highest chance of mortality from pericardial drainage? - select one

A) Group 1

B) Group 2

C) Group 3

D) Group 4

E) Group 5

Answer: A

One remarkable endeavor in pulmonary hypertension (PH) is its classification into five groups based on underlying pathology.

Group 1: Pulmonary Arterial Hypertension (PAH)

Group 2: PH Due to Left Heart Disease

Group 3: PH Due to Lung Diseases and/or Hypoxia

Group 4: Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

Group 5: PH With Unclear or Multifactorial Mechanisms

Although it is known that any patient with PH has a higher chance of hemodynamic collapse during pericardiocentesis, knowing the patient's underlying pathology may help in clinical decision-making if the situation arises. Patients with Group 1 have higher mortality rates compared with other non-PAH groups during such a procedure, with an adjusted odds ratio (aOR) of 2.35 and a 95% confidence interval (CI) of 1.46-3.80.

Some reports suggest that performing this procedure gradually, under the guidance of a Pulmonary Artery Catheter (PAC/Swan-Ganz), may help.

#pulmonary

#procedures

References:

1. Vasquez MA, Iskander M, Mustafa M, et al. Pericardiocentesis Outcomes in Patients With Pulmonary Hypertension: A Nationwide Analysis from the United States. Am J Cardiol 2024; 210:232.

2. Singh A, Mosarla R, Carroll K, Sulica R, Pashun R, Bangalore S, Yuriditsky E. Pericardiocentesis in Severe Pulmonary Arterial Hypertension Guided by a Pulmonary Artery Catheter. JACC Case Rep. 2024 May 1;29(12):102339. doi: 10.1016/j.jaccas.2024.102339. PMID: 38984206; PMCID: PMC11232420.

3. Cabada-Garcia MJ et.al. Safety of pericardiocentesis in pulmonary arterial hypertension: a systematic review. Front Cardiovasc Med. 2025 Aug 18;12:1610419. doi: 10.3389/fcvm.2025.1610419. PMID: 40901363; PMCID: PMC12400511.

iNO weaning

Q: A 54-year-old female is in the ICU due to Pulmonary Arterial Hypertension (PAH) and has been dependent on inhaled Nitric Oxide (iNO) for the last few days. Every time there is an attempt to wean and discontinue iNO, the patient becomes hemodynamically unstable. Which one trick may help to wean and discontinue iNO relatively easily?

Answer: Addition of sildenafil 

It is well known that abrupt discontinuation of inhaled NO, particularly in patients who are dependent on it for many days, can precipitate rapid rebound of pulmonary hypertension and worsening of ventilation/perfusion (V/Q) mismatch, resulting in hypoxemia and/or hemodynamic instability. Risks continue to rise after the first 10-12 hours of dependence, particularly in older patients.

One marker for weaning-related hemodynamic instability is a patient whose blood pressure and hemodynamics respond well at initiation. Responders are at higher risk of instability on discontinuation!

Overlapping weaning with coadministration of sildenafil may transit weaning smoothly, along with slow weaning, may be over the days. Also, keeping FiO2 higher during weaning may help.

#pulmonary

#pharmacology

References:

1. Atz AM, Wessel DL. Sildenafil ameliorates effects of inhaled nitric oxide withdrawal. Anesthesiology 1999; 91:307.

2. Khawaja H, Sanders TA, Schreiber M, Bondi D, Shah P, Brennan G. Sildenafil as Bridge Therapy for Inhaled Nitric Oxide in Preterm Neonates. J Pediatr Pharmacol Ther. 2024 Oct;29(5):525-529. doi: 10.5863/1551-6776-29.5.525. Epub 2024 Oct 14. PMID: 39411417; PMCID: PMC11472410.

K_Kidney-Liver connection

Q: What is the K-Kidney-Liver connection in hepatic encephalopathy?

Answer: Exacerbation of hepatic encephalopathy in hypokalemia 

Although all electrolytes need to be managed in hepatic encephalopathy, potassium plays an integral role. Hypokalemia increases kidney ammonia production, which directly exacerbates hepatic encephalopathy.

Other causes of acute exacerbation of hepatic encephalopathy are:

• Gastrointestinal bleeding
• Infection/sepsis 
• Metabolic alkalosis
• Renal insufficiency
• Hypovolemia
• Hypoxia
• Sedative
• Hypoglycemia
• Constipation
• Hepatocellular carcinoma 
• Hepatic vein or portal vein thrombosis

#hepatology

#neurology

#electrolyte

References:

1. Ullah H, Et.al.. Hypokalemia as a responsible factor related with the severity of hepatic encephalopathy: a wide multination cross-sectional study. Ann Med Surg (Lond). 2023 Jun 23;85(6):2427-2431. doi: 10.1097/MS9.0000000000000470. PMID: 37363515; PMCID: PMC10289733.

2. Javed MW, Ahmad E, Ahmad H, Nayyer ZA. IMPACT OF HYPOKALEMIA ON HEPATIC ENCEPHALOPATHY AND ITS EFFECT ON DURATION OF STAY IN HOSPITAL. J Ayub Med Coll Abbottabad. 2024 Jul-Sep;36(3):506-509. doi: 10.55519/JAMC-03-13014. PMID: 39623823.

3. Mikkelsen ACD, Thomsen KL, Vilstrup H, Aagaard NK. Hypokalaemia - an active contributor to hepatic encephalopathy? Metab Brain Dis. 2023 Jun;38(5):1765-1768. doi: 10.1007/s11011-022-01096-0. Epub 2022 Nov 3. PMID: 36326977.

VPA side effects

Q: Valproic Acid (VPA) overdose may cause? - select one

A) anion gap metabolic acidosis (AGA)

B) non-anion gap metabolic acidosis (NAGA)

Answer: A

VPA has seen renewed enthusiasm in US ICUs because of its efficacy in delirium. That also brings concern for VPA toxicity. Besides the dreaded complications of cerebral edema and subclinical hyperammonemia and Valproate-related hyperammonemic encephalopathy, popularly known as VHE, it can also cause significant electrolyte and metabolic abnormalities. The most common are

• hypernatremia
• hyperosmolality
• hypocalcemia, and 
• elevated anion gap metabolic acidosis

- Hypernatremia occurs because VPA is administered as a sodium salt.

- Hyperosmolality occurs because VPA and its metabolites are low-molecular-weight, osmotically active acids.

- AGA may occur from mitochondrial dysfunction, carnitine deficiency, and/or overproduction of toxic VPA metabolites, which are themselves anions.

- Hypocalcemia occurs as calcium binds to anionic VPA metabolites.

#toxicity

#electrolytes

References:

1. Khoo SH, Leyland MJ. Cerebral edema following acute sodium valproate overdose. J Toxicol Clin Toxicol 1992; 30:209. 

2. Sammar A, Tawfik M, Fatima F, Butler A, Aylor-Lee K. Valproate-Induced Hyperammonemic Encephalopathy Causing New-Onset Seizures. Cureus. 2023 Oct 18;15(10):e47288. doi: 10.7759/cureus.47288. PMID: 38021840; PMCID: PMC10656206.

3. Anderson, GO, Ritland, S. Life threatening intoxication with sodium valproate. Clin Toxicol 1995; 33:279.

CRRT and magnesium

Q: Use of Regional citrate anticoagulation in Continuous Renal Replacement Therapy (CRRT) will cause? - Select one

A) hypermagnesemia

B) hypomagnesemia

Answer: B

Regional citrate anticoagulation should be considered a major intervention in all patients requiring CRRT, as it may cause alkalosis due to citrate. The concentration of buffers, i.e.,  bicarbonate and lactate, should be reduced. Also, citrate can bind magnesium. Dialysate magnesium should be raised to 0.75 mmol/L from 0.5 mmol/L.

#procedures

#nephrology

References:

1. DePriest J, Dodson C, Phelps B. The Impact of Regional Citrate Anticoagulation on Magnesium Replacement During CRRT. Hosp Pharm 2023; 58:255.

2. Billiet N, Merckx L, van der Laenen M, Vanelderen P, Boer W. Magnesium profiles in renal replacement therapy (rrt) on icu: citrate CVVH (CICVVH) vs. intermittent haemodialysis (IHD). Intensive Care Med Exp. 2015 Oct 1;3(Suppl 1):A630. doi: 10.1186/2197-425X-3-S1-A630. PMCID: PMC4796953.

EKG and RVMI

Q: In acute Right Ventricular Myocardial Infarction (RVMI), which electrocardiogram (EKG) lead's ST-elevation has the highest sensitivity and specificity?

Answer: V4R

Patients with inferior-posterior ST-elevation MI mostly have RVMI, causing the classic triad of:

• hypotension
• elevated jugular venous pressure (JVP), and 
• clear lung fields

ST elevation >1 mm in lead V4R has> 90% sensitivity and specificity for scintigraphic evidence of RV infarction and 80% for echocardiographic evidence of RV dysfunction. A clinical pearl to remember is that the right-sided ST elevation is often transient, lasting less than 10 hours in 50% of patients with RV infarction.

#cardiology

References:

1. Watanabe S, Onuma J, Ishida R, Masuda R, Usui M. Clinical Significance of V4R ST-Segment Elevation on a Synthesized 18-Lead Electrocardiogram in Patients With Anterior ST-Segment Elevation Myocardial Infarction. Catheter Cardiovasc Interv. 2026 Jul;108(1):221-227. doi: 10.1002/ccd.70646. Epub 2026 Apr 26. PMID: 42036972.

2. Braat SH, Brugada P, de Zwaan C, et al. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J 1983; 49:368.

3. Candell-Riera J, Figueras J, Valle V, et al. Right ventricular infarction: relationships between ST segment elevation in V4R and hemodynamic, scintigraphic, and echocardiographic findings in patients with acute inferior myocardial infarction. Am Heart J 1981; 101:281.

SAH, SIADH and CSW

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Q: Hyponatremia in Subarachnoid hemorrhage (SAH) due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and cerebral salt wasting can be distinguished by? 

A) level of hyponatremia 

B) serum osmolality

C) urine sodium

D) urine osmolality 

E) intravascular volume status

Answer: E

Hyponatremia in SAH may occur via two mechanisms, i.e., SIADH or cerebral salt wasting. Both are physiologically distinct entities, but hard to differentiate. Both entities have similar levels of hyponatremia, low serum osmolality (<274 mosmol/kg), high urine sodium (>40 mEq/L), and high urine osmolality (>100 mosmol/kg).

  

The major distinguishing feature is intravascular volume status. Patients with SIADH are euvolemic or maybe even hypervolemic. In contrast, patients with cerebral salt wasting tend to be hypovolemic.

  

#electrolytes

#nephrology

#neurology

  

  

References:

  

1. Muehlschlegel S. Subarachnoid Hemorrhage. Continuum (Minneap Minn) 2018; 24:1623.

  

2. Sterns RH, Silver SM. Cerebral salt wasting versus SIADH: what difference? J Am Soc Nephrol. 2008 Feb;19(2):194-6. doi: 10.1681/ASN.2007101118. Epub 2008 Jan 23. PMID: 18216309.

DAPT score

Q: The DAPT (Dual antiplatelet therapy) score is created to decide whether DAPT should be started, continued, or stopped? - Select one

A) at the time of the insertion of coronary stents

B) in the event of major surgery while the patient is on DAPT

C) at 12 months after insertion of a coronary stent

D) in patients with major bleeding risk

Answer: C

The DAPT score was developed to determine whether extended DAPT (i.e., beyond 12 months) might be appropriate. The DAPT score is based on eleven variables:

• Age 
• Diabetes Mellitus
• Cigarette Smoking Within Last Two Years
• Prior Myocardial Infarction or Percutaneous Coronary Intervention
• History of Congestive Heart Failure or Left Ventricular Ejection Fraction lower than 30%
• Hypertension
• Renal Insufficiency
• Peripheral Arterial Disease
• Myocardial Infarction at Presentation
• Stenting of Vein Graft
• Stent Diameter less than 3mm

Entering the data into the calculator will show the change in Risk if DAPT is continued or discontinued.

*Calculator link in reference #3

#cardiology

References:

1. Tian J, Wang Z, Wang Y, et al. Extended Dual Antiplatelet Therapy for Multivessel Coronary Artery Disease. N Engl J Med 2026; 395:233.

2. Mihatov N, Secemsky EA, Kereiakes DJ, Steg G, Serruys PW, Chichareon P, Shen C, Yeh RW. Utility of the dual antiplatelet therapy score to guide antiplatelet therapy: A systematic review and meta-analysis. Catheter Cardiovasc Interv. 2021 Mar;97(4):569-578. doi: 10.1002/ccd.29352. Epub 2020 Oct 28. PMID: 33111495; PMCID: PMC8620187.

3. https://tools.acc.org/DAPTriskapp/#!/content/calculator/

Vanc in critically ill patients

Q: Critically ill patients may require ___________ vancomycin loading doses? - select one

A) higher

B) lower

Answer: A

Critically ill patients usually have a high volume of distribution, which may increase vancomycin clearance. These patients may require higher vancomycin loading doses up to 25 to 30 mg/kg to achieve optimal vancomycin levels, particularly in the initial phase of illness. 

In these patients, it should be kept in mind that concomitant renal insufficiency or the need for renal replacement therapy/dialysis may significantly alter the need. Close monitoring of peak and, particularly, trough levels should guide therapy.

#pharmacology

#ID

References:

1. Pongchaidecha M, Changpradub D, Bannalung K, et al. Vancomycin Area under the Curve and Pharmacokinetic Parameters during the First 24 Hours of Treatment in Critically Ill Patients using Bayesian Forecasting. Infect Chemother 2020; 52:573.

2. Ishigo T, Ibe Y, Fujii S, et al. Effect of renal clearance on vancomycin area under the concentration-time curve deviations in critically ill patients. J Infect Chemother 2023; 29:769.

3. Alsultan A, Dasuqi SA, Almohaizeie A, et al. External Validation of Obese/Critically Ill Vancomycin Population Pharmacokinetic Models in Critically Ill Patients Who Are Obese. J Clin Pharmacol 2024; 64:353.

Haloperidol vs Droperidol

Q: 52 years old male admitted to ICU for acute psychosis became violent towards medical staff. Pharmacy suggested Droperidol. How Droperidol is different from Haloperidol?

Answer: Droperidol has an advantage over haloperidol in that it has:

• more rapid onset of action 
• shorter duration of effect
• can be used as monotherapy
• IM works as well as IV 

Droperidol is an analog of haloperidol. It has an advantage over haloperidol, with a more rapid onset of action (3-10 minutes) and a shorter duration of action (2-4 hours). In contrast, the onset of action of haloperidol, whether given intravenously (IV) or intramuscularly (IM), occurs within 30 to 60 minutes, and the duration of action can last up to a full day. Droperidol can be given IV or IM; however, compared with haloperidol, IM droperidol is rapidly absorbed and is preferable if the patient is not cooperative enough to allow IV access. Administration of Haloperidol usually requires co-administration of other drugs such as benzodiazepines, whereas droperidol works well as a monotherapy. 

#psychiatry

#pharmacology

References:

1. Battaglia J. Pharmacological management of acute agitation. Drugs 2005; 65:1207.

2. Thomas H Jr, Schwartz E, Petrilli R. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med 1992; 21:407.

3. Knott JC, Taylor DM, Castle DJ. Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department. Ann Emerg Med 2006; 47:61.

4. Page CB, Parker LE, Rashford SJ, et al. A Prospective Before and After Study of Droperidol for Prehospital Acute Behavioral Disturbance. Prehosp Emerg Care 2018; 22:713.

Acute HIV lasting longer than 2 weeks

Q: A 24-year-old male who just returned from vacation presented to the ED with a mononucleosis-like illness. Given a history of unprotected sex while on vacation, an HIV test was sent, which unfortunately came back positive. Patient reports his symptoms have been lasting for the last three weeks. What's the importance of his acute HIV infection lasting longer than usual?

Answer: Correlate with more rapid progression to AIDS 

Symptoms of acute HIV infection are usually most like a mononucleosis-like illness with fever, lymphadenopathy, sore throat, rash, myalgia/arthralgia, diarrhea, and headache. 

It is rarely realized that up to 60 percent of patients who acquire HIV may never experience these symptoms, which is both good and bad! Good - because those patients whose symptoms are severe and last longer than the usual 2-week period are found to correlate with more rapid progression to AIDS. Bad - because they may not get diagnosed for a long time!

During the acute HIV phase, there is rapid viral replication and infection of CD4 cells, and the plasma viral RNA level is usually very high. There may also be a transient drop in CD4 cell count.

#ID

References:

1. Pedersen C, Lindhardt BO, Jensen BL, et al. Clinical course of primary HIV infection: consequences for subsequent course of infection. BMJ 1989; 299:154.

2. Chéret A. Acute HIV-1 Infection: Paradigm and Singularity. Viruses. 2025 Mar 3;17(3):366. doi: 10.3390/v17030366. PMID: 40143294; PMCID: PMC11945883.

3. Cowan E, Vail RM, Shah SS, et al. Diagnosis and Management of Acute HIV Infection [Internet]. Baltimore (MD): Johns Hopkins University; 2024 Dec. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563020/

Colchicine and pericarditis

Q: Colchicine is found to be effective in pericarditis caused by? - select one

A) systemic inflammatory diseases

B) bacterial pericarditis

C) malignancy-related pericarditis

Answer: A

Colchicine is widely used for pericarditis, but it should be reserved for specific situations. Its use may be particularly harmful in bacterial pericarditis, where it may impair the clearance of the infectious organism. Similarly, it has no role in malignancy-related pericarditis and/or pericardial effusion. Also, it is not recommended in patients with recurrent pericarditis.

Said above, colchicine is an effective treatment in acute idiopathic, viral, and pericarditis caused by systemic inflammatory diseases and post-cardiac injury & surgery patients. If used, it is recommended to continue for 12 weeks after an initial episode, though many patients may develop diarrhea, nausea, and vomiting. In such cases, the dose can be decreased. Rare side effects are bone marrow suppression and liver and muscle injuries. The dose should be adjusted for lower renal GFR.

#cardiology

#pharmacology

References:

1. Schulz-Menger J, Collini V, Gröschel J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J 2025; 46:3952.

2. Alabed S, Cabello JB, Irving GJ, et al. Colchicine for pericarditis. Cochrane Database Syst Rev 2014; :CD010652.

3. Imazio M, Brucato A, Belli R, et al. Colchicine for the prevention of pericarditis: what we know and what we do not know in 2014 - systematic review and meta-analysis. J Cardiovasc Med (Hagerstown) 2014; 15:840.

Transmission of human babesiosis

Q: Babesiosis is mostly transmitted by? - select one

A) blood transfusion

B) solid organ transplantation

C) transplacental

D) tick vectors

Answer: D

The objective of this question is to emphasize that babesiosis has increased considerably in the Northeast of the USA and is an emerging infectious disease of concern. 

The major cause is the rising deer population with concomitant increased tick density, due to lack of predators and insufficient culling of the herd. Another major reason is the expanding real estate in wooded areas.

Rash is the crucial differential diagnosis from Lyme disease, as rash rarely occurs in babesiosis. Both diseases may co-exist, though.

In its severe form, it can cause renal and liver insufficiency, ARDS, CHF, severe anemia, DIC, and shock. Spontaneous splenic rupture may occur from excessive erythrophagocytosis, a marker of high mortality.

#ID

References:

1. Krause PJ, Auwaerter PG, Bannuru RR, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA): 2020 Guideline on Diagnosis and Management of Babesiosis. Clin Infect Dis 2021; 72:185.

2.  Dumic I, Patel J, Hart M, et al. Splenic Rupture as the First Manifestation of Babesia Microti Infection: Report of a Case and Review of Literature. Am J Case Rep 2018; 19:335.

3. Krause PJ. Human babesiosis. Int J Parasitol. 2019 Feb;49(2):165-174. doi: 10.1016/j.ijpara.2018.11.007. Epub 2019 Jan 26. PMID: 30690090.

Angioedema Following Discontinuation of ACE Inhibitor Therapy

Q: Angioedema may occur even after Angiotensin Converting Enzyme inhibitor (ACE-I) is discontinued?

A) True

B) False

Answer: A

Although it is true that the only reliable treatment of ACE-I-induced angioedema is to discontinue it, it may take many months before it takes effect, and almost half of the patients may have a recurrent episode, particularly in the first month. Risk may get higher if the patient has any other reason to have angioedema.

#pharmacology

References:

1. Beltrami L, Zanichelli A, Zingale L, et al. Long-term follow-up of 111 patients with angiotensin-converting enzyme inhibitor-related angioedema. J Hypertens 2011; 29:2273.

2. Perman B, Narechania S, Malesker M. Geriatric Pharmacotherapy Case Series: Recurrent Angioedema Following Discontinuation of ACE Inhibitor Therapy. Sr Care Pharm. 2023 Jan 1;38(1):16-20. doi: 10.4140/TCP.n.2023.16. PMID: 36751921.