Severe spruelike enteropathy associated with olmesartan.
OBJECTIVE
To report the response to discontinuation of olmesartan, an angiotensin II receptor antagonist commonly prescribed for treatment of hypertension, in patients with unexplained severe spruelike enteropathy.


METHODS
All 22 patients included in this report were seen at Mayo Clinic in Rochester, Minnesota, between August 1, 2008, and August 1, 2011, for evaluation of unexplained chronic diarrhea and enteropathy while taking olmesartan. Celiac disease was ruled out in all cases. To be included in the study, the patients also had to have clinical improvement after suspension of olmesartan.


RESULTS
The 22 patients (13 women) had a median age of 69.5 years (range, 47-81 years). Most patients were taking 40 mg/d of olmesartan (range, 10-40 mg/d). The clinical presentation was of chronic diarrhea and weight loss (median, 18 kg; range, 2.5-57 kg), which required hospitalization in 14 patients (64%). Intestinal biopsies showed both villous atrophy and variable degrees of mucosal inflammation in 15 patients, and marked subepithelial collagen deposition (collagenous sprue) in 7. Tissue transglutaminase antibodies were not detected. A gluten-free diet was not helpful. Collagenous or lymphocytic gastritis was documented in 7 patients, and microscopic colitis was documented in 5 patients. Clinical response, with a mean weight gain of 12.2 kg, was demonstrated in all cases. Histologic recovery or improvement of the duodenum after discontinuation of olmesartan was confirmed in all 18 patients who underwent follow-up biopsies.


CONCLUSIONS
Olmesartan may be associated with a severe form of spruelike enteropathy. Clinical response and histologic recovery are expected after suspension of the drug.
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
Alberto
A
Rubio-Tapia
Margot L
ML
Herman
Jonas F
JF
Ludvigsson
Darlene G
DG
Kelly
Thomas F
TF
Mangan
Tsung-Teh
TT
Wu
Joseph A
JA
Murray
D015746:Abdominal Pain / Q000139:chemically induced; D000368:Aged; D000369:Aged, 80 and over; D000740:Anemia / Q000175:diagnosis; D047228:Angiotensin II Type 1 Receptor Blockers / Q000009:adverse effects*; D001284:Atrophy / Q000139:chemically induced; D001706:Biopsy; D046728:Colitis, Microscopic / Q000139:chemically induced; D003094:Collagen / Q000032:analysis; D003967:Diarrhea / Q000139:chemically induced*; D005221:Fatigue / Q000139:chemically induced; D005260:Female; D005756:Gastritis / Q000139:chemically induced; D006760:Hospitalization; D006801:Humans; D034141:Hypoalbuminemia / Q000175:diagnosis; D007093:Imidazoles / Q000009:adverse effects*; D007249:Inflammation / Q000473:pathology; D007413:Intestinal Mucosa / Q000473:pathology; D007422:Intestines / Q000473:pathology*; D008214:Lymphocytes / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000139:chemically induced; D012720:Severity of Illness Index; D013270:Stomach / Q000473:pathology*; D013777:Tetrazoles / Q000009:adverse effects*; D014839:Vomiting / Q000139:chemically induced; D014883:Water-Electrolyte Imbalance / Q000175:diagnosis; D015431:Weight Loss / Q000187:drug effects; D015032:Zinc / Q000172:deficiency
D047228:Angiotensin II Type 1 Receptor Blockers; D007093:Imidazoles; D013777:Tetrazoles; C437965:olmesartan; D003094:Collagen; D015032:Zinc