Acute Renal Failure Due to Sprue-Like Syndrome Induced by Olmesartan

Objective: Olmesartan is an antihypertensive, blocking angiotensin II receptor. It has an excellent tolerability profile but, more than other angiotensin II receptor inhibitors, it can cause severe sprue-like enteropathy (OAS). Although the first description of this syndrome dates back to 2012, still today, the diagnosis can be difficult; delay in the diagnosis can lead to the appearance of a severe clinical complicance. Design and method: We describe the case of acute renal failure in a patient on treatment with olmesartan. 79-year-old hypertensive female. From eight weeks presence of diarrhoea and a reduction of six kilograms. For this reason she had undergone a gastroenterological evaluation which had excluded thyroid, parasitological and celiac causes and had recommended coloscopy. For the subsequent finding of hypokalaemia (2.7 mM/L) and renal insufficiency (clearance of 11.8 ml/min 1.73 m2), patient was referred from the ED to our Unit. Patient underwent to clinical, biochemical, virological and instrumental tests, including coloscopy that excluded specific causes. Withdrawal of olmesartan resulted in diarrhea disappearing within a few hours. Patient was discharged in good condition, with normalization of kidney function. She received an ACE-I as antihypertensive therapy. At the 10-week outpatient follow-up, patient continues to have no diarrhea and has regained the lost weight. Results: Olmesartan can rarely cause severe enteropathy. Symptoms may appear months or years after starting treatment; this may contribute to the diagnostic delay. Diagnosis is substantially one of exclusion and, given the seriousness of the enteric symptoms, rechallenge is often not possible. Withdrawal of olmesartan usually results in termination of the syndrome within a few hours. In the case presented, the severity of the OAS led to the onset of severe renal insufficiency which hospitalization. Discontinuation of the drug led to the disappearance of the sprue-like symptoms already on the second day Conclusions: Although olmesartan is generally well tolerated, rarely, it can induce OAS and severe renal impairment as reported in our case report. In subjects treated with olmesartan it is necessary to consider the possibility of incurring OAS and to interrupt the therapy as soon as this clinical evidence is suspected.