{"id":8414,"date":"2024-06-07T09:00:43","date_gmt":"2024-06-07T09:00:43","guid":{"rendered":"https:\/\/www.kauveryhospital.com\/ima-journal\/?p=8414"},"modified":"2025-04-09T10:31:12","modified_gmt":"2025-04-09T10:31:12","slug":"telmisartan-associated-sprue-like-enteropathy","status":"publish","type":"post","link":"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-june-2024\/telmisartan-associated-sprue-like-enteropathy\/","title":{"rendered":"Telmisartan Associated Sprue Like Enteropathy"},"content":{"rendered":"<p class=\"caps\">[vc_row][vc_column][vc_column_text]<\/p>\n<h2><b>CASE STUDY: <\/b><\/h2>\n<p style=\"text-align: left;\">A 40 years old gentleman with the known case of systemic hypertension for 5 years on\u00a0treatment with Telmisartan and Metoprolol, presented with semisolid consistency of\u00a0stools 5 to 6 episodes per day for past 1 year. Initially he was treated with the Anti\u00a0diarrheal, Luminal antibiotics in the first two OPD reviews. He was suggested to do stool\u00a0tests including Stool routine microscopy, Fecal calprotectin and baseline bloods\u00a0includes CBC, LFT, Thyroid profile and Serum electrolytes which were normal. CT\u00a0abdomen revealed no abnormalities. Hence he was suggested to undergo endoscopy\u00a0and colonoscopy as there was no symptomatic relief. OGD revealed mildly edematous\u00a0mucosa in the D2. D2 biopsy was taken and sent for HPE reports. D2 biopsy revealed\u00a0increased Intraepithelial lymphocytosis and partial villous blunting in D2 mucosa.\u00a0Colonoscopy was normal.<\/p>\n<p style=\"text-align: left;\">In view of Sprue like histology patient was asked to do serum IgA Anti Tissue Transglutaminase Enzyme (TTG) test done to rule out celiac disease and it was negative. On reviewing the regular medication list patient was suggested to withhold Telmisartan. After cardiac consultation Calcium Channel Blockers were initiated in place of Telmisartan, patients\u2019s diarrhoea improved over 1 month. He was able to tolerate gluten diet during this period. Hence, the diagnosis was Telmisartan associate sprue like enteropathy was concluded.<\/p>\n<h2><b>DISCUSSION: <\/b><\/h2>\n<p style=\"text-align: left;\">Case reports have shown that the Angiotensin Receptor Blockers (ARB) induced Sprue\u00a0Like Enteropathy (SLE) is a condition present with diarrhoea due to mucosal\u00a0malabsorption. It affects both men and women equally. In general SLE presents with the\u00a0symptoms like chronic diarrhoea associated with the weight loss in most cases and the\u00a0other symptoms may include fatigue, nausea, vomiting, abdominal pain.<\/p>\n<p style=\"text-align: left;\">Increased CD8 + T cells and IL \u2013 15 over expression in the duodenal epithelial cells has\u00a0been noted to represent immune mediated injury (reference 1)<\/p>\n<p style=\"text-align: left;\">Immune injury is postulated to be the cause of Sprue Like Enteropathy as symptoms onset has a latent period of month to years after drug initiation. Insidious immune injury to the villi has been postulated as cause for delayed onset symptoms.<\/p>\n<p style=\"text-align: left;\">Upper GI scopy suggestive of villous atrophy has been noted in previous case reports\u00a0(Eg : Scalloping which improves with withdrawal of drug ) (reference 2)<\/p>\n<p style=\"text-align: left;\">Duodenal histology in sprue like Enteropathy due to Angiotensin Receptor Blockers has\u00a0been characterized to have increased Intestinal Intraepithelial lymphocytosis in 71%\u00a0cases, Eosinophilic infiltrates in 50% cases (reference 3)<\/p>\n<p style=\"text-align: left;\">Increased number of cases of Sprue Like Enteropathy secondary to Angiotensin\u00a0Receptor Blockers based therapies other than Olmesartan suggest that this adverse\u00a0event is a class effect of sartans rather than a individual drug.<\/p>\n<p style=\"text-align: left;\">Discontinuation of treatment is most effective way to treat symptoms and also helps to\u00a0confirm diagnosis.<\/p>\n<p><b>ENDOSCOPIC FINDINGS IN OUR PATIENT<\/b><\/p>\n<h2><u><b><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-8422\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-1.jpg\" alt=\"\" width=\"450\" height=\"365\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-1.jpg 569w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-1-300x244.jpg 300w\" sizes=\"auto, (max-width: 450px) 100vw, 450px\" \/><\/b><\/u><\/h2>\n<p><b><u>Image 1<\/u> : <\/b>Mild edematous mucosa noted in the 2nd part of duodenum<\/p>\n<h2><u><b><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-8423\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-2.jpg\" alt=\"\" width=\"450\" height=\"363\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-2.jpg 613w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-2-300x242.jpg 300w\" sizes=\"auto, (max-width: 450px) 100vw, 450px\" \/><\/b><\/u><\/h2>\n<p><b><u>Image 2<\/u> : <\/b>Colonoscopy showed no significant abnormalities in mucosa\u00a0upto terminal Ileum<\/p>\n<p><b>PHOTOMICROGRAPHS \u2013 DUODENAL HPE <\/b><\/p>\n<h2><u><b><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-8424\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-3.png\" alt=\"\" width=\"525\" height=\"429\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-3.png 702w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-3-300x245.png 300w\" sizes=\"auto, (max-width: 525px) 100vw, 525px\" \/><\/b><\/u><\/h2>\n<p><b><u>Image 3<\/u> : <\/b>Increased Intraepithelial lymphocytes in D2<\/p>\n<h2><u><b><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-8425\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-4.jpg\" alt=\"\" width=\"525\" height=\"380\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-4.jpg 688w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/image-4-300x217.jpg 300w\" sizes=\"auto, (max-width: 525px) 100vw, 525px\" \/><\/b><\/u><\/h2>\n<p><b><u>Image 4<\/u> : <\/b>Partial villous blunting in the D2<\/p>\n<h2><u><b>CONCLUSION: <\/b><\/u><\/h2>\n<p style=\"text-align: justify;\">All sprue may not be celiac or tropical sprue. Drug induced Sprue need to be kept in the\u00a0mind. Every prescription of the patient must be clearly scrutinized to find the possible\u00a0offending agents in the case of Chronic diarrhoea.<\/p>\n<p style=\"text-align: left;\">This case report illustrates a dramatic improvement in the diarrhoea once Telmisartan\u00a0was stopped.<\/p>\n<p style=\"text-align: left;\">Careful drug history helps in the diagnosis and treatment of Drug Induced Diarrhoea.<\/p>\n<h2><strong>REFERENCES:<\/strong><\/h2>\n<p>1. Cyrany J, Vasatko T, Machac J, Nova M, Szanyi J, Kopacova M. Letter: Telmisartan-associated enteropathy \u2013 is there any class effect? Aliment Pharmacol Ther. 2014;40(5):569\u2013570. Doi: 10.1111\/apt.12850. [PubMed] [CrossRef] [Google Scholar]<br \/>\n2. Solano-Iturri G, Garc\u00eda-Jim\u00e9nez N, Solano-Iturri JD, et al.. Olmesartan-associated sprue-like enteropathy: an emerging cause of drug-induced chronic diarrhea. Rev Gastroenterol Mex 2018;83:71\u20132. 10.1016\/j.rgmxen.2017.03.009 [PubMed] [CrossRef] [Google Scholar]<br \/>\n3. Marhne Costett et al duodenal histology in SLE to ARB ,Italy, Diarrhoea and liver disease Journal, volume 53,issue 10,Oct 2021,Page 1262 \u2013 1267<\/p>\n<p>&nbsp;<\/p>\n<h3><b>AUTHOR: <\/b><\/h3>\n<p><img decoding=\"async\" class=\"alignleft\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2022\/01\/DrArvindJanardhanan-150x150.jpg\" alt=\"\" \/><b>DR.M.A.Aravind, <\/b><br \/>\n<em>Senior Consultant, Medical Gastroenterologist<\/em><br \/>\nKauvery Hospital, Alwarpet,<br \/>\nChennai[\/vc_column_text][vc_empty_space][vc_column_text]<\/p>\n<h3><b>CO \u2013 AUTHOR:<\/b><\/h3>\n<p><strong><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-8472 size-full\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2024\/06\/Jennithau-Joan-of-Arck.jpg\" alt=\"\" width=\"138\" height=\"175\" \/>A.Jennithau Joan of Arck,<\/strong><br \/>\nBsc.Physician Assistant intern,<br \/>\nKauvery Hospital, Chennai[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][vc_column_text] CASE STUDY: A 40 years old gentleman with the known case of systemic hypertension for 5 years on\u00a0treatment with Telmisartan and Metoprolol, presented with semisolid consistency of\u00a0stools 5 to<\/p>\n","protected":false},"author":2,"featured_media":8415,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[76],"tags":[],"class_list":["post-8414","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ima-journal-june-2024"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Telmisartan Associated Sprue Like Enteropathy<\/title>\n<meta name=\"description\" content=\"A 40 years old gentleman with the known case of systemic hypertension for 5 years 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