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Severe Spruelike Enteropathy Associated With Olmesartan

Open AccessPublished:June 25, 2012DOI:



      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.

      Patients and 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.


      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.


      Olmesartan may be associated with a severe form of spruelike enteropathy. Clinical response and histologic recovery are expected after suspension of the drug.


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      Linked Article

      • Small Bowel Histopathologic Findings Suggestive of Celiac Disease in an Asymptomatic Patient Receiving Olmesartan
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          Rubio-Tapia et al1 recently reported a possible association of olmesartan therapy with an unexplained severe enteropathy symptomatically resembling celiac disease (CD) or sprue. The 22 patients described were seen at Mayo Clinic in the relatively short period of August 1, 2008, to August 1, 2011. The usual presentation was chronic diarrhea and weight loss, sometimes requiring hospitalization. Onset of symptoms was months to years after initiation of olmesartan treatment. Intestinal biopsy specimens from 15 patients revealed villous atrophy and variable degrees of mucosal inflammation.
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      • Olmesartan and Intestinal Adverse Effects in the ROADMAP Study
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          We read the article by Rubio-Tapia and colleagues1 with great interest. In this article, the authors describe the occurrence of severe spruelike enteropathy in 22 patients, all of whom received olmesartan (predominantly 40 mg/d) besides other drugs. All patients had long-lasting diarrhea (3-53 months) and weight loss (2.5-50 kg). Many patients also experienced nausea and vomiting (68% of patients), abdominal pain (50%), bloating (41%), and fatigue (68%). Interestingly, these symptoms disappeared after use of olmesartan was stopped.
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        • PDF