ACE inhibitors and ARBs: Managing potassium and renal function

Tasnim Momoniat; Duha Ilyas; Sunil Bhandari

doi:10.3949/ccjm.86a.18024

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Figure 1
The renin-angiotensin-aldosterone system and drugs that inhibit it.

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TABLE 1

Our advice for managing patients receiving ACE inhibitors or ARBs

Before starting or changing the dose

Review medications

Check baseline blood values of potassium, bicarbonate, and creatinine; assess proteinuria

Ensure patient is volume-replete

Do not start or increase the dose of a renin-angiotensin-aldosterone system inhibitor if serum potassium is elevated

Use an ACE inhibitor or ARB cautiously; start with a low dose and titrate upward slowly every 2 weeks if creatinine rises < 30% from baseline and GFR drops < 25%

Reduce dose if maximal doses are not tolerated (see below)

Repeat blood testing 10–14 days after starting or changing the dose

Check potassium and renal function after each dose escalation

If serum potassium is persistently > 5.0 mmol/L

Give dietary advice

Review medications again

Consider a thiazide or loop diuretic to reduce potassium level

Consider adding sodium bicarbonate if serum bicarbonate level is < 22 mmol/L

Remeasure potassium after 10–14 days

If > 5.0 mmol/L, continue

If 5.0–5.5 mmol/L, reduce dose and monitor closely

if >5.5 mmol/L, consider stopping

If renal function declines, ie, if creatinine rises > 30% from baseline or GFR drops > 25% after starting an ACE inhibitor or ARB:

Investigate for any other underlying cause, eg, bilateral renal artery stenosis

Repeat blood tests after 10–14 days

If no improvement, reduce dose by 50%

If still no improvement, reduce the dose further or stop the drug

For patients with illness or dehydration

Temporarily stop the ACE inhibitor or ARB, diuretics, and other antihypertensive and nephrotoxic drugs

Avoid medications that may impair renal function

Restart once symptoms resolve and the patient is rehydrated and biochemically stable

Recheck renal function after starting to ensure it remains stable

Ongoing monitoring

Continue to monitor once patient is established and stabilized on treatment with an ACE inhibitor or ARB according to the stage of their chronic kidney disease and heart failure, their medication history, and clinical condition. Monitoring every 3–6 months, as well as when patients have an intercurrent illness, is usually adequate.