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. |
ACE = angiotensin-converting enzyme, ARB = angiotensin II receptor blocker