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