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Medicines Monitoring

ACE inhibitors and angiotensin II receptor blockers monitoring

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Topics: AzilsartanCandesartanCaptopril · EnalaprilEprosartanFosinoprilImidaprilIrbesartanLisinoprilLosartanMonitoringOlmesartanPerindoprilQuinaprilRamiprilTelmisartanValsartan ·
Using this page · Individualise medicines monitoring

This medicines monitoring page has been written using publications and expert opinion. It is designed to save clinician time, but not replace professional responsibility. When using this page you should: ensure an individualised monitoring plan is developed in partnership with the patient and take account of any locally agreed advice and guidance.

Contents
  1. Before starting
    1. Required
  3. After started or dose changed
    1. Heart failure
    2. Heart failure with other risk factors
    3. Hypertension
    4. Hypertension with other risk factors
    5. Post myocardial infarction
  5. Ongoing once stable
    1. Heart failure
    2. Hypertension
    3. Post myocardial infarction
  7. Abnormal results
    1. Potassium (Heart failure)
    2. Potassium (Hypertension)
    3. Sodium
    4. Renal function (Heart failure)
    5. Renal function (Hypertension)
  9. Bibliography
  10. Update history

Before starting

Required

  • Baseline
    • Blood pressure
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Serum potassium
    • Serum sodium

Caution in patients with CKD and raised potassium

Initiation not normally appropriate if pre-treatment potassium greater than 5.0mmol/L

Seek specialist advice for some patients

Seek specialist advice prior to initiation for patients where there is:

  • severe or unstable heart failure
  • renovascular disease
  • eGFR less than 30ml/min/1.73m2
  • hyponatraemia (sodium less than 130mmol/L)
  • hypovolaemia
  • hypotension (systolic blood pressure less than 90mmHg)
  • concomitant multiple or high-dose diuretics (equivalent to 80mg furosemide daily or more)
  • concomitant high-dose vasodilator
  • haemodynamically significant valve disease

After started or dose changed

Heart failure

  • Within 1 - 2 weeks, then monthly for 3 months
    • Blood pressure
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Serum sodium
    • Serum potassium

Repeat monitoring at any time patient acutely unwell.

Heart failure with other risk factors

  • Within 5 - 7 days, then monthly for 3 months
    • Blood pressure
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Serum sodium
    • Serum potassium

Other risk factors

Other risk factors includes people:

  • with existing CKD stage 3 or higher
  • aged 60 years or over
  • with relevant co-morbidities such as diabetes mellitus or peripheral arterial disease
  • taking a combination of an ACE-inhibitor (ACEI) plus a diuretic or an aldosterone antagonist

Hypertension

  • Within 1 - 2 weeks
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Serum sodium
    • Serum potassium
  • Within 1 month
    • Blood pressure

Hypertension with other risk factors

  • Within 7 days
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Serum sodium
    • Serum potassium
  • Within 1 month
    • Blood pressure

Other risk factors

Other risk factors includes people:

  • with or at risk of hyperkalaemia
  • with deteriorating renal function (such as with, peripheral vascular disease, diabetes mellitus, pre-existing renal impairment or older people)

Post myocardial infarction

  • Within 1 - 2 weeks
    • Blood pressure
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Serum sodium
    • Serum potassium

Increasing monitoring frequency for some patients at increased risk of renal impairment

Myocardial infarction patients at increased risk of deterioration of renal function may need more frequent monitoring than normal.

Ongoing once stable

Heart failure

  • 6 monthly
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Serum sodium
    • Serum potassium

Repeat monitoring at any time patient acutely unwell.

Increasing monitoring frequency for some patients at increased risk

Consider more frequent monitoring (for example every 3 months) when there are concerns regarding the person’s clinical condition, concomitant drugs, or co-morbidities.

Hypertension

  • Annually
    • Serum sodium
    • Serum potassium
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)

Post myocardial infarction

  • Annually
    • Blood pressure
    • Serum sodium
    • Serum potassium
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)

Increasing monitoring frequency for some patients at increased risk of renal impairment

Myocardial infarction patients at increased risk of deterioration of renal function may need more frequent monitoring than normal.

Abnormal results

Some increase in serum creatinine and potassium levels is expected after starting or increase the dose of an ACEI.

Potassium (Heart failure)

Value between 5.0 – 5.5 mmol/L

  • May continue ACEI/ARB. If increase persists, investigate other causes of hyperkalaemia and treat accordingly.
  • Review concurrent medication that may increase potassium.

Value between 5.5 – 6.0 mmol/L

  • Stop ACEI/ARB and seek specialist advice.
  • Review concurrent medication that may increase potassium.

Value above 6.0 mmol/L

  • Stop ACEI/ARB and other drugs that may increase potassium and seek urgent specialist advice.

Potassium (Hypertension)

Value between 5.0 – 5.9 mmol/L

  • Investigate other causes of hyperkalaemia and treat accordingly.
  • Stop or reduce the dose of potassium-sparing diuretics or nephrotoxic drugs, such as NSAIDS.
  • If level persists despite these measures, reduce ACEI/ARB dose and review in 5 – 7 days.

Value above 6.0 mmol/L

  • Stop ACEI/ARB and other drugs that may increase potassium and seek urgent specialists advice.

Sodium

Value is below 132mmol/L

  • Obtain specialist advice

Renal function (Heart failure)

eGFR decrease less than 25%; creatinine increase less than 30%

  • No further action needed

eGFR decrease more than 25%; creatinine increase more than 30%

  • Remeasure renal function within 1 – 2 weeks
  • Investigate other causes of deteriorating renal function, such as volume depletion
  • Stop or reduce the dose of the following concomitant drugs (where appropriate):
      • nephrotoxic drugs
      • vasodilators
      • potassium supplements or potassium-sparing diuretics
      • diuretics (consider dose reduction if patient hypovolaemic)

If the decrease in eGFR or the increase in serum creatinine level persists despite these measures:

  • Stop the ACEI/ARB, or
  • Reduce dose to a previously tolerated dose and remeasure renal function in 5 – 7 days

eGFR less than 30ml/min/1.73m2 ; creatinine increase more than 30 – 50% or level greater than 200 micromol/L

  • Review volume status and temporarily reduce dose of ACEI/ARB, or
  • Stop diuretic (if applicable) or ACEI/ARB

eGFR 20-25ml/min/1.73m2 ; creatinine increase between 50 – 100% or level greater than 256 micromol/L

  • Reduce dose or stop diuretic (if applicable), and / or
  • Stop ACEI/ ARB and consider specialist referral

eGFR less than 20 ml/min/1.73m2 ; creatinine increase greater than 100% or level greater than 310 micromol/L

  • Stop ACEI/ARB and refer to specialist

If there is a significant decline in the eGFR consider the possibility of renal artery stenosis and refer for specialist assessment.

Renal function (Hypertension)

eGFR decrease less than 25%; creatinine increase less than 30%

  • Continue ACEI/ARB
  • Recheck renal function in 1-2 weeks

eGFR decrease more than 25%; creatinine increase more than 30%

  • Investigate other causes of deteriorating renal function, such as volume depletion.
  • Consider concurrent medication which could contriubute to deterioration in renal function, and stop or reduce the dose where possible, for example:
    • nephrotoxic drugs
    • vasodilators
    • potassium supplements or potassium-sparing diuretics
    • diuretics

If the decrease in eGFR or the increase in serum creatinine levels persists despite these measures

  • Stop ACEI/ARB, or reduce to a previously tolerated lower dose.
  • Recheck renal function in 5-7 days
  • Add an alternative antihypertensive medication if required.

Bibliography

Update history

  1. Full review and update complete. Amendments made on how to manage abnormal potassium and renal function results to reflect current advice. Layout of abnormal results sections split up by indication.
  1. Error under Renal function corrected: now says eGFR less than 20ml/min/1.73m2
  1. Link to "sick day" guidance updated.
  1. Published

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