drugs affecting renin angiotensin system (hypertension) Flashcards
use of ACEi in HF
(bonus - state HF treatment)
1st line treatment (mainly HF-REF): ACEi combined with BB
ACEi not tolerated? give ARB
still symptoms? + MRA
still symptoms? specialist re use of entresto, dapag, empag, ivabradine, amiodarone, digoxin
ACE
If ACE + ARB not tolerated - specialist re hydralazine + nitrate (esp black pt)
true or false - potassium supplements and potassium sparing diuretics (SEAT) should be discontinued before introducing ACEi because of risk of hyperkalaemia
true
BUT low dose spironolactone may be beneficial in severe HD and can be used with ACEi in treatment of HF as long as serum potassium is monitored carefully
(severe HF: monitor potassium and creatinine 1 week after initiation, after any dose increase, monthly for 3 months, then every 3 months for 1y, then every 6 months)
For patients on high doses of loop diuretics (e.g. furosemide 80 mg daily or more), the ACE inhibitor may need to be initiated under specialist supervision.
Why?
Profound first-dose hypotension may occur when ACE inhibitors are introduced to patients with heart failure who are already taking a high dose of a loop diuretic
Temporary withdrawal of the loop diuretic reduces the risk, but may cause severe rebound pulmonary oedema.
ACEi first line for hypertension is appropriate for …..
ANY patient with T2D
Any NON-black patient WITHOUT T2D under 55
3 types of patient that may respond less well to ACEi
black african/afro carribbean
over 55
primary aldosterism
ACEi are particularly indicated for hypertension in patients with ….
T1D with nephropathy
they are renoprotective in diabetes
true or false - do ACEi have a role in management of diabetic nephropathy
yes
True or false - ACEi are used in the early and long term management of pt who have had a MI
True
also may have role in preventing CV events
ACE/ARB and aliskerin - 2 important notes
contraindications to aliskerin treatment
Concomitant treatment with an ACE inhibitor or an angiotensin-II receptor antagonist in patients with an eGFR less than 60 mL/minute/1.73 m2
Concomitant treatment with an ACE inhibitor or an angiotensin-II receptor antagonist in patients with diabetes mellitus
what needs to be checked before starting ACEi or increasing dose
- renal function and electrolytes before
- also monitor during treatment, more freq if features of nephrotoxicity or electrolyte disturbances present
ACEi - concomitant treatment with NSAIDs and potassium sparing diuretics
Concomitant treatment with NSAIDs increases the risk of renal damage, and potassium-sparing diuretics (or potassium-containing salt substitutes) increase the risk of hyperkalaemia.
Why should NSAID combined with ACE be avoided
increased risk of renal damage
are ACE recommended in pt with severe bilateral renal artery stenosis
no
they will reduce or abolish GFR and are likely to cause severe and progressive renal failure
concomitant use of ACEi and diuretics
ACEi can cause a v rapid fall in BP in volume-depleted patients; treatment should therefore be initiated with very low doses
If diuretic >80mg furosemide or equivalent, initiate ACEi under close supervision; in some pt diuretic may need to be reduced or discont at least 24h before
If high dose diuretic therapy cannot be stopped (e.g. in HF due to risk of pulmonary oedema), close observation after first dose, for at least 2 hours or until BP has stabilised
Why are ARBs less likely to cause cough than ACEi?
unlike ACE inhibitors, they do not inhibit the breakdown of bradykinin and other kinins, and thus are less likely to cause the persistent dry cough
