drugs affecting renin angiotensin system (hypertension)

Question 1

use of ACEi in HF

(bonus - state HF treatment)

Answer 1

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)

Question 2

true or false - potassium supplements and potassium sparing diuretics (SEAT) should be discontinued before introducing ACEi because of risk of hyperkalaemia

Answer 2

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)

Question 3

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?

Answer 3

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.

Question 4

ACEi first line for hypertension is appropriate for …..

Answer 4

ANY patient with T2D
Any NON-black patient WITHOUT T2D under 55

Question 5

3 types of patient that may respond less well to ACEi

Answer 5

black african/afro carribbean
over 55
primary aldosterism

Question 6

ACEi are particularly indicated for hypertension in patients with ….

Answer 6

T1D with nephropathy
they are renoprotective in diabetes

Question 7

true or false - do ACEi have a role in management of diabetic nephropathy

Answer 7

yes

Question 8

True or false - ACEi are used in the early and long term management of pt who have had a MI

Answer 8

True
also may have role in preventing CV events

Question 9

ACE/ARB and aliskerin - 2 important notes

Answer 9

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

Question 10

what needs to be checked before starting ACEi or increasing dose

Answer 10

• renal function and electrolytes before
• also monitor during treatment, more freq if features of nephrotoxicity or electrolyte disturbances present

Question 11

ACEi - concomitant treatment with NSAIDs and potassium sparing diuretics

Answer 11

Concomitant treatment with NSAIDs increases the risk of renal damage, and potassium-sparing diuretics (or potassium-containing salt substitutes) increase the risk of hyperkalaemia.

Question 12

Why should NSAID combined with ACE be avoided

Answer 12

increased risk of renal damage

Question 13

are ACE recommended in pt with severe bilateral renal artery stenosis

Answer 13

no
they will reduce or abolish GFR and are likely to cause severe and progressive renal failure

Question 14

concomitant use of ACEi and diuretics

Answer 14

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

Question 15

Why are ARBs less likely to cause cough than ACEi?

Answer 15

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

Question 16

name some ARBs

Answer 16

losartan, valsartan, candesartan (these are licensed in HF)
others include irebsartan, olmesartan, telmisartan etc

Question 17

Use of ACE PLUS ARB not recommended. However can be initiated under SPECIALIST supervision only. Which ARBs are licensed as adjuncts to ACEi in management of HF when other treatments unsuitable?

Answer 17

candesartan
valsartan

Question 18

name a renin INHIBITOR licensed for treatment of hypertension

hint - contraindicated in hereditary or idiopathic angioedema, concomitant ACE/ARB in pt with eGFR less than 60, concomitant ACE or ARB in pt with DM

Answer 18

aliskerin

Question 19

why is combination therapy with two drugs affecting the renin-angiotensin system (ACE inhibitors, angiotensin-II receptor antagonists, and aliskiren) not recommended

Answer 19

increased risk of hyperkalaemia, hypotension, and renal impairment, compared to use of a single drug.

Question 20

Patients with …………… are particularly susceptible to developing hyperkalaemia and should not be given an ACE inhibitor with an angiotensin-II receptor antagonist

Answer 20

diabetic nephropathy

Question 21

MOA ACEi

Answer 21

inhibit conversion of angiotensin 1 to angiotensin 2