Choice of antihypertensive agent

Choice of antihypertensive agents

• when implementing blockade of the renin-angiotensin system start treatment with an ACE inhibitor first then move to an ARB if the ACE inhibitor is not tolerated
• offer a low-cost renin-angiotensin system antagonist (ACE inhibitor or ARB) to people with CKD and:
  
  
  • diabetes and an ACR of 3 mg/mmol or more (ACR category A2 or A3)
    
    
  • hypertension and an ACR of 30 mg/mmol or more (ACR category A3)
    
    
  • an ACR of 70 mg/mmol or more (irrespective of hypertension or cardiovascular disease)
    
    
• do not offer a combination of renin-angiotensin system antagonists to people with CKD
  
  
• measure serum potassium concentrations and estimate the GFR before starting renin-angiotensin system antagonists. Repeat these measurements between 1 and 2 weeks after starting renin-angiotensin system antagonists and after each dose increase
  
  
• do not routinely offer a renin-angiotensin system antagonist to people with CKD if their pretreatment serum potassium concentration is greater than 5.0 mmol/litre
  
  
• when hyperkalaemia precludes use of renin-angiotensin system antagonists, assessment, investigation and treatment of other factors known to promote hyperkalaemia should be undertaken and the serum potassium concentration rechecked
  
  
• concurrent prescription of drugs known to promote hyperkalaemia is not a contraindication to the use of renin-angiotensin system antagonists, but be aware that more frequent monitoring of serum potassium concentration may be required
  
  
• stop renin-angiotensin system antagonists if the serum potassium concentration increases to 6.0 mmol/litre or more and other drugs known to promote hyperkalaemia have been discontinued
  
  
• following the introduction or dose increase of renin-angiotensin system antagonists, do not modify the dose if either the GFR decrease from pretreatment baseline is less than 25% or the serum creatinine increase from baseline is less than 30%
  
  
• if there is a decrease in eGFR or increase in serum creatinine after starting or increasing the dose of renin-angiotensin system antagonists, but it is less than 25% (eGFR) or 30% (serum creatinine) of baseline, repeat the test in 1-2 weeks. Do not modify the renin-angiotensin system antagonist dose if the change in eGFR is less than 25% or the change in serum creatinine is less than 30%
  
  
• if the eGFR change is 25% or more, or the change in serum creatinine is 30% or more:
  • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
  • if no other cause for the deterioration in renal function is found, stop the renin-angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if required

Reference:

• NICE (July 2014). Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care