choice of antihypertensive agent

Last reviewed 01/2018

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