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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
    2. Sodium
    3. Renal function
    4. Patients with Chronic Kidney Disease
  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

  • Before and after each dose change
    • Blood pressure
  • Within 1 - 2 weeks
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Serum sodium
    • Serum potassium

Repeat monitoring at any time patient acutely unwell or their renal function may be compromised.

Heart failure with other risk factors

  • Within 5 - 7 days
    • 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

  • Every 3 - 6 months
    • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Serum sodium
    • Serum potassium

Repeat monitoring at any time patient acutely unwell or their renal function may be compromised.

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 increasing the dose of an ACEI or ARB.

Potassium

Value above 5.5 mmol/L

  • Follow local guidelines

Value 6.0 mmol/L or above in people with CKD

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

Sodium

Value is below 132mmol/L

  • Obtain specialist advice

Renal function

Creatinine increase more than 50%

  • Follow local guidelines

Creatinine increase more than 50% (Heart failure)

  • Follow local guidelines
  • A transient decrease in renal function should not prompt stopping ACEI/ARB

An increase in serum creatinine of less than 50% above baseline, as long as it is less than 266 micromol/L, or a decrease in eGFR of less than 10% from baseline, as long as eGFR is over 25 mL/min/1.73 m2, can be considered as acceptable.

Patients with Chronic Kidney Disease

eGFR decrease less than 25% or creatinine increase less than 30% from baseline

  • Do not change dose
  • Repeat test in 1 to 2 weeks and if the change in eGFR remains less than 25% or the change in serum creatinine remains less than 30% do not change the ACEI/ARB dose

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

  • Investigate other causes of deteriorating renal function, such as volume depletion or concurrent medication such as, NSAIDs.
  • If no alternative cause is identified:
    • Stop ACEI/ARB or reduce to previously tolerated dose
  • Add another antihypertensive medication if needed

Bibliography

Update history

  1. Updated to bring in line with updated version of NICE NG106 (Chronic heart failure) resulting in abnormal results section being streamlined.
  1. Republished
  2. 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