Interruption of prolonged ramipril treatment in hypertensive patients: effects on the renin-angiotensin system

Deprescribing in Palliative Cancer Care

The aim of palliative care is to maintain as high a quality of life (QoL) as possible despite a life-threatening illness. Thus, the prescribed medications need to be evaluated and the benefit of each treatment must be weighed against potential side effects. Medications that contribute to symptom relief and maintained QoL should be prioritized. However, studies have shown that treatment with preventive drugs that may not benefit the patient in end-of-life is generally deprescribed very late in the disease trajectory of cancer patients. Yet, knowing how and when to deprescribe drugs can be difficult. In addition, some drugs, such as beta-blockers, proton pump inhibitors, anti-depressants and cortisone need to be scaled down slowly to avoid troublesome withdrawal symptoms. In contrast, other medicines, such as statins, antihypertensives and vitamins, can be discontinued directly. The aim of this review is to give some advice according to when and how to deprescribe medications in palliative cancer care according to current evidence and clinical praxis. The review includes antihypertensive drugs, statins, anti-coagulants, aspirin, anti-diabetics, proton pump inhibitors, histamin-2-blockers, bisphosphonates denosumab, urologicals, anti-depressants, cortisone, thyroxin and vitamins.

Continuation of Angiotensin-Converting Enzyme Inhibitors on the Day of Surgery Is Not Associated With Increased Risk of Hypotension Upon Induction of General Anesthesia in Elective Noncardiac Surgeries

OBJECTIVE

The aim of this study was to find out whether the preoperative continuation of angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) treatment is associated with intraoperative hypotension immediately after induction of general anesthesia in elective noncardiac surgeries.

DESIGN

Retrospective cohort study.

SETTING

Single institutional university hospital.

PARTICIPANTS

Four hundred patients who underwent elective noncardiac surgery under general anesthesia, with ACE-I or ARB on their list of preoperative home medications, were included.

INTERVENTION

Preoperative ACE-I and ARB use was evaluated, and patients were divided into an ACE-I/ARB group versus non-ACE-I/ARB group.

MEASUREMENTS

The primary outcome measure was intraoperative hypotension after induction of general anesthesia. The secondary outcome measure was preoperative medication use, medications taken the morning of surgery, induction medication and dosage, and vasopressor medication use during induction.

RESULTS

Three hundred forty-nine patients were included for final analysis. The mean admission American Society of Anesthesiologists status was 2.7 ± 0.5, age 65 ± 11 years, and body mass index 31 ± 6.9 kg/m². There were no statistically significant changes between the no ACE-I/ARB group and the ACE-I/ARB group in systolic blood pressure (p = 0.853), diastolic blood pressure (p = 0.357), and heart rate (p = 0.220) change over the 15 minutes. There was no statistical difference in induction medication dose (propofol, fentanyl, and rocuronium) and pressor use (p = 0.137) for hypotension between the 2 groups. Statistically significant hypotension (p < 0.001) occurred in both groups equally over 15 minutes.

CONCLUSION

Continuation of ACE-I/ARB on the day of surgery was not associated with increased risk of intraoperative hypotension upon induction and within 15 minutes of general anesthesia in elective noncardiac surgeries.

Can ACE-I Be a Silent Killer While Normal Renal Functions Falsely Secure Us?

The current case report represents a warning against serious hyperkalaemia and acidosis induced by ACE-I during surgical stress while normal renal function could deceive the attending anaesthetist. Arterial gas analysis for follow-up of haemoglobin loss accidentally discovered hyperkalaemia and acidosis. Glucose-insulin and furosemide successfully corrected hyperkalaemia after 25 minutes and acidosis after 3 hours. These complications could be explained by a deficient steroid stress response to surgery secondary to suppression by ACE-I. Event analysis and database search found that ACE-I induced aldosterone deficiency aggravated by surgical stress response with an inadequate increase in aldosterone secretion due to angiotensin II deficiency as a sequel of ACE-I leading to defective secretion of H+ and K+. Furosemide is recommended to secrete H+ and K+ compensating for aldosterone deficiency in addition to other antihyperkalaemia measures. Anaesthetising an ACE-I treated patient requires considering ACE-I as a potential cause of hyperkalaemia and acidosis.

[Patient adherence in antihypertensive treatment]

Hypertension is one of the most frequent chronic diseases as well as most important cardiovascular risk factors in developed countries. Blood pressure control to target levels can significantly decrease the risk for development of coronary artery disease, stroke, chronic renal disease and mortality. Adequately maintained blood pressure is very important in high risk patients. In the treatment of hypertension, life style therapy and drug treatment have essential roles. Further, patient adherence plays a significant part of the treatment, too. Importantly, about half of the patients only become adherent to antihypertensive therapy by the end of the first year treatment. Hence, non-adherence of patients is an important cause for resistant hypertension. Adherence is influenced by the complexity of drug regimen and characteristic of drug class, as well as age and gender of patients.

Association of B2 receptor polymorphisms and ACE activity with ACE inhibitor-induced angioedema in black and mixed-race South Africans

Angiotensin-converting enzyme (ACE) inhibitors are first-line therapy for the treatment of hypertension, congestive heart failure, and diabetic nephropathy. ACE inhibitors are associated with adverse side effects such as persistent dry cough (ACE-cough) and, rarely, life-threatening angioedema (ACE-AE). The authors investigated the influence of ACE I/D polymorphism in combination with serum ACE activity, B₂ receptor -9/+9 polymorphism, and B₂ receptor C-58T single nucleotide polymorphism (SNP) on the development of ACE-AE and ACE-cough. The frequencies of ACE I/D as well as B₂ receptor +9/-9 and C-58T polymorphisms were compared in patients with ACE-AE, ACE-cough, and ACE inhibitor-exposed controls, and serum ACE activity was measured. There were 52 cases of ACE-AE, 36 cases of ACE-cough, and 77 controls. The genotyping revealed a significant association between the B₂ -9 allele and ACE inhibitor-induced AE (62% vs 38%, P=.008), and ACE inhibitor-induced cough (61% vs 38%, P=.02) when compared with controls. There was no significant association between ACE I/D polymorphism as well as the B₂ C-58T SNP with both ACE-induced AE and cough. ACE activity was significantly higher in controls compared with patients with ACE-AE (34.5 ± 1.14 mU/mL vs 17.8 ± 0.86 mU/mL, P=.0001) and ACE-cough (34.5 ± 1.14 mU/mL vs 23.3 ± 1.88 mU/mL, P=.0001). Thus, our data suggest that the B₂ -9 allele and reduced ACE activity are associated with both ACE-AE and ACE-cough.

Withdrawal syndrome following cessation of antihypertensive drug therapy

In this study, a review of the available information concerning abrupt withdrawal of antihypertensive drug therapy is presented. Abrupt withdrawal of these drugs can produce a syndrome of sympathetic overactivity that includes nervousness, tachycardia, headache, agitation and nausea 36-72 h after cessation of the drug. A withdrawal syndrome may occur after discontinuation of almost all types of antihypertensive drugs, but mostly occurs with clonidine, beta-blockers, methyldopa and guanabenz. Less commonly can produce a rapid increase of the blood pressure to pre-treatment levels or above, or both and/or myocardial ischaemia. Although the exact incidence of the syndrome is not known, it appears to be rare, at least in patients receiving standard doses of the above antihypertensive drugs. The best treatment is prevention. In this study regarding the withdrawal syndrome that follows cessation of antihypertensive drugs therapy, a reference to the abrupt discontinuation of the main categories of antihypertensive drugs is also attempted.