Comparative effects on dynamic renal potassium excretion of ACE inhibition versus angiotensin receptor blockade in hypertensive patients with type II diabetes mellitus

A comparative study assessing the incidence and degree of hyperkalemia in patients on angiotensin-converting enzyme inhibitors versus angiotensin-receptor blockers

OVERVIEW

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin-receptor blockers (ARB) are the most commonly prescribed anti-hypertensive medications in the United States, yet whether ACEI or ARB use is associated with a greater risk of hyperkalemia remains uncertain. Using real-world evidence from electronic health records, our study demonstrates that treatment with ACEI is associated with both a higher incidence and greater degree of hyperkalemia than treatment with ARB in adjusted models, especially in patients with chronic kidney disease. Providers should therefore consider this possible difference in hyperkalemia risk when choosing between ACEI and ARB therapy.

Characterization of Potassium-Induced Natriuresis in Hypertensive Postmenopausal Women During Both Low and High Sodium Intake

BACKGROUND

Potassium-induced natriuresis may contribute to the beneficial effects of potassium on blood pressure but has not been well-characterized in human postmenopausal hypertension. We determined the time course and magnitude of potassium-induced natriuresis and kaliuresis compared with hydrochlorothiazide in 19 hypertensive Hispanic postmenopausal women. We also determined the modulating effects of sodium intake, sodium-sensitivity, and activity of the thiazide-sensitive NCC (sodium-chloride cotransporter).

METHODS

Sixteen-day inpatient confinement: 8 days low sodium followed by 8 days high sodium intake. During both periods, we determined sodium and potassium excretion following 35 mmol oral KCl versus 50 mg hydrochlorothiazide. We determined sodium-sensitivity as change in 24-hour systolic pressure from low to high sodium. We determined NCC activity by standard thiazide-sensitivity test.

RESULTS

Steady-state sodium intake was the key determinant of potassium-induced natriuresis. During low sodium intake, sodium excretion was low and did not increase following 35 mmol KCl indicating continued sodium conservation. Conversely, during high sodium intake, sodium excretion increased sharply following 35 mmol KCl to ≈37% of that produced by hydrochlorothiazide. Under both low and high sodium intake, 35 mmol potassium was mostly excreted within 5 hours, accompanied by a sodium load reflecting the steady-state sodium intake, consistent with independent regulation of sodium/potassium excretion in the human distal nephron.

CONCLUSIONS

Potassium-induced natriuresis was not greater in sodium-sensitive versus sodium-resistant hypertensives or hypertensives with higher versus lower basal NCC activity. We studied an acute KCl challenge. It remains to further characterize potassium-induced natriuresis during chronic potassium increase and when potassium is administered a complex potassium-containing meal.

Thiazide-Sensitive NCC (Sodium-Chloride Cotransporter) in Human Metabolic Syndrome: Sodium Sensitivity and Potassium-Induced Natriuresis

The thiazide-sensitive sodium-chloride cotransporter (NCC;SLC12A3) is central to sodium and blood pressure regulation. Metabolic syndrome induces NCC upregulation generating sodium-sensitive hypertension in experimental animal models. We tested the role of NCC in sodium sensitivity in hypertensive humans with metabolic syndrome. Conversely, oral potassium induces NCC downregulation producing potassium-induced natriuresis. We determined the time course and magnitude of potassium-induced natriuresis compared with the natriuresis following hydrochlorothiazide (HCTZ) as a reference standard. We studied 19 obese hypertensive humans with metabolic syndrome during 13-day inpatient confinement. We determined sodium sensitivity by change in 24-hour mean systolic pressure by automated monitor from days 5 (low sodium) to 10 (high sodium). We determined NCC activity by standard 50 mg HCTZ sensitivity test (day 11). We determined potassium-induced natriuresis following 35 mmol KCl (day 13). We determined (1) whether NCC activity was greater in sodium-sensitive versus sodium-resistant participants and correlated with sodium sensitivity and (2) time course and magnitude of potassium-induced natriuresis following 35 mmol KCl directly compared with 50 mg HCTZ. NCC activity was not greater in sodium-sensitive versus sodium-resistant humans and did not correlate with sodium sensitivity. Thirty-five-millimoles KCl produced a rapid natriuresis approximately half that of 50 mg HCTZ with a greater kaliuresis. Our investigation tested a key hypothesis regarding NCC activity in human hypertension and characterized potassium-induced natriuresis following 35 mmol KCl compared with 50 mg HCTZ. In obese hypertensive adults with metabolic syndrome ingesting a high-sodium diet, 35 mmol KCl had a net natriuretic effect approximately half that of 50 mg HCTZ.

Risk of hyperkalemia in patients with moderate chronic kidney disease initiating angiotensin converting enzyme inhibitors or angiotensin receptor blockers: a randomized study

Background

Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are renoprotective but both may increase serum potassium concentrations in patients with chronic kidney disease (CKD). The proportion of affected patients, the optimum follow-up period and whether there are differences between drugs in the development of this complication remain to be ascertained.

Methods

In a randomized, double-blind, phase IV, controlled, crossover study we recruited 30 patients with stage 3 CKD under restrictive eligibility criteria and strict dietary control. With the exception of withdrawals, each patient was treated with olmesartan and enalapril separately for 3 months each, with a 1-week wash-out period between treatments. Patients were clinically assessed on 10 occasions via measurements of serum and urine samples. We used the Cochran–Mantel–Haenszel statistics for comparison of categorical data between groups. Comparisons were also made using independent two-sample t-tests and Welch’s t-test. Analysis of variance (ANOVA) was performed when necessary. We used either a Mann–Whitney or Kruskal-Wallis test if the distribution was not normal or the variance not homogeneous.

Results

Enalapril and olmesartan increased serum potassium levels similarly (0.3 mmol/L and 0.24 mmol/L respectively). The percentage of patients presenting hyperkalemia higher than 5 mmol/L did not differ between treatments: 37% for olmesartan and 40% for enalapril. The mean e-GFR ranged 46.3 to 48.59 ml/mint/1.73 m² in those treated with olmesartan and 46.8 to 48.3 ml/mint/1.73 m² in those with enalapril and remained unchanged at the end of the study. The decreases in microalbuminuria were also similar (23% in olmesartan and 29% in enalapril patients) in the 4 weeks time point. The percentage of patients presenting hyperkalemia, even after a two month period, did not differ between treatments. There were no appreciable changes in sodium and potassium urinary excretion.

Conclusions

Disturbances in potassium balance upon treatment with either olmesartan or enalapril are frequent and without differences between groups. The follow-up of these patients should include control of potassium levels, at least after the first week and the first and second month after initiating treatment.

Trial registration

The trial EudraCT “2008-002191-98”.

A comparative study of the prevalence of hyperkalemia with the use of angiotensin-converting enzyme inhibitors versus angiotensin receptor blockers

Background and objectives

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are increasingly used in a variety of settings including heart failure, renal failure, arterial hypertension, and diabetic nephropathy. The objective of this study was to investigate the prevalence of hyperkalemia with ACEI and ARB use, in a population of the United States veterans.

Design, settings, material, and measurements

Retrospective observational cohort study of 1163 patients on ACEIs and 1168 patients on ARBs in a single Veterans Affairs Medical Center. Electronic medical records were reviewed over a 12-month period with data collected on various demographic, laboratory, comorbidity, and medication related variables.

Results

Hyperkalemia (>5 mEq/L) was observed in 20.4% of patients on ACEIs and 31.0% on ARBs. Severe hyperkalemia (6 mEq/L or higher), was observed in 0.8% of ACEI and 2.8% of ARB users. In univariate logistic regression analyses, diabetes mellitus; serum glucose, total carbon dioxide content, creatinine, and estimated glomerular filtration rate (GFR) were significantly associated with hyperkalemia. ARB use, when compared to ACEI, was associated with a 42% increase in odds of hyperkalemia (odds ratio [OR] = 1.42; p = 0.001) in a model including adjustment for GFR and a 56% increase in odds of hyperkalemia (OR = 1.56; p < 0.001) in a model including adjustment for serum creatinine.

Conclusions

Hyperkalemia, associated with the use of ACEIs and ARBs, is usually mild and severe hyperkalemia is rare. Hyperkalemia is more common with ARBs than ACEIs. ARB use, when compared to ACEI use, may significantly and independently be associated with increased odds of hyperkalemia.

Recursive estimation method for predicting residual bladder urine volumes to improve accuracy of timed urine collections*

Clinical research studies often collect data via repeated measurements of collected urine. Unfortunately, the accuracy of timed urine collections is limited by the presence of a residual volume of urine remaining in the bladder following each timed void due to incomplete emptying of the bladder. This residual urine volume adds significant imprecision to the urine collection method, rendering an important and fundamental clinical research tool inaccurate. We present an unbiased method to estimate the residual bladder volumes via a mathematical model of the bladder process. Regardless of the substance of primary interest, the model leverages conservation of mass and conservation of concentration principles towards a substance of secondary interest in order to solve a system of recursive equations, resulting in our Recursive Residual Estimation method to predict the residual volumes at each time point. We verify the model on simulated patients and also investigate the sensitivity of the model to initial value specification.

17β-Estradiol deficiency reduces potassium excretion in an angiotensin type 1 receptor-dependent manner

This study examined the effects of ovariectomy (OVX) and 17β-estradiol (E2) replacement (OVX + E2) on renal function in Sprague-Dawley rats. OVX caused a 40% decrease in the fractional excretion of potassium (FEK+) that was prevented by E2 replacement [Sham, 24.2 ± 2.9%; OVX, 14.5 ± 2.1% ( P < 0.05 vs. OVX + E2); and OVX + E2, 26.2 ± 2.7%; n = 7–11] and that corresponded to significant increases in plasma potassium [(in mmol/l): Sham, 3.15 ± 0.087; OVX, 3.42 ± 0.048 ( P < 0.05 vs. OVX + E2); and OVX + E2, 3.19 ± 0.11; n = 7–11]. No effects of OVX were detected on plasma levels of sodium and aldosterone. Angiotensin II type 1 receptor (AT1R) densities in ovariectomized rats were 1.4-fold and 1.3-fold higher in glomerular [maximum binding capacity (Bmax; in fmol/mg protein): Sham, 482 ± 21; OVX, 666 ± 20 ( P < 0.05 vs. OVX + E2); and OVX + E2, 504 ± 26; n = 7–11] and proximal tubular [Bmax (in fmol/mg protein): Sham, 721 ± 16; OVX, 741 ± 24 ( P < 0.05 vs. OVX + E2); and OVX + E2, 569 ± 23; n = 7–11] membranes compared with E2 replete animals, respectively. Both the angiotensin-converting enzyme inhibitor captopril and the AT1R antagonist losartan prevented the OVX-induced decrease in the FEK+ and the increase in renal AT1R densities, suggesting that E2 deficiency reduces potassium excretion in an ANG II/AT1R-dependent manner. These findings may have implications for renal function in postmenopausal women as well as contribute to the reasons underlying the age-induced increase in susceptibility to hypertension-associated disease in women.

Potential side effects of renin inhibitors – mechanisms based on comparison with other renin–angiotensin blockers

Angiotensin (Ang) II plays important roles in the development of hypertension and cardiovascular and renal injury. Pharmaceutical approaches to block its activity led to the development of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Numerous trials have documented their efficacy in controlling blood pressure, minimising left ventricular remodelling, preventing progression to heart failure, ameliorating proteinuria and retarding renal disease progression. Although they are considered safe in general, there remain concerns about the potential for adverse events in certain target populations. Recently, several novel, low molecular weight renin inhibitors without the extended peptide-like backbone of previous renin inhibitors were developed with favourable pharmacokinetic properties. They have been shown to successfully reduce Ang II levels in normal volunteers and to lower blood pressure in patients with mild-to-moderate hypertension. In this review, the authors summarise current knowledge about these renin inhibitors.

Candesartan

Candesartan cilexetil is the prodrug of candesartan, an angiotensin II receptor antagonist. Candesartan binds selectively and non-competitively to the angiotensin II receptor type 1, thus preventing the actions of angiotensin II. Clinical trials have demonstrated its efficacy at a dose range of 2 to 32 mg once daily in hypertension of all grades, heart failure, in reducing urinary albumin excretion in diabetes mellitus and in coexisting hypertension and renal failure. Pharmacokinetic properties of candesartan cilexetil in elderly patients are not significantly different from those in younger individuals. Hepatic impairment does not change pharmacokinetics of candesartan cilexetil at doses up to 12 mg/day. No dose adjustment is necessary in patients with mild or moderate renal impairment. Tolerability of candesartan cilexetil is not much different from that of placebo. All adverse events are usually of mild to moderate severity and not dose-related. The most common adverse events were headache, upper respiratory tract infection, back pain, and dizziness. The incidence of these adverse effects, as well as of cough, was similar in patients treated with candesartan cilexetil or placebo. The incidence of adverse events in long-term trials was not different from that in short-term trials. Tolerability of candesartan cilexetil does not differ with either age or gender.

[Do generic drugs help control expenditure on hypertension? Apropos of a case]

OBJECTIVE

In this article we analyze the influence of generic drugs on pharmaceutical expenditure on hypertension from the payer's perspective (the public health service), by examining the most widely used drugs: angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs).

METHODS

Based on billing data to the public health service from all the pharmacies in the Health Area of Malaga, we studied the utilization (containers and cost) of ACEi (generic drugs ACEi+G and brand name) and ARBs (brand name only) (subgroup C09 ATC index) from 1999 to 2002. The mean price (weighted according to sales) and the percentage of deviation of prescriptions from one group of drugs to another was also studied.

RESULTS

The increase in consumption of packages in subgroup C09 was 20.79%; the increase was greater for ARBs (136%) and for ACEi+G (177%). The total amount spent during the study period increased by more than 42%. Expenditure on ACEis decreased by almost 7%, despite the increase in expenditure on ACEi+G, whereas expenditure on ARBs increased by more than 154%. The mean price of this subgroup, weighted according to sales, increased by nearly 18%. The mean weighted price of the generic drugs, captopril and enalapril, and that of the brand name, trandolapril, decreased. Notable among ARBs was the increase in mean price weighted according to sales of irbesartan (9%) and valsartan (16%).

CONCLUSIONS

The use of generic drugs has reduced expenditure on ACEi and the mean weighted price of the subgroup. However, the increased use of generic drugs has not produced the expected savings for the Department of Health. This could be due to deviation of prescription scores toward drugs not affected by substitution by the pharmacy.