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

Emergency Department Presentation of Life-threatening Symptomatic Hyperkalemia From an Angiotensin Receptor Blocker in a Low-risk Individual

Hyperkalemia is a common electrolyte abnormality with characteristic electrocardiogram changes. Both angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) increase the risk of developing hyperkalemia. This case highlights a rare life-threatening episode of hyperkalemia in an individual whose only risk factor was an ARB. A 58-year-old female presented with sudden-onset chest pressure, light-headedness, and diaphoresis. Her initial electrocardiogram showed a nearly sinusoidal rhythm with a widened ventricular depolarization (QRS) and prolonged QT-interval (QTc). Life-threatening hyperkalemia of 9.1 mmol/L was confirmed with a rapid point-of-care electrolyte panel. She was rapidly treated with calcium, potassium-shifting and eliminating medications, and emergent hemodialysis. After stabilization, a thorough workup found that the patient's only risk factor for hyperkalemia was her use of an ARB. While both ARBs and ACEIs are commonly associated with mild hyperkalemia, life-threatening hyperkalemia is rare, particularly in patients without concomitant renal failure, diabetes mellitus, adrenal disease, or potassium-sparing diuretic use. However, this case illustrates that life-threatening hyperkalemia is possible in patients solely taking an ARB without prior significant risk factors. Despite normal renal function in an individual without heart failure or diabetes, this patient developed life-threatening hyperkalemia.

Determining Factors Influencing RAS Inhibitors Re-Initiation in ICU: A Modified Delphi Method

Background

Renin-angiotensin system inhibitors (RASi) are not re-initiated for almost a quarter of patients who suffered acute kidney injury 6 months after discharge. This discontinuation might be partly explained by the nephrotoxicity of these medications, yet they remain of benefit, especially for patients with heart failure.

Objective

To determine the factors deemed by clinicians to influence RASi re-initiation and set threshold values for important safety parameters.

Design

Three-round modified online Delphi survey.

Setting

The study was conducted in Quebec, Canada.

Participants

Twenty clinicians from nephrology, intensive care medicine, and internal medicine.

Measurements

The factors' importance was rated on 4-point Likert-type scale, ranging from "not important" to "very important" by the panelists.

Methods

We conducted a brief literature review to uncover possible influencing factors followed by a 3-round modified Delphi survey to establish a consensus on the importance of these factors.

Results

We recruited 20 clinicians (7 nephrologists, 3 internists, and 10 intensive care physicians). We created a list of 25 factors, 15 of which met consensus. Eleven of these factors, including serum creatinine, glomerular filtration rate, and acute kidney injury (AKI) stage, were deemed as important while 4, such as responsibility ambiguity and absence of feedback, were deemed as not important. The majority of the 10 factors which did not meet consensus were related to the clinical setting, such as a pharmacist follow-up and the required time to ensure optimal RASi re-initiation.

Limitations

Quebec clinicians' agreement might not reflect the opinion of the rest of Canada. The survey measures clinicians' belief rather than their actual practice.

Conclusion

Renin-angiotensin system inhibitors re-initiation is a rather complex concept which encompasses several factors. Our research uncovered some of these factors which may be used to develop guidelines on optimal RASi re-initiation.

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.

The Use of Antihypertensive Drugs as Coadjuvant Therapy in Cancer

Cancer is a complex group of diseases that constitute the second largest cause of mortality worldwide. The development of new drugs for treating this disease is a long and costly process, from the discovery of the molecule through testing in phase III clinical trials, a process during which most candidate molecules fail. The use of drugs currently employed for the management of other diseases (drug repurposing) represents an alternative for developing new medical treatments. Repurposing existing drugs is, in principle, cheaper and faster than developing new drugs. Antihypertensive drugs, primarily belonging to the pharmacological categories of angiotensin-converting enzyme inhibitors, angiotensin II receptors, direct aldosterone antagonists, β-blockers and calcium channel blockers, are commonly prescribed and have well-known safety profiles. Additionally, some of these drugs have exhibited pharmacological properties useful for the treatment of cancer, rendering them candidates for drug repurposing. In this review, we examine the preclinical and clinical evidence for utilizing antihypertensive agents in the treatment of cancer.

Management of hyperkalemia during treatment with mineralocorticoid receptor blockers: findings from esaxerenone

The nonsteroidal mineralocorticoid receptor (MR) blocker esaxerenone has demonstrated good antihypertensive activity in a variety of patients, including those with uncomplicated grade I-III hypertension, hypertension with moderate renal dysfunction, hypertension with type 2 diabetes mellitus with albuminuria, and hypertension associated with primary aldosteronism. Hyperkalemia has long been recognized as a potential side effect occurring during treatment with MR blockers, but there is a lack of understanding and guidance about the appropriate management of hyperkalemia during antihypertensive therapy with MR blockers, especially in regard to the newer agent esaxerenone. In this article, we first highlight risk factors for hyperkalemia, including advanced chronic kidney disease, diabetes mellitus, cardiovascular disease, age, and use of renin-angiotensin-aldosterone system inhibitors. Next, we examine approaches to prevention and management, including potassium monitoring, diet, and the use of appropriate therapeutic techniques. Finally, we summarize the currently available data for esaxerenone and hyperkalemia. Proper management of serum potassium is required to ensure safe clinical use of MR blockers, including awareness of at-risk patient groups, choosing appropriate dosages for therapy initiation and dosage titration, and monitoring of serum potassium during therapy. It is critical that physicians take such factors into consideration to optimize MR blocker therapy in patients with hypertension.

Effect of telmisartan, angiotensin-converting enzyme inhibition, or both, on proteinuria and blood pressure in dogs

Background

The use of telmisartan (TEL), an angiotensin‐receptor blocker, for the control of systemic hypertension and proteinuria in dogs has not been reported extensively in a clinical setting.

Objectives

To determine the effects of an angiotensin‐converting enzyme inhibitor (ACEi) alone, ACEi in combination with TEL, or TEL alone on systolic blood pressure and proteinuria in dogs with protein losing nephropathy (PLN).

Animals

Forty‐two client‐owned dogs being treated for PLN.

Methods

Retrospective observational study of medical records of dogs at a university teaching hospital from 2012 to 2018 with the use of benazepril or enalapril alone, TEL alone, or both modalities for the management of PLN. Noninvasive blood pressure and urine protein to creatinine ratio (UPC) were compared among the treatment groups over time. A multivariable mixed‐effects linear regression model followed by post hoc analysis was used to estimate the marginal means and differences between the treatment groups.

Results

In comparison to group ACEi alone, combination treatment of an ACEi with TEL significantly reduced (P = .007) systolic blood pressure by 13 mm Hg (95% confidence interval [95% CI]: 4‐22 mm Hg). Angiotensin‐converting enzyme inhibitor + TEL in comparison to ACEi alone showed significant (P = .01) reduction in UPC of 2.5 (95% CI: 0.6‐4.4). The UPC of group ACEi + TEL was significantly lower (P = .01) in comparison to TEL alone by 3.8 (95% CI: 0.8‐6.8).

Conclusions and Clinical Importance

Telmisartan can be used to treat systemic hypertension and proteinuria in dogs.

Antihypertensive Prescribing for Uncomplicated, Incident Hypertension: Opportunities for Cost Savings

Background

A range of first-line similarly effective medications ranging in price are recommended for treating uncomplicated hypertension. Considering drug costs alone, thiazides and thiazide-like diuretics are the most cost-efficient option. We determined incident prescribing of thiazides for newly diagnosed hypertension as first-line treatment in Alberta, factors that predicted receiving thiazides vs more costly medications, and how much could be saved if more patients were prescribed thiazides.

Methods

Using a retrospective cohort design, factors predicting receiving thiazides vs other agents were determined using mixed effects logistic regression. Cost savings were simulated by shifting patients from other antihypertensive medications to thiazides and calculating the difference.

Results

Within our cohort of 89,548 adults, only 12% received thiazides as first-line treatment whereas 44% received angiotensin converting enzyme inhibitors, 17% received angiotensin receptor blockers, 16% received calcium channel blockers, and 10% received β-blockers. Antihypertensive medications were typically prescribed by office-based, general practitioners (88%). Being male and receiving a prescription from a physician with ≥ 20 years of practice and a high clinical workload were associated with increased odds of receiving nonthiazides. In the extreme case that all patients received thiazides as their first prescription, spending would have been reduced by a maximum of 95% (CAD$1.8 million).

Conclusions

Only 12% of Albertan adults with incident, uncomplicated hypertension were prescribed thiazides as first-line treatment. With the opportunity for drug cost savings, future research should evaluate the risk of adverse events and side effects across the drug classes and whether the costs associated with managing those risks could offset the savings achieved through increased thiazide use.

Association of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Blockers With Severity of COVID-19: A Multicenter, Prospective Study

BACKGROUND

Speculations whether treatment with angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) predisposes to severe coronavirus disease 2019 (COVID-19) or worsens its outcomes. This study assessed the association of ACE-I/ARB therapy with the development of severe COVID-19.

METHODS

This multi-center, prospective study enrolled patients hospitalized for COVID-19 and receiving one or more antihypertensive agents to manage either hypertension or cardiovascular disease. ACE-I/ARB therapy associations with severe COVID-19 on the day of hospitalization, intensive care unit (ICU) admission, mechanical ventilation and in-hospital death on follow-up were tested using a multivariate logistic regression model adjusted for age, obesity, and chronic illnesses. The composite outcome of mechanical ventilation and death was examined using the adjusted Cox multivariate regression model.

RESULTS

Of 338 enrolled patients, 245 (72.4%) were using ACE-I/ARB on the day of hospital admission, and 197 continued ACE-I/ARB therapy during hospitalization. Ninety-eight (29%) patients had a severe COVID-19, which was not significantly associated with the use of ACE-I/ARB (OR 1.17, 95% CI 0.66-2.09; P = .57). Prehospitalization ACE-I/ARB therapy was not associated with ICU admission, mechanical ventilation, or in-hospital death. Continuing ACE-I/ARB therapy during hospitalization was associated with decreased mortality (OR 0.22, 95% CI 0.073-0.67; P = .008). ACE-I/ARB use was not associated with developing the composite outcome of mechanical ventilation and in-hospital death (HR 0.95, 95% CI 0.51-1.78; P = .87) versus not using ACE-I/ARB.

CONCLUSION

Patients with hypertension or cardiovascular diseases receiving ACE-I/ARB therapy are not at increased risk for severe COVID-19 on admission to the hospital. ICU admission, mechanical ventilation, and mortality are not associated with ACE-I/ARB therapy. Maintaining ACE-I/ARB therapy during hospitalization for COVID-19 lowers the likelihood of death.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT4357535.

Prevalence and factors associated with false hyperkalaemia in Asians in primary care: a cross-sectional study (the Unlysed Hyperkalaemia- the Unseen Burden (UHUB) study)

Serum potassium is part of routine laboratory tests done for patients with hypertension or diabetes mellitus in primary care. Those found to have raised potassium (K>5.5 mmol/L) are recalled for repeat potassium in emergency departments or primary care clinics. Repeat potassium are often normal (≤5.5 mmo/L), that is, false hyperkalaemia. Haemolysis is known to cause false hyperkalaemia. We postulated that unlysed false hyperkalamia was prevalent and was associated with factors such as delayed processing time.

OBJECTIVE

We aimed to determine the prevalence of unlysed false hyperkalaemia and the factors associated with false-and-true-hyperkalaemia.

SETTING

Outpatients in a cluster of public primary care clinics (polyclinics) in Singapore.

PARTICIPANTS

All patients of any ethnicity aged ≥21 with serum potassium test done.

METHODS

Electronic health records of index patients with potassium >5.5 mmol/L and its corresponding laboratory processing time in seven local polyclinics were reviewed between August 2015 and August 2017. Haemolysed specimens and patients on sodium polystyrene sulfonate (SPS) suspension were excluded. If repeat potassium level was ≤5.5 mmol/L within 8 days, the case was defined as false hyperkalaemia. The proportion of such patients was computed to determine its prevalence. Linear and logistic regressions were used to identify the associated factors.

RESULTS

The study population comprised of 3014 index cases, of which 1575 had repeat potassium tests without preceding SPS. 86.4% (1362/1575) of them had potassium ≤5.5 mmol/L. The average processing time among specimens with potassium ≥6.0 mmol/L was 50 min longer, compared with those with potassium <5.1 mmol/L. Risk factors significantly associated with false hyperkalaemia included estimated glomerular filtration rate (eGFR) (60-89 mL/min/1.73 m², OR=3.25, p<0.001;>90 mL/min/1.73 m², OR=3.77, p<0.001) and delayed laboratory processing time (beta coefficient 0.001, p<0.001).

CONCLUSION

The prevalence of false hyperkalaemia was 86.4%. Recommendation to repeat potassium tests may target those with eGFR<60ml/min/1.73m².

Oral sodium and potassium binders in heart failure

Significant improvements in the morbidity and mortality associated with chronic heart failure have been gained with the use ACE inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, and diuretics. However, the use of these agents is often limited by their propensity to precipitate worsening renal function and hyperkalemia, particularly in patients with chronic kidney disease. Several pharmacologic agents have been developed in recent years that utilize the gastrointestinal tract as an alternate route for drug absorption, electrolyte exchange, and drug and electrolyte elimination. The existing data establishing the safety and efficacy of these novel agents will be the focus of this review.

Hyperkalemia of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in hemodialysis: a meta-analysis

The safety of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) used in hemodialysis (HD) patients was evaluated. Medline, Embase, the Cochrane Library, some databases of clinical trial registries, grey literatures, other reference lists of eligible articles and review articles for the randomized clinical trials (RCTs) on comparison of ACEIs/ARBs or placebo in HD patients were retrieved. RCTs reporting the risk of hyperkalemia by using ACEIs/ARBs in HD patients were selected. Eight articles met the eligibility criteria and were subjected to meta-analysis by using the Cochrane Collaboration's RevMan 4.2 software package. The results showed that there was no significant difference in hyperkalemia in HD patients between ACEIs or ARBs group and control group (ACEIs vs. control: RD=0.03, 95% CI=-0.13-0.18, Z=0.34, P=0.73; ARBs vs. control: RD=-0.02, 95% CI=-0.07-0.03, Z=0.75, P=0.45). However, there was no significant difference in the serum potassium between ACEIs or ARBs group and control group in HD patients (ACEIs vs. control: WMD=0.10, 95% CI=0.06-0.15, Z=4.64, P<0.00001; ARBs vs. control: WMD=-0.24, 95% CI=-0.37-0.11, Z=3.58, P=0.0003). The use of ACEIs or ARBs could not cause an increased risk of hyperkalemia in HD patients, however the serum potassium could be increased with use of ACEIs in HD patients. Therefore the serum potassium concentration should still be closely monitored when ACEIs are taken during the maintenance HD.

Comparative effect of angiotensin II type I receptor blockers and calcium channel blockers on laboratory parameters in hypertensive patients with type 2 diabetes

BACKGROUND

Both angiotensin II type I receptor blockers (ARBs) and calcium channel blockers (CCBs) are widely used antihypertensive drugs. Many clinical studies have demonstrated and compared the organ-protection effects and adverse events of these drugs. However, few large-scale studies have focused on the effect of these drugs as monotherapy on laboratory parameters. We evaluated and compared the effects of ARB and CCB monotherapy on clinical laboratory parameters in patients with concomitant hypertension and type 2 diabetes mellitus.

METHODS

We used data from the Clinical Data Warehouse of Nihon University School of Medicine obtained between Nov 1, 2004 and July 31, 2011, to identify cohorts of new ARB users (n = 601) and propensity-score matched new CCB users (n = 601), with concomitant mild to moderate hypertension and type 2 diabetes mellitus. We used a multivariate-adjusted regression model to adjust for differences between ARB and CCB users, and compared laboratory parameters including serum levels of triglyceride (TG), total cholesterol (TC), non-fasting blood glucose, hemoglobin A1c (HbA1c), sodium, potassium, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyltransferase (GGT), hemoglobin and hematocrit, and white blood cell (WBC), red blood cell (RBC) and platelet (PLT) counts up to 12 months after the start of ARB or CCB monotherapy.

RESULTS

We found a significant reduction of serum TC, HbA1c, hemoglobin and hematocrit and RBC count and a significant increase of serum potassium in ARB users, and a reduction of serum TC and hemoglobin in CCB users, from the baseline period to the exposure period. The reductions of RBC count, hemoglobin and hematocrit in ARB users were significantly greater than those in CCB users. The increase of serum potassium in ARB users was significantly greater than that in CCB users.

CONCLUSIONS

Our study suggested that hematological adverse effects and electrolyte imbalance are greater with ARB monotherapy than with CCB monotherapy.