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Schmidt et al examined the adherence to serum creatinine and potassium monitoring and discontinuation guidelines following initiation of treatment with ACE inhibitors (ACEI) or angiotensin receptor blockers (ARBs) in a general practice-based cohort study using electronic health records from the UK Clinical Practice Research Datalink and Hospital Episode Statistics.; and whether high-risk patients were monitored.1 223,814 new ACEI/ARB users were investigated.1 Only 10% of patients had neither baseline nor follow-up monitoring of creatinine within 12 months before and 2 months after initiation of an ACEI/ARB, 28% had monitoring only at baseline, 15% only at follow-up, and 47% both at baseline and follow-up.1 The median period between the most recent baseline monitoring and drug initiation was 40 days (IQR 12–125 days). 34% of patients had baseline creatinine monitoring within 1 month before initiating therapy, but <10% also had the guideline-recommended follow-up test recorded within 2 weeks. Among patients experiencing a creatinine increase ≥30% (n=567, 1.2%) or potassium level >6 mmol/L (n=191, 0.4%), 80% continued treatment.1 Although patients with prior myocardial infarction, hypertension or baseline potassium >5 mmol/L were at high risk of ≥30% increase in creatinine after ACEI/ARB initiation, there was no evidence that they were more frequently monitored.1
In our opinion, it is indeed disheartening and most disappointing that healthcare providers contin...
In our opinion, it is indeed disheartening and most disappointing that healthcare providers continue to use ACEIs/ARBs without reverence to safety guidelines as acknowledged in this report.1 It is most germane to observe here that the renal downside of angiotensin blockade with ACEIs/ARBs is often overlooked. Indeed, the recently published 2017 position paper on the pharmacologic treatment of hypertension in adults aged 60 years or older, representing the Clinical Practice Guidelines from the American College of Physicians and the American Academy of Family Medicine, had highlighted cough and hyperkalemia among important adverse effects of angiotensin blockers but had most infamously failed to cite renal failure as an important adverse effect of angiotensin blockers.2
The safety imperative for continued monitoring of serum creatinine and potassium among all users of ACEIs/ARBs cannot be overemphasized.1 This mantra is necessary both following initiation of angiotensin blockade and must be continued indefinitely as long as the patient remains on angiotensin blockade.3-9 We had described the syndrome of late onset renal failure from angiotensin blockade (LORFFAB), a then unrecognized syndrome, in 2005, from the Renal Unit of Mayo Clinic Health System in Northwestern Wisconsin in the USA.3 Subsequently, we have variously reported on the multiple presentations of this syndrome.3-7
Lastly, while we support the use of ACEIs/ARBs in the various pharmaceutical indications, we will continue to call for caution in the use of these agents, more so in older (>65-year old) patients with advanced stages of chronic kidney disease. 10 We most emphatically support the sentiments and concerns of Schmidt et al that only one-tenth of patients initiating ACEI/ARB therapy receive the guideline-recommended creatinine monitoring and that, moreover, the vast majority of the patients fulfilling post-initiation discontinuation criteria for creatinine and potassium increases continued on treatment.1
1. Schmidt M, Mansfield KE, Bhaskaran K, et al. Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin–angiotensin system blockade: a UK general practice-based cohort study. BMJ Open 2017;7:e012818. doi:10.1136/bmjopen-2016012818
2. Qaseem A, Wilt TJ, Rich R, et al. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017 Mar 21;166(6):430-437. doi: 10.7326/M16-1785. Epub 2017 Jan 17.
3. Onuigbo MA, Onuigbo NT. Late onset renal failure from angiotensin blockade (LORFFAB): a prospective thirty-month Mayo Health System clinic experience. Med Sci Monit. 2005 Oct;11(10):CR462-9. Epub 2005 Sep 26.
4. Onuigbo MA, Onuigbo NT. Late onset azotemia from RAAS blockade in CKD patients with normal renal arteries and no precipitating risk factors. Ren Fail 2008;30:73-80.
5. Onuigbo MA, Onuigbo NT. Late-onset renal failure from angiotensin blockade (LORFFAB) in 100 CKD patients. Int Urol Nephrol. 2008;40(1):233-9. doi: 10.1007/s11255-007-9299-2. Epub 2008 Jan 15.
6. Onuigbo MA. Reno-prevention vs. reno-protection: a critical re-appraisal of the evidence-base from the large RAAS blockade trials after ONTARGET—a call for more circumspection. QJM 2009;102:155-167.
7. Onuigbo MA. Analytical review of the evidence for renoprotection by renin-angiotensin-aldosterone system blockade in chronic kidney disease - a call for caution. Nephron Clin Pract. 2009;113(2):c63-9, discussion c70. doi: 10.1159/000228536. Epub 2009 Jul 14.
8. Onuigbo MA. The impact of stopping inhibitors of the renin-angiotensin system in patients with advanced chronic kidney disease. Nephrol Dial Transplant. 2010 Apr;25(4):1344-5. doi: 10.1093/ndt/gfp678. Epub 2009 Dec 27.
9. Onuigbo MA. Can ACE inhibitors and angiotensin receptor blockers be detrimental in CKD patients? Nephron Clin Pract. 2011;118(4):c407-19. doi: 10.1159/000324164. Epub 2011 Mar 7.
10. Oh YJ, Kim SM, Shin BC, Kim HL, Chung JH, Kim AJ et al. The Impact of Renin-Angiotensin System Blockade on Renal Outcomes and Mortality in Pre-Dialysis Patients with Advanced Chronic Kidney Disease. PLoS One. 2017 Jan 25;12(1):e0170874. doi: 10.1371/journal.pone.0170874. eCollection 2017.