2015;17:1032-1041, 7. In: Post TW, ed. Valsartan, candesartan, losartan, irbesartan, References:[1][2][3][4][5][6][7][7][8][9], Acute kidney injury is a potential side effect of all types of RAAS inhibitors, especially in patients with pre-existing kidney disease or in combination with NSAIDs!References:[8][11][12]. Only potassium levels above 5.5 mmol/L increase the risk of mortality (7), meaning that there is not much concern when potassium levels are elevated but stay below 5 mmol/L. - J Am Coll Cardiol 2020, 10' education - Dec. 9, 2019 - Prof. Kausik Ray, MD, 10' education - Sep. 30, 2019 - Prof. Wouter Jukema, Literature - Dec. 1, 2020 - Giustino G, et al. A second study showed similar results for patients with stage 3-4 CKD, HF and diabetes and remarkably, mortality rates were almost comparable for patients who received reduced doses and those who discontinued. Franzosi MG, Santoro E, Zuanetti G, et al. Target Audience and Goal Statement. We list the most important adverse effects. Gout and its comorbidities: implications for therapy. Palmer BV. Moreover, if a patient has hyperkalaemia, this does not deny the patient from benefit: it was demonstrated that also patients with high potassium levels benefit from spironolactone treatment, since patients with high and low potassium levels had a similar decreased risk of death as placebo-treated patients (7). Renin-angiotensin-aldosterone system (RAAS) inhibitors are a group of drugs that act by inhibiting the renin-angiotensin-aldosterone system (RAAS) and include angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors. Clinical pharmacokinetics and pharmacodynamics of Aliskiren. Methods for Improvement Consultants © 2015 RASI Chart What is it? Prof. Zannad explained the implementation of RAAS inhibitors (RAASi) for the treatment of HF in clinical practice and their clinical impact. They are particularly important in the treatment of hypertensive diabetic patients, as they prevent the development of diabetic nephropathy. 2020, 3' education - Sep. 7, 2020 - Prof. Renato D. Lopes, MD, PhD, 5' education - Aug. 27, 2017 - ESC 2017, Barcelona, Spain, 10' education - June 12, 2018 - Prof. Frank Visseren - Utrecht, The Netherlands - Online CME, 10' education - June 12, 2018 - Prof. Richard Hobbs - Oxford, UK - Online CME, 10' education - June 6, 2018 - Prof. Kees Hovingh - Amsterdam, The Netherlands - Online CME, 5' education - Nov. 23, 2020 - Prof. Deepak Bhatt, MD, 3' education - Oct. 27, 2020 - Prof. Kausik Ray, MD, 10' education - Oct. 26, 2020 - Prof. Ulrich Laufs, MD, 10' education - Nov. 3, 2020 - Prof. Erik Stroes, MD, 10' education - Nov. 9, 2020 - Prof. John Kastelein, MD, 3' education - Mar. The selection is not exhaustive. Moreover, this algorithm provides information about how frequently potassium levels should be checked. 2020. Drugs.com provides accurate and independent information on more than 24,000 prescription drugs, over-the-counter medicines and natural products. These problems increase morbidity and mortality in the elderly. - JAMA. Angiotensin-converting enzyme inhibitors (ACE inhibitors) are a group of medicines that are mainly used to treat certain heart and kidney conditions; however, they may be used in the management of other conditions such as migraine and scleroderma.. In the nearby future, new potassium binders may optimise RAASi therapy, by allowing uptitration of the dose of RAASi. He showed that RAASi are frequently omitted or discontinued in clinical practice, although HF guidelines strongly recommend the use of RAASi for several indications. Study treatment in this study refers to ZS or placebo, while RAASi therapies are considered background therapy and will not be provided by the study sponsor. 22, 2018 - Filippo Crea, Angelyn Bethel, Eduard Montanya - Online CME, 10' education - Nov. 24, 2020 - Prof. Francesco Cosentino, MD, 3' education - Dec. 15, 2020 - Prof. van der Meer, MD, PhD, Literature - Dec. 8, 2020 - Unlu O, et al. These increased risks of mortality are similar for all types of RAASi. However, when alternative definitions of RAASi exposure were investigated (such as only including patients in receipt of RAASi over the duration of the follow-up period, or intervals where a RAASi therapy had been prescribed), the association pattern between serum potassium levels and the likelihood of RAASi discontinuation was preserved. Share this page with your colleagues and friends: 10' education - Feb. 11, 2020 - Prof. Deepak Bhatt, MD - Online CME, 10' education - Feb. 4, 2020 - Jorge Plutzky, MD - Online CME, 10' education - Jan. 16, 2020 - Prof. Børge Nordestgaard, MD, 10' education - Dec. 10, 2020 - Prof. Subodh Verma, MD, 10' education - Dec. 3, 2020 - Prof. Eduard Montanya, MD, 10' education - Dec. 1, 2020 - Prof. Naveed Sattar, MD, 10' education - Mar. The DIAMOND study is designed to further support the use of Veltassa ® to effectively control high blood potassium levels, thereby enabling optimal RAASi therapy in HF patients. Dr Piña leads a discussion on overcoming challenges with hyperkalemia when managing patients with HF on RAASi therapy. heart failure with reduced ejection fraction, Heart failure with reduced ejection fraction, http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf, https://www.uptodate.com/contents/renin-angiotensin-system-inhibition-in-the-treatment-of-hypertension, http://www.cvphysiology.com/Blood%20Pressure/BP015, https://www.uptodate.com/contents/aliskiren-drug-information, https://www.uptodate.com/contents/angiotensin-converting-enzyme-inhibitors-and-receptor-blockers-in-acute-myocardial-infarction-clinical-trials, https://www.uptodate.com/contents/major-side-effects-of-angiotensin-converting-enzyme-inhibitors-and-angiotensin-ii-receptor-blockers, https://www.uptodate.com/contents/angiotensin-converting-enzyme-inhibitors-and-receptor-blockers-in-pregnancy, https://www2.kidney.org/professionals/kdoqi/guidelines_bp/guide_11.htm, Drug interactions (see “Interactions” below). Presently, RAASi treatment is frequently discontinued due to the risk of hyperkalaemia (elevated blood potassium levels). 2015 Jan 15;372(3):222-31. Lazich I, et al., Semin Nephrol. BMC Nephrology (2018) 19:211 Page 6 of 16 increased unce rtainty of the ass ociation bet ween hyperk a- Discontinuation and reinitiating medication can be guided by an algorithm, for instance as used in EMPHASIS-HF (8). Pitt B, et al., Eur Heart J 2011;32:820-828. A method used to clarify roles and responsibilities. Effect of Enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. Epstein M, et al., Am J manag care 2015;21:S212-S220, 6. Zannad F, et al., N Engl J Med 2011;364:11-21, 19. Phillips CO, et al., Arch intern med. Who is At Risk for Hyperkalemia? Cost … Pitt B, et al., N Engl J Med 2003;348:1309-1321, 18. Vardeny O, et al., Circ Heart Fail 2014;7:573-579, 8. 2015 Jun;349(6):510-5, 5. Dürrenmatt Hall. and enabling optimal RAASi therapy in patients with CKD. John Deanfield, Jan Danser and Murray Epstein, 10' education - Apr. The study will evaluate the potential of Veltassa to improve outcomes by enabling heart failure patients, with or without chronic kidney disease, to be treated with renin-angiotensin-aldosterone system inhibitors (RAASi) therapy in accordance with HF treatment guidelines. For a vast majority of the HFpEF patients, a RAASi‐based therapy is used. However, said Zannad, ‘dose reduction or discontinuation is not always needed, as hyperkalaemia is just a very expected adverse event of RAASi’. Polónia J. Interaction of antihypertensive drugs with anti-inflammatory drugs. Roett MA, Liegl S, Jabbarpour Y. Diabetic nephropathy - the family physician's role. - PLoS Biol 2020, Literature - Sep. 28, 2020 - Mayl JJ et al. - JACC Cardiovasc Interv 2020, Literature - Nov. 6, 2020 - Szarek M, et al. Lecture - Apr. - Eur Heart J. 2020, 10' education - Sep. 21, 2020 - Fabrice Martens, MD, PhD, prof. Matthew Budoff, MD and prof. Gabriel Steg MD. 29, 2020 - Profs. Reported percentages of RAASi therapy (single or dual) discontinuation due to hyperkalemia from randomized trials of various patient groups (e.g. hypertension or heart failure) have been relatively low (0.4–8.1% [3,20]) while data on the patterns of RAASi therapy following hyperkalemia in CKD in routine clinical settings are limited. 2014;371:993-1004, 16. Raebel MA, et al., Pharmacoepidemiology and drug safety 2007;16:55-64. Renin angiotensin aldosterone system inhibitors/antagonists/blockers (RAASi) are a cornerstone in treatment of patients with cardiovascular diseases especially in those with heart failure (HF) due to their proven effect on surrogate and hard endpoints. The selection is not exhaustive. Methods: A patient-level simulation model was designed to fully characterise the natural history of CKD over a lifetime horizon, and predict the associations between serum potassium levels, RAASi use … Stamp LK, Chapman PT. The definition of hyperkalemia varies and limits such as >5.5, >6.0, or >7.0 mEq/L are used to indicate severity.1 Repetitive consecutive measures of serum potassium are needed to determine if hyperkalemia is sustained or a transient event. RAASi therapy was comprised of ACE inhibitors, ARBs, renin inhibitors and MRAs Furuland et al. *“Dose reduction or discontinuation is not always needed, as hyperkalaemia is just a very expected adverse event of RAASi”*. Maggioni AP, et al., Eur J Heart Fail. - J Am Coll Cardiol. In addition and more importantly, patients who did receive medication, were frequently underdosed, because these patients were at increased risk for concomitant adverse events (2-4). Definition of Hyperkalemia. Literature - Oct. 6, 2020 - Camm AJ et al. Cooper WO, Hernandez-diaz S, Arbogast PG, et al. Find out what is the full meaning of RAASI on Abbreviations.com! Renin–angiotensin–aldosterone system inhibitors (RAASi) are now a standard treatment in most patients with cardiovascular disease, especially in those with heart failure (HF). Unfortunately, it has been shown that measurements of potassium are not regularly executed in common practice (9). Do not combine direct renin inhibitors with ACE inhibitors or ARBs, especially in patients with diabetes or pre-existing kidney disease!References:[17][18][19][20][21], , which increases the retention of water and sodium, Contraindications for ACE inhibitors and ARBs, : GFR is already decreased and further reduction may lead to. ACE inhibitors and ARBs are commonly used in the treatment of patients with hypertension, heart failure with reduced ejection fraction, certain types of chronic kidney disease, and patients who have suffered a myocardial infarction. Harel Z, Gilbert C, Wald R, et al. In: Post TW, ed. Normally, angiotensin II constricts efferent vessels and thereby increases the GFR. The benefits of RAAS Inhibition Heart failure and CKD patients treated at guideline target doses of RAAS inhibition consistently have better clinical outcomes than patients who are treated with lower doses or who discontinue treatment1-13 Online-CME - This course consists of 3 parts. Gheorghiade M, et al., Congest heart fail. Yusuf S, Pitt B, Davis CE, Hood WB, Cohn JN. - J Am Heart Assoc. To date, real-world experiences and clinical trial data demonstrate that patients on potassium binders are able to significantly improve the likelihood they’ll remain on RAASi therapy. 9, 2018 - VBWG at ACC, Orlando, FL, USA - Prof. Mardi Gomberg-Maitland, Falls Church, VA, USA - Online CME, 5' education - Aug. 29, 2017 - ESC 2017, Barcelona, Spain - Prof Nazzareno Galiè - Bologna, Italy, Literature - June 6, 2017 - Kylhammar D, et al. 2014;34:333-339, 20. Acute Versus Chronic Hyperkalemia 3, 4 Direct renin inhibitors may be considered in hypertensive patients if ACE inhibitors or ARBs are not well tolerated; however, they should never be used in combination with other RAAS inhibitors. Packham DK, et al., N Engl J Med. You give aggressive therapy, you do lab testing, you bring them back to the clinic to prevent worsening of those particular diseases per se. Cagnoni F, Njwe CA, Zaninelli A, et al. However, kidney function was defined by a single baseline serum creatinine level within 12 months and single follow-up creatinine level within 2 months of RAASI therapy initiation. Renin-angiotensin-aldosterone system inhibitors (RAASi) are of prognostic benefit in patients with heart failure with reduced ejection fraction (HFrEF) and post myocardial infarction (MI) left ventricular systolic dysfunction (LVSD) and as such should be continued wherever possible for these indications. - Circ Heart Fail 2020, 10' education - Aug. 27, 2018 - Burkert Pieske, MD - Berlin, Germany - Online CME, Slides (presentation) - Aug. 27, 2018 - Carolyn Lam, MD - Singapore, 10' education - Aug. 27, 2018 - Barry Borlaug - Rochester, MN, USA - Online CME, Literature - Dec. 8, 2020 - Elbatreek MH, et al. Hyperkalaemia can be prevented by monitoring potassium levels, which can be done by e.g. Many factors affect potassium homeostasis.2 Table 1. The increasing longevity of humans results in a higher number of elderly patients’ presenting with multiple chronic diseases such as hypertension, diabetes, and chronic kidney disease (CKD). He showed that RAASi are frequently omitted or discontinued in clinical practice, although HF guidelines strongly recommend the use of RAASi for several indications. 14-09-2017 18:30 - 20:00 1 viewers. A dramatic effect on mortality in patients that did not receive or discontinued therapy with RAASi was reported by a Swedish registry (6). The effect of combination treatment with aliskiren and blockers of the renin-angiotensin system on hyperkalaemia and acute kidney injury: systematic review and meta-analysis. Lisbon 2017. 'Renin Angiotensin Aldosterone System Inhibitors' is one option -- get in to view more @ The Web's largest and most authoritative acronyms and abbreviations resource. Hence, Zannad emphasised that patients be maintained on RAASi medication when they are at risk of hyperkalaemia, thereby offering patients a life-saving therapy. In this study the adjusted incidence rates of hyperkalemia in CKD patients with and without RAASi therapy were 8.22 and 1.77 per 100 patient-months, respectively.2 Interestingly, RAASis seem to induce hyperkalemia even in patients receiving maintenance dialysis,10 most likely due to their effect on gastrointestinal potassium secretion. In a retrospective study, the frequency of underdosing of RAASi was independent of risk factors such as chronic kidney disease (CKD) and diabetes, and was noted in about two third of patients. Shirazian S, et al., Am J Med Sci. telemedicine. Townsend RR. 2020, 10' education - Nov. 24, 2020 - Anthony Fauci, MD. 2014;7:51-58, 9. Read our disclaimer. 2012;18:9-17, 4. They block the production of angiotensin II, a substance that narrows blood vessels and releases hormones such as aldosterone … 2015;17:1075-1083, 15. - J Am Coll Cardiol. Major congenital malformations after first-trimester exposure to ACE inhibitors. This is an international, multicentre, parallel-group, randomised, double-blind, placebo controlled, phase II study to evaluate the benefits and risks of using sodium zirconium cyclosilicate (ZS) to initiate and intensify renin angiotensin aldosterone system inhibitor (RAASi) therapy in … An unmet need exists for new hyperkalemia management guidelines that effectively incorporate classification and monitoring for hyperkalemia, optimization of renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and use of the newer potassium (K +) binders. Write comment. hypertension or heart failure) have been relatively low (0.4–8.1% [3,20]) while data on the patterns of RAASi therapy following hyperkalemia in CKD in routine clinical settings are limited. This activity is intended for nephrologists, cardiologists, and primary care physicians. POINTER: While the RASI method is an integral part Literature - Sep. 7, 2020 - Mehta A et al., - J Am Coll Cardiol. 12. Users of renin angiotensin aldosterone system inhibitors (RAASi) or diuretics have a slightly increased risk of acute kidney injury (AKI), new study findings in BMC Nephrology confirm. McMurray JJV, et al., N Engl J med. - J Am Coll Cardiol 2020, 5' education - Oct. 7, 2020 - Aernoud Fiolet, MD and prof. Jan Hein Cornel, MD, PhD, 10' education - Oct. 20, 2020 - Prof. Richard Hobbs, MD, 5' education - Jan. 15, 2020 - Thomas Gaziano, MD, Literature - Nov. 4, 2019 - Alexander M et al, - BMJ 2019, Literature - Dec. 15, 2020 - Castañer O, et al. Di Tano G, et al., Eur J Heart Fail. The first meta-analysis identified 33 randomized controlled trials with 68,405 patients, and reported that dual RAASi therapy was associated with a 55% higher relative risk of … Therefore, discontinuation of RAASi is not needed when levels are below this line and only dose reduction or temporary dose reduction should be considered. A common side effect of ACE inhibitors is a bradykinin-induced cough, which may necessitate switching to an alternative therapy (e.g. Unfortunately, these events are frequently associated with HF (2-4). Krum H, et al., Eur J Heart Fail. Furthermore, discontinuation was observed in 15-25% of patients (5). Complexity of Medication Regimen. August P. Angiotensin Converting Enzyme Inhibitors and Receptor Blockers in Pregnancy. Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). Standards of Medical Care in Diabetes 2016. Patients will participate in the study for approximately 16 to 18 weeks in total, depending on the duration of the screening period. Vaidyanathan S, Jarugula V, Dieterich HA, Howard D, Dole WP. Patients ( 8 ):510-5, 5 to be investigated in clinical practice and their clinical impact and peer-reviewed physicians—but. 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