ACE inhibitor + ARB therapy: renal toxicity mirrors that seen in RCTs
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ACE inhibitor + ARB therapy: renal toxicity mirrors that seen in RCTs While randomised controlled trials (RCTs) have reported an increased incidence of renal dysfunction associated with ACE inhibitor/angiotensin receptor blocker (ARB) combination therapy, it had been speculated that this may not be present in clinical practice, where clinicians can minimise the risk by individualising the dosing of both drugs. A populationbased longitudinal analysis conducted using data from elderly residents of Alberta, Canada, however, shows that the hazard ratios for hyperkalaemia and renal dysfunction associated with combination therapy in clinical practice closely mirror those reported in RCTs.1 The researchers found that renal dysfunction was significantly more common among combination therapy recipients than among monotherapy recipients (5.2 vs 2.4 events per 1000 patients per month; adjusted hazard ratio [HR] 2.36; 95% CI 1.51, 3.71), as was hyperkalaemia (2.5 vs 0.9 events per 1000 patients per month; adjusted HR 2.42; 1.36, 4.32). The researchers suggest, however, that the most striking findings were: a) that the majority (86.4%) of combination therapy recipients did not have either heart failure or proteinuria – the two indications for which combination therapy has been proven to be beneficial – and b) that combination therapy was frequently discontinued after only a few months; and in most cases, patients experienced relatively minor changes in glomerular filtration rate or serum potassium levels during this time – suggesting that renal toxicity was not the reason these patients discontinued combination therapy. In an accompanying commentary, Christopher Phillips of the Morehouse School of Medicine suggests that improved patient selection with better risk-benefit assessments, including patient eligibility, appropriate clinical indications and tests for baseline renal function, could reassure prescribers that combination therapy remains a viable option for certain patients.2 1. McAlister FA, et al. The safety of combining angiotensin-converting-enzyme inhibitors with angiotensin-receptor blockers in elderly patients: a populationbased longitudinal analysis. CMAJ: Canadian Medical Association Journal : 21 Mar 2011. Available from: URL: http://dx.doi.org/10.1503/cmaj.101333. 2. Phillips CO. Combining angiotensin-receptor blockers with angiotensinconverting-enzyme inhibitors. CMAJ: Canadian Medical Association Journal : 21 Mar 2011. Available from: URL: http://dx.doi.org/10.1503/cmaj.110366. 801085375
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Reactions 16 Apr 2011 No. 1347
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