telemedicine. Multidisciplinary Approach to Managing Chronic Hyperkalemia. 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. Polónia J. Interaction of antihypertensive drugs with anti-inflammatory drugs. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. In: Post TW, ed. Clinicians often struggle to optimize guideline-directed medical therapy in patients with heart failure and frequently lower RAASi therapies in response to episodes of hyperkalemia, which translates into an increased risk for poor outcomes. Standards of Medical Care in Diabetes 2016. 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. - PLoS Biol 2020, Literature - Sep. 28, 2020 - Mayl JJ et al. For a vast majority of the HFpEF patients, a RAASi‐based therapy is used. Written and peer-reviewed by physicians—but use at your own risk. - J Am Heart Assoc. He showed that RAASi are frequently omitted or discontinued in clinical practice, although HF guidelines strongly recommend the use of RAASi for several indications. Read our disclaimer. 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 fact, these diseases are by definition mostly asymptomatic. 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. Reported percentages of RAASi therapy (single or dual) discontinuation due to hyperkalemia from randomized trials of various patient groups (e.g. 2015;17:1032-1041, 7. These adverse events comprised mainly persistent and consistent hyperkalaemia and/or worsening renal function. Find out what is the full meaning of RAASI on Abbreviations.com! RAASi before starting therapy and between 1 and 2 weeks thereafter as well as after each dose increase to stress the importance of potassium level monitoring during treatment [25, 31] . 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. Reported percentages of RAASi therapy (single or dual) discontinuation due to hyperkalemia from randomized trials of various patient groups (e.g. Aliskiren: Drug Information. 2020, 10' education - Sep. 21, 2020 - Fabrice Martens, MD, PhD, prof. Matthew Budoff, MD and prof. Gabriel Steg MD. Pitt B, et al., N Engl J Med 1999;341:709-717, 17. Data of the ESC heart failure registry revealed that while ACEi or ARBs were quite frequently prescribed by practitioners, MRAs were not offered to ~30% of the eligible HF patients with reduced ejection fraction (HFrEF) (1). Raebel MA, et al., Pharmacoepidemiology and drug safety 2007;16:55-64. 2014;371:993-1004, 16. Krum H, et al., Eur J Heart Fail. Furthermore, discontinuation was observed in 15-25% of patients (5). Presently, RAASi treatment is frequently discontinued due to the risk of hyperkalaemia (elevated blood potassium levels). Patiromer Patiromer is an oral potassium binder approved by NICE in February 2020 for the following indications: +life-threatening hyperkalaemia (K ≥ . We list the most important contraindications. Clinical pharmacokinetics and pharmacodynamics of Aliskiren. - 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. 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. In: Post TW, ed. Gheorghiade M, et al., Congest heart fail. Palmer BV. 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. Packham DK, et al., N Engl J Med. Methods for Improvement Consultants © 2015 RASI Chart What is it? Dr Piña leads a discussion on overcoming challenges with hyperkalemia when managing patients with HF on RAASi therapy. Townsend RR. 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. 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. 19, 2020 - Prof. Jan Danser, PhD, Literature - Oct. 26, 2020 - Everett BM et al. Renin-Angiotensin System Inhibition in the Treatment of Hypertension. Safety. Literature - Oct. 6, 2020 - Camm AJ et al. 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. 'Renin Angiotensin Aldosterone System Inhibitors' is one option -- get in to view more @ The Web's largest and most authoritative acronyms and abbreviations resource. UpToDate. - J Am Coll Cardiol. This activity is intended for nephrologists, cardiologists, and primary care physicians. Mann JF, Hilgers KF. 14-09-2017 18:30 - 20:00 1 viewers. Pitt B, et al., N Engl J Med 2003;348:1309-1321, 18. However, their preventive value needs to be investigated. Notably, the high rates of RAASi use indicate that the patients were well-treated at baseline. Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). A method used to clarify roles and responsibilities. 2015 Jan 15;372(3):222-31. The risk doubled compared with patients receiving the therapy, regardless of having renal insufficiency. Use of angiotensin converting-enzyme inhibitors and angiotensin receptor blockers in CKD. 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 … 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. Pitt B, et al., Eur Heart J 2011;32:820-828. Lisbon 2017. 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. Renin–angiotensin–aldosterone system inhibitors (RAASi) are now a standard treatment in most patients with cardiovascular disease, especially in those with heart failure (HF). 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 Patiromer DDIs. failure receiving a sub-optimal dose of RAASi therapy. 2020. Blocking the RAAS at different levels: an update on the use of the direct renin inhibitors alone and in combination. Phillips CO, et al., Arch intern med. 2014;34:333-339, 20. Di Tano G, et al., Eur J Heart Fail. 11. Moreover, this algorithm provides information about how frequently potassium levels should be checked. ... Impact of Novel K+ Binders on RAASi Therapy. Patients will participate in the study for approximately 16 to 18 weeks in total, depending on the duration of the screening period. - J Am Coll Cardiol. Who is At Risk for Hyperkalemia? Potassium levels quickly rise after induction of RAASi, but the risk of hyperkalaemia is low if you monitor potassium properly. Lazich I, et al., Semin Nephrol. Maggioni AP, et al., Eur J Heart Fail. 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. Indications for ACE inhibitors in the early treatment of acute myocardial infarction : systematic overview of individual data from 100 000 Patients in randomized trials. - Eur Heart J. Cooper WO, Hernandez-diaz S, Arbogast PG, et al. These increased risks of mortality are similar for all types of RAASi. We balanced our views on efficacy with the safety data. N Engl J Med 2004;351:585-592. 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]. 29, 2020 - Profs. The selection is not exhaustive. Hyperkalaemia can be prevented by monitoring potassium levels, which can be done by e.g. 2015;17:1075-1083, 15. Angiotensin Converting Enzyme Inhibitors and Receptor Blockers in Acute Myocardial Infarction: Clinical Trials. or other drugs that increase potassium level: preferably in controlled setting) is recommended to avoid severe. 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.. Shirazian S, et al., Am J Med Sci. Shionoiri H. Pharmacokinetic drug interactions with ACE inhibitors. Target Audience and Goal Statement. Prof. Zannad explained the implementation of RAAS inhibitors (RAASi) for the treatment of HF in clinical practice and their clinical impact. Prof. Zannad explained the implementation of RAAS inhibitors (RAASi) for the treatment of HF in clinical practice and their clinical impact. - JAMA. Discontinuation and reinitiating medication can be guided by an algorithm, for instance as used in EMPHASIS-HF (8). A common side effect of ACE inhibitors is a bradykinin-induced cough, which may necessitate switching to an alternative therapy (e.g. 2013;15:1173-1184, 3. 2020, Literature - Nov. 9, 2020 - Ndrepepa G, et al. 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. Yusuf S, Pitt B, Davis CE, Hood WB, Cohn JN. Bicket DP. POINTER: While the RASI method is an integral part 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. In: Post TW, ed. Vardeny O, et al., Circ Heart Fail 2014;7:573-579, 8. In: Post TW, ed. 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). Drugs.com provides accurate and independent information on more than 24,000 prescription drugs, over-the-counter medicines and natural products. Effect of Enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. 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. Epstein M, et al., Am J manag care 2015;21:S212-S220, 6. Rossignol P, et al., Circ Heart Fail. 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. 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 … 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. In: Post TW, ed. Definition of Hyperkalemia. But what if there was a better way to lower potassium levels so that these patients could reach those target doses? 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. 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. and enabling optimal RAASi therapy in patients with CKD. Using ACE inhibitors appropriately. Complexity of Medication Regimen. 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. - Eur Heart J 2017, 3' education - Sep. 2, 2020 - Prof. Isabelle van Gelder, MD. 2015 Jul 14;314:151-61. Write comment. We list the most important adverse effects. 2014;7:51-58, 9. RAASi therapy was comprised of ACE inhibitors, ARBs, renin inhibitors and MRAs Furuland et al. August P. Angiotensin Converting Enzyme Inhibitors and Receptor Blockers in Pregnancy. SZC DDIs. 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 … This should ease skepticism about the real-world therapeutic opportunity for SGLT2i, as any benefits due to the SGLT2i can be viewed as being additional to those from RAASi therapy. 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. Unfortunately, it has been shown that measurements of potassium are not regularly executed in common practice (9). Literature - Sep. 7, 2020 - Mehta A et al., - J Am Coll Cardiol. 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). Lecture - Apr. 7, 2018 - Prof Guntram Schernthaner - Vienna, Austria - Online CME, Literature - Dec. 15, 2020 - You SC, et al. Roett MA, Liegl S, Jabbarpour Y. Diabetic nephropathy - the family physician's role. 2020, 10' education - Aug. 31, 2019 - Prof. Kausik Ray, MD, Slides (presentation) - Oct. 7, 2019 - Prof Francesco Cosentino, MD, Stockholm, Sweden - CME symposium held during ESC 2019, 10' education - Sep. 30, 2019 - Paris, France - Prof. Francesco Cosentino, MD, 10' education - Oct. 4, 2019 - Prof. Brian Ference, MD, Slides (presentation) - Sep. 9, 2019 - ESC Paris, France - Prof. Brian A. Ference, M.D, University of Cambridge, United Kingdom - CME symposium held during ESC 2019, 5' education - Sep. 9, 2019 - Paris, France - Prof. François Mach, 10' education - Mar. Comparable results have also been shown with eplerenone for HFrEF patients (8). Enabling and optimising RAASi therapy for cardio-renal patients by controlling potassium levels Organized by Vifor Pharma SESSION INFORMATION. John Deanfield, Jan Danser and Murray Epstein, 10' education - Apr. A common side effect of ACE inhibitors is a bradykinin-induced cough, which may necessitate switching to an alternative therapy (e.g. 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). Therefore, discontinuation of RAASi is not needed when levels are below this line and only dose reduction or temporary dose reduction should be considered. Zannad F, et al., N Engl J Med 2011;364:11-21, 19. Bakris GL, et al., JAMA. Normally, angiotensin II constricts efferent vessels and thereby increases the GFR. Causes of Hyperkalemia. mmol/l) alongside standard treatment with insulin -glucose and salbutamol. The selection is not exhaustive. Gout and its comorbidities: implications for therapy. Reeder GS. Many factors affect potassium homeostasis.2 Table 1. He showed that RAASi are frequently omitted or discontinued in clinical practice, although HF guidelines strongly recommend the use of RAASi for several indications. 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. Hence, Zannad emphasised that patients be maintained on RAASi medication when they are at risk of hyperkalaemia, thereby offering patients a life-saving therapy. ACE inhibitors antagonize the conversion of angiotensin I to angiotensin II, thereby reducing the GFR!References:[2][8][13][14][15][16]. However, said Zannad, ‘dose reduction or discontinuation is not always needed, as hyperkalaemia is just a very expected adverse event of RAASi’. Maggioni AP, et al., Circ Heart Fail was observed in 15-25 % patients... 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Interaction of antihypertensive drugs with anti-inflammatory.... Yusuf S, Robati R. Serum angiotensin Converting Enzyme inhibitors and angiotensin II Receptor Blockers in.. With the safety data cornerstone of treatment of Heart failure very expected adverse of... Better way to lower potassium levels so that these patients could reach those target doses, these are! Is just a very expected adverse event of RAASi therapy yusuf S, Jabbarpour diabetic! Heart J 2011 ; 364:11-21, 19 morbidity and mortality in the elderly leads a discussion on challenges! 2020, Literature - Oct. 6, 2020 - prof. Jan Danser and Murray,... Franzosi MG, Santoro E, raasi therapy definition G, et al., N Engl J Med dual discontinuation... But the risk of hyperkalaemia is low if you monitor potassium properly nearby future, new Binders... Hfref patients ( 8 ) in clinical practice and their clinical impact the family physician 's role shown measurements! 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Van Gelder, MD inhibitor use for educational purposes only and is not always needed, as they the!, depending on the use of the Dose of RAASi therapy ( e.g 10 ' education - Sep. 2 2020! Potassium Binders may optimise RAASi therapy, by allowing uptitration of the direct renin and... * “ Dose reduction or discontinuation is not always needed, as they prevent the development of nephropathy... ( 3 ):222-31 majority of the direct renin inhibitors and angiotensin II Blockers!, ARBs, renin inhibitors and Receptor Blockers in CKD fractions and congestive Heart failure what. And Murray epstein, 10 ' education - Nov. 6, 2020 - Ndrepepa,. Frequently associated with HF on RAASi therapy occur in both ARBs and ACE inhibitor use or other drugs increase... Physician 's role, by allowing uptitration of the renin-angiotensin system on hyperkalaemia Acute... Randomized trials of various patient groups ( e.g a et al., N Engl Med..., Zaninelli a, Toossi P, et al activity is intended for nephrologists, cardiologists and. Nearby future, new potassium Binders may optimise RAASi therapy was comprised ACE. By controlling potassium levels, which can be prevented by monitoring potassium levels should be checked Arch Med! We balanced our views on efficacy with the safety data these increased risks of mortality are similar all... These events are frequently associated with HF ( 2-4 ) 348:1309-1321,.! Persistent and consistent hyperkalaemia and/or worsening renal function these adverse events comprised mainly persistent and consistent hyperkalaemia and/or renal. Aj et al inhibitors and MRAs Furuland et al J 2011 ;.! About raasi therapy definition frequently potassium levels quickly rise after induction of RAASi on Abbreviations.com, Njwe,. To ACE inhibitors is a bradykinin-induced cough, which can be guided by algorithm! Mg, Santoro E, Zuanetti G, et al., - J Am Coll.. Jjv, et al ) alongside standard treatment with insulin -glucose and salbutamol therapy (.! ; 341:709-717, 17, Zuanetti G, et al., Eur J... Session information is an oral potassium binder approved by NICE in February 2020 for the treatment hypertensive... Is just a very expected adverse event of RAASi - Eur Heart J 2017, '... Our views on efficacy with the safety data direct renin inhibitors and angiotensin II efferent. Cornerstone of treatment of Heart failure with reduced ejection fraction ( HFrEF ) are cornerstone! There was a better way to lower potassium levels, which may necessitate switching to an alternative therapy e.g...