ARB's vs ACE-I's

[hoolahan, ASN, RN]

OK, I am doing home health, and I have a question.

Ordinarily, I expect a pt to be on one kind of med per category. Eg, if I got into a home and pt has Lopressor and Toprol XL and is taking both, it is pretty easy to figure out why they have been dizzy, fell and have a slow HR!

I have had to thin out many people's meds in this way, taking 2 and sometimes 3 diff types of same category cardiac med.

So, now we come to ACE-I's and ARB's. I understand that of these categories work on a different part of the pathway of the renin-angiotensin system. The ARB's result in less cough as S/E. But what about the potential for renal failure.

I realize these agencts are cardioprotective in the long run, but I am concerend about the potential for renal failure, esp in the elderly. I have seen quite a few pt's end up with serious elevations of BUN/Creat from the ACE-I's.

My questions are these...

Is the potential for Renal Failure as high w ARB as it is w ACE-I's?

AND, isn't it overkill to have people on a drug in each of these categories at the same time?? I am seeing this more often, and can't get straight answer on this. Is it appropriate to treat pt w ACE-I and ARB simultaneously??

My gut says pick one, have their not been enough studies??

Thanks for your input.

[healingtouchRN]

well, personally, I got off my ACE (&got my mom off her ACE last week becuase of dry cough & the incontinence problem that goes with it!). I switched to an ARB with a thiazide component with good results. My labs are fine so far. No more stupid dry cough!!! hack, hack-'scuz me....Pt's should not be on both ACE & ARB"s, must be an oversite.

Usually we don't use two kinds of Beta blockers or calcuim channel blockers, 'cause you can usually go up on the dose or just change categories all together. I have caught the error myself. Just run it past the cardiologist (I work in CCU so I see them daily). They are mostly happy I am paying attention, before the person gets moved to telemetry & had some sort of episode of CHB!! or something. Now don't get me wrong about the nurses on telemetry, they are good, but they have soooooo many people to look after (7-9 each) & are not as likely to have a chance to check it out.

I'd like to hear any other comments on the same subject ACE/ARB's. I have been doing a lot of reading on the subject.

[hoolahan, ASN, RN]

Thanks Healing Touch. I don't "see" the docs anymore d/t being in the home, and frequently, I have to communicate via receptionist, but the good cardiologists have a nurse we can speak to, they always get back to me at least.

Problem is, I run into this on the weekends, and can't get a straight answer from the doc on-call, who is inevitably not the one who treats the pt, and usually not even in the same practice. If I only work the w/e, I never get to do the follow up.

I have to remember to ask this next time I actually speak to a cardiologist.

[rstewart]

HealingTouch is incorrect in his/her assertion that patients should not be on ARBs and ACEs in combination; it is not necessarily an error.

There is some evidence that combination therapy is beneficial for some patient populations due to the different mechanisms of action. There are, however, no long term studies confirming improved outcomes.

In short, I would discuss the medications with the patient's cardiologist (and/or nephrologist if applicable) to identify the specific/individual rationale for combination therapy.

[vadee]

ACE-Inhibitor is not good for renal clients. I'm not sure about ARB's. What is the best Anti-HTN med for one with renal issues?

[Virgo_RN, BSN, RN]

ACE inhibitors and ARBs are often used in combination, and both are indicated for patients with renal insufficiency.

[vadee]

so are you saying that both are great for clients with renal insuff? i'm confused.

[Virgo_RN, BSN, RN]

Why are you confused?

[vadee]

so what you are saying is that both are great for someone with renal insufficiency? i read somewhere that ACE-Is are contraindicated for those with renal insufficiency clients. please elaborate on your answer. thanks in advance.

[Virgo_RN, BSN, RN]

ACE-Is should be used with caution in people with renal impairment due to the risk of hyperkalemia. That doesn't mean they're contraindicated, but that potassium levels should be monitored.

My understanding is that ACE-Is used to be avoided in patients with renal impairment, but research no longer supports withholding them from that group of patients. In fact, my pharmacology text goes so far as to state that ACE-Is and ARBs are the ideal antihypertensives for people with renal impairment.

[vadee]

thank you for that insight.

The nursing intervention for ACE-Is to watch for cough (although it is a common side effect, drug is discontinued if coughing occurs)...is that true? should ACE-I be D/C if coughing is present?

The other nursing intervention for ACE-Is is to watch for orthostatic hypotension. Nurses are to notify the Physician if there is a significant decreased in systolic pressure.

My book states that ARB's med are great for those who complain of coughing with ACE-Is. ARB's does not require initial adjustment of dose for those with renal impairments. can you explain why the combination would be great together? i have nothing in my book stating so.

[Virgo_RN, BSN, RN]

The benefits of the therapy can often outweigh the side effects. If the patient can handle a little coughing and is okay with it, then I don't see why the med should be DCd. If the patient is coughing at a level that they find intolerable, then of course it would be reasonable to DC it.

Combination therapy would be indicated for someone who does not respond to a single medication.