Should medications be adjusted for a patient with a history of Acute Kidney Injury (AKI) who is currently taking Losartan (Angiotensin II Receptor Antagonist), Hydrochlorothiazide (HCTZ) (Thiazide Diuretic), and Amlodipine (Calcium Channel Blocker) for Hypertension (HTN)?

From the Guidelines

For a patient with a history of acute kidney injury (AKI) who is taking losartan, hydrochlorothiazide (HCTZ), and amlodipine for hypertension, I recommend temporarily discontinuing both losartan and HCTZ while maintaining amlodipine during the acute phase of kidney injury. Losartan, an angiotensin receptor blocker (ARB), can impair kidney autoregulation and worsen kidney function during AKI, as suggested by the KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease 1. Similarly, HCTZ, a thiazide diuretic, may be ineffective with reduced kidney function and could contribute to electrolyte imbalances. Amlodipine, a calcium channel blocker, is generally safer in kidney injury and can be continued for blood pressure control. Once kidney function stabilizes and improves, losartan could be cautiously reintroduced at a lower dose with close monitoring of kidney function and potassium levels, following the guidelines outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. For patients with chronic kidney disease following AKI, an alternative regimen might include amlodipine with careful reintroduction of an ACE inhibitor or ARB at reduced dosing, while potentially replacing HCTZ with a loop diuretic like furosemide if diuresis is needed. Regular monitoring of kidney function, electrolytes, and blood pressure is essential during any medication changes. Some key points to consider when managing hypertension in patients with AKI or chronic kidney disease include:

• Monitoring serum creatinine and potassium levels within 2-4 weeks after starting or changing the dose of ACE inhibitors or ARBs 1
• Avoiding the use of ACE inhibitors or ARBs in combination with direct renin inhibitors or other ACE inhibitors or ARBs 1
• Using loop diuretics instead of thiazide diuretics in patients with moderate to severe chronic kidney disease (GFR <30 mL/min) 1
• Considering the use of alternative antihypertensive agents, such as calcium channel blockers or beta blockers, in patients with AKI or chronic kidney disease 1

From the FDA Drug Label

The safety and efficacy of losartan potassium and hydrochlorothiazide as initial therapy for severe hypertension (defined as a mean SiDBP≥110 mmHg confirmed on 2 separate occasions off all antihypertensive therapy) was studied in a 6-week double-blind, randomized, multicenter study. A starting dose of 25 mg is recommended for patients with possible intravascular depletion (e.g., on diuretic therapy).

There is no direct information in the provided drug labels that suggests changing the medications (losartan, HCTZ, and amlodipine) for a patient with a history of Acute Kidney Injury (AKI) and hypertension (HTN).

• The labels provide information on the dosage and administration of losartan and HCTZ, but do not address the specific scenario of a patient with AKI.
• Caution is advised when using these medications in patients with renal impairment, but the labels do not provide explicit guidance on changing medications in this context 2, 3.

From the Research

Medication Considerations for Hypertension Management

The patient is currently taking losartan, HCTZ, and amlodipine for hypertension management. Considering the patient's history of Acute Kidney Injury (AKI), it is essential to evaluate the current medication regimen.

Efficacy of Combination Therapies

• The study 4 compared the efficacy of losartan + HCTZ and losartan + amlodipine combination therapies in patients with hypertension. The results showed that both combination therapies were effective in reducing blood pressure, with losartan + HCTZ being more efficacious in decreasing systolic blood pressure.
• Another study 5 compared the efficacy of losartan/HCTZ and candesartan/amlodipine combination therapies in patients with hypertension. The results showed that both combination therapies were effective in reducing blood pressure, with similar efficacy in reducing systolic and diastolic blood pressure.
• The study 6 evaluated the efficacy and safety of the losartan-HCTZ combination tablet in patients with hypertension uncontrolled by ARB monotherapy or combination therapy with a CCB. The results showed that the losartan-HCTZ combination tablet was effective in reducing blood pressure and had a good tolerability profile.
• The study 7 compared the efficacy of combined therapy with losartan, amlodipine, and HCTZ in patients with stage 2 hypertension. The results showed that the combination of losartan and amlodipine reduced blood pressure more effectively than the maximal doses of ARB or CCB with HCTZ.
• The study 8 compared the efficacy of combination ARB/CCB with HCTZ vs the maximal recommended dose of an ARB with HCTZ in patients with stage 2 hypertension. The results showed that the combination ARB/CCB with HCTZ reduced blood pressure more effectively than the maximal dose of an ARB with HCTZ.

Considerations for Medication Changes

• Based on the studies 4, 5, 6, 7, 8, the current medication regimen of losartan, HCTZ, and amlodipine may be effective in managing the patient's hypertension.
• However, considering the patient's history of AKI, it is essential to monitor the patient's kidney function and adjust the medication regimen as needed to minimize the risk of further kidney damage.
• The patient's medication regimen should be individualized based on their specific needs and medical history, and any changes to the medication regimen should be made under the guidance of a healthcare professional.