From the Guidelines
When GFR is low, ACE inhibitors (like lisinopril, enalapril) or ARBs (such as losartan, valsartan) are typically the best blood pressure medications to use, as they help protect kidney function while controlling blood pressure 1. The usual starting dose for lisinopril is 5-10mg daily or losartan 25-50mg daily, with adjustments based on blood pressure response. These medications work by reducing pressure within the kidneys' filtering units and decreasing protein leakage, which helps preserve remaining kidney function. However, these medications require careful monitoring as they can sometimes cause potassium levels to rise or GFR to decrease slightly when first started. Some key points to consider when using these medications include:
- Diuretics like chlorthalidone or indapamide may be added at low doses if additional blood pressure control is needed, but high doses should be avoided as they can worsen kidney function 1.
- Calcium channel blockers such as amlodipine (5-10mg daily) are another good option that can be used alone or in combination with ACE inhibitors/ARBs.
- Certain pain medications (NSAIDs like ibuprofen) should be avoided as they can further worsen kidney function when GFR is already low. It's also important to note that the use of ACE inhibitors or ARBs in patients with low GFR requires careful consideration of the potential risks and benefits, including the risk of hyperkalemia and acute kidney injury 1.
From the FDA Drug Label
The pharmacokinetics of amlodipine are not significantly influenced by renal impairment. Patients with renal failure may therefore receive the usual initial dose The best blood pressure medication to use when GFR is low is amlodipine, as its pharmacokinetics are not significantly affected by renal impairment.
- Key points:
- Amlodipine can be used at the usual initial dose in patients with renal failure.
- The pharmacokinetics of amlodipine are not significantly influenced by renal impairment 2.
- This makes amlodipine a suitable option for patients with low GFR.
From the Research
Blood Pressure Medications for Low GFR
When considering blood pressure medications for individuals with low Glomerular Filtration Rate (GFR), several factors must be taken into account.
- The choice of medication can significantly impact renal function and cardiovascular risk.
- Studies have shown that certain medications may be more beneficial than others in preserving renal function and reducing cardiovascular risk.
Calcium Channel Blockers
Calcium channel blockers are a class of medications that can effectively lower blood pressure and have been shown to be beneficial in certain patient populations.
- According to 3, calcium channel blockers can reduce blood pressure across all patient groups, regardless of sex, race/ethnicity, age, and dietary sodium intake.
- However, 4 suggests that calcium channel blockers may not be the best choice for patients with polycystic kidney disease, as they may contribute to a reduction in estimated GFR.
- On the other hand, 5 found that the calcium channel blocker cilnidipine can reduce albuminuria, urinary liver-type fatty acid binding protein, and plasma aldosterone levels in patients with chronic kidney disease.
Renin-Angiotensin-Aldosterone System Inhibitors
Renin-angiotensin-aldosterone system inhibitors, such as angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, are also commonly used to lower blood pressure and have been shown to have renoprotective effects.
- According to 6, these medications can have a beneficial effect on renal function, but the impact of early GFR decline on long-term renal outcomes is still unclear.
- 7 found that an initial decline in estimated GFR of up to 20% after blood pressure lowering can be accepted, and that the limit can be extended up to 46% depending on the achieved blood pressure reduction.
Considerations for Patients with Low GFR
When selecting a blood pressure medication for patients with low GFR, it is essential to consider the potential impact on renal function and cardiovascular risk.
- Patients with low GFR may require closer monitoring of their renal function and adjustment of their medication regimen as needed.
- The choice of medication should be individualized based on the patient's specific needs and medical history.