What is the best antihypertensive medication to use in a patient with impaired renal function, specifically a glomerular filtration rate (GFR) of 26?

From the Guidelines

For patients with a GFR of 26, ACE inhibitors or angiotensin receptor blockers (ARBs) are the preferred blood pressure medications due to their ability to lower blood pressure and protect remaining kidney function. The most recent and highest quality study, 1, published in 2022, supports the use of ACE inhibitors and ARBs in patients with chronic kidney disease, including those with a GFR of 26. Specific options include lisinopril (ACE inhibitor) at 2.5-10 mg daily or losartan (ARB) at 25-50 mg daily, with doses kept on the lower end due to reduced kidney function.

Some key points to consider when using ACE inhibitors or ARBs in patients with a GFR of 26 include:

• Dose adjustments are necessary with this level of kidney impairment
• Regular monitoring of kidney function and potassium levels is essential as these medications can cause potassium retention
• Combination therapy may be needed to reach blood pressure targets, with calcium channel blockers like amlodipine (2.5-5 mg daily) often added as they work well with ACE inhibitors/ARBs and require minimal dose adjustment in kidney disease
• Diuretics may also be used, but thiazides are less effective at this GFR level, so loop diuretics like furosemide are typically preferred

It's also important to note that ACE inhibitors and ARBs should not be discontinued for minor increases in serum creatinine (<30%), in the absence of volume depletion, as stated in 1. Additionally, the use of ACE inhibitors and ARBs has been shown to slow the progression of kidney disease and reduce the risk of cardiovascular events, as demonstrated in 1 and 1. Always consult with a nephrologist for personalized medication selection as individual factors like potassium levels, degree of proteinuria, and other medical conditions will influence the optimal choice.

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 26 is amlodipine, as its pharmacokinetics are not significantly influenced by renal impairment.

• Key points:
  • Amlodipine can be used in patients with renal failure
  • The usual initial dose can be administered to patients with renal failure
  • No significant change in dosage is required for patients with a GFR of 26 2

From the Research

Blood Pressure Medication Options for Patients with Low GFR

When considering blood pressure medication for patients with a glomerular filtration rate (GFR) of 26, several factors must be taken into account. The following options are available:

• Calcium channel blockers: These medications have been shown to effectively lower blood pressure in patients with hypertension, including those with chronic kidney disease 3. However, they may not be as effective in reducing the progression of renal disease as other classes of medications, such as inhibitors of the renin-angiotensin system.
• Angiotensin II receptor blockers (ARBs): ARBs have been shown to be effective in reducing blood pressure and slowing the progression of renal disease in patients with chronic kidney disease 4. However, the combination of an ARB and a calcium channel blocker may not provide additional benefits in reducing the risk of contrast-induced nephropathy 5.
• ACE inhibitors: ACE inhibitors have been shown to be effective in reducing blood pressure and slowing the progression of renal disease in patients with chronic kidney disease 6.

Considerations for Patients with Low GFR

When selecting a blood pressure medication for patients with a low GFR, the following considerations should be taken into account:

• The potential for the medication to reduce the progression of renal disease
• The risk of adverse effects, such as hyperkalemia or worsening renal function
• The potential for interactions with other medications
• The patient's overall health status and comorbidities

Medication Options

Based on the available evidence, the following medication options may be considered for patients with a GFR of 26:

• Calcium channel blockers, such as amlodipine 3, 7
• ARBs, such as losartan 4
• ACE inhibitors, such as lisinopril 6 It is essential to carefully evaluate the potential benefits and risks of each medication option and to monitor the patient's renal function and overall health status closely. 3, 5, 4, 6, 7