What is the management of asymptomatic hyperkalemia in a patient on perindopril (Angiotensin-Converting Enzyme Inhibitor)?

From the Guidelines

For asymptomatic hyperkalemia in a patient on perindopril, the primary management step is to continue the RAASi therapy and consider adding a potassium-lowering agent, such as patiromer (Veltassa) or sodium zirconium cyclosilicate (SZC), to enable the patient to continue benefiting from the RAASi therapy while minimizing the risk of hyperkalemia. According to the expert consensus document on the management of hyperkalaemia in patients with cardiovascular disease treated with renin angiotensin aldosterone system inhibitors 1, therapies aimed at lowering potassium levels and enabling patients to continue RAASi therapy should be considered. The use of potassium binders, such as patiromer or SZC, can help to normalize elevated potassium levels and prevent recurrences of hyperkalemia in patients with hyperkalaemia on RAASi therapy.

In patients with potassium levels between 4.5 and 5 mEq/L, it is recommended to titrate or start RAASi therapy and closely monitor potassium levels 1. If potassium levels raise above 5.0 mEq/L, potassium-lowering measures should be initiated. 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 also recommends considering loop or thiazide diuretics to increase potassium excretion and reduce the occurrence of hyperkalemia 1.

Key considerations in the management of asymptomatic hyperkalemia in patients on perindopril include:

• Evaluating the patient's diet, use of supplements, salt substitutes, and nutraceuticals that contain potassium
• Monitoring kidney function and potassium levels closely
• Considering the use of potassium-lowering agents, such as patiromer or SZC, to enable the patient to continue benefiting from RAASi therapy
• Avoiding the use of drugs that may contribute to hyperkalemia or reduce kidney function
• Titration of RAASi therapy to the maximum tolerated evidence-based doses shown to reduce the risk of cardiovascular and renal events in clinical trials.

From the FDA Drug Label

Hyperkalemia: Elevations of serum potassium have been observed in some patients treated with ACE inhibitors, including perindopril erbumine tablets. Risk factors for the development of hyperkalemia include renal insufficiency, diabetes mellitus and the concomitant use of agents such as potassium-sparing diuretics, potassium supplements and/or potassium-containing salt substitutes Drugs associated with increases in serum potassium should be used cautiously, if at all, with perindopril erbumine tablets.

The management of asymptomatic hyperkalemia in a patient on perindopril is not explicitly stated in the drug label. However, it is recommended that drugs associated with increases in serum potassium should be used cautiously, if at all, with perindopril erbumine tablets.

• Risk factors for hyperkalemia should be identified and addressed.
• Potassium supplements and potassium-sparing diuretics should be used with caution.
• Renal function should be monitored, especially in patients with renal insufficiency or diabetes mellitus 2.

From the Research

Management of Asymptomatic Hyperkalemia

The management of asymptomatic hyperkalemia in a patient on perindopril (Angiotensin-Converting Enzyme Inhibitor) involves several considerations:

• Monitoring of serum potassium levels to assess the severity of hyperkalemia 3, 4
• Review of medications that may be contributing to hyperkalemia, such as renin-angiotensin-aldosterone system inhibitors (RAASis) like perindopril 5, 6
• Consideration of potassium-binding medications, such as patiromer or sodium zirconium cyclosilicate, to help lower serum potassium levels 5, 3, 6
• Dietary counseling to restrict potassium intake, if necessary 4

Treatment Options

Treatment options for asymptomatic hyperkalemia may include:

• Patiromer, a potassium-binding polymer that can help lower serum potassium levels 5
• Sodium zirconium cyclosilicate, another potassium-binding medication that can be used to treat hyperkalemia 3, 6
• Adjustment of RAASi dosage or consideration of alternative antihypertensive medications that do not increase serum potassium levels 7, 6

Considerations for Patients on Perindopril

For patients on perindopril, consideration should be given to:

• The potential for perindopril to increase serum potassium levels, particularly in patients with chronic kidney disease 7
• The importance of monitoring serum potassium levels regularly to detect any changes or abnormalities 3, 4
• The potential benefits of continuing RAASi therapy, such as perindopril, in patients with cardiovascular or renal disease, despite the risk of hyperkalemia 5, 6