What are the best blood pressure medications for End-Stage Renal Disease (ESRD), malignant hypertension (MHTN), Systemic Lupus Erythematosus (SLE), and Sjögren's syndrome?

From the Guidelines

For patients with end-stage renal disease (ESRD), malignant hypertension, systemic lupus erythematosus (SLE), and Sjögren's syndrome, the most effective blood pressure management strategy is to use a combination of medications, with ACE inhibitors or angiotensin receptor blockers (ARBs) as first-line treatments, according to the 2024 ESC guidelines 1. The recommended approach involves using a single-pill combination of two major drug classes, such as ACE inhibitors, ARBs, dihydropyridine calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics, at low doses initially.

• Specific options include lisinopril (10-40 mg daily) or losartan (25-100 mg daily), which provide renoprotection and help manage proteinuria common in these autoimmune conditions.
• Calcium channel blockers like amlodipine (5-10 mg daily) are excellent add-on agents as they don't worsen renal function and effectively lower blood pressure.
• For malignant hypertension, immediate-acting medications may be needed initially, such as IV labetalol or nicardipine in a hospital setting, followed by transition to oral medications.
• Loop diuretics like furosemide (20-80 mg daily or twice daily) are often necessary for fluid management in ESRD. Key considerations include:
• Medication doses must be adjusted for kidney function, with lower doses typically required in ESRD.
• Blood pressure goals should be individualized but generally aim for <130/80 mmHg, as recommended by the 2020 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1.
• Regular monitoring of kidney function, electrolytes (particularly potassium with ACE inhibitors/ARBs), and blood pressure is essential. In cases of resistant hypertension, the addition of spironolactone or other mineralocorticoid receptor antagonists (MRAs) like eplerenone should be considered, as per the 2024 ESC guidelines 1. It's also important to note that the combination of an ACE inhibitor and an ARB is not recommended, as stated in the 2020 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1 and the 2018 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.

From the FDA Drug Label

The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Treatment with losartan resulted in a 16% risk reduction in this endpoint (see Figure 4 and Table 4) Treatment with losartan also reduced the occurrence of sustained doubling of serum creatinine by 25% and ESRD by 29% as separate endpoints, but had no effect on overall mortality (see Table 4).

The best blood pressure medication for ESRD mentioned in the study is losartan, as it reduced the occurrence of ESRD by 29%. For malignant hypertension, SLE, and Sjogren’s syndrome, there is no direct information in the provided drug label to support a specific blood pressure medication. Key points:

• Losartan is effective in reducing the risk of ESRD in patients with type 2 diabetes and nephropathy.
• The study does not provide information on the best blood pressure medications for malignant hypertension, SLE, or Sjogren’s syndrome 2.

From the Research

Blood Pressure Management in ESRD, Malignant HTN, SLE, and Sjogrene's Syndrome

• The management of blood pressure in End-Stage Renal Disease (ESRD) is complicated by various factors, including missed dialysis treatments and intradialytic changes in blood pressure 3.
• Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers are reasonable first-line agents for most ESRD patients 3.
• For patients with ESRD, controlling blood pressure through volume control and sodium restriction can help optimize hypertension treatment 4.
• The use of ACE inhibitors and ARBs in ESRD patients may reduce the risk of mortality, including cardiovascular death and all-cause mortality 5.

Hypertension Management in SLE and Sjogrene's Syndrome

• Systemic lupus erythematosus (SLE) is associated with a high burden of cardiovascular disease, which is in part imputed to classical vascular risk factors such as hypertension 6.
• Hypertension is frequent among patients with SLE, and its management is crucial to prevent damage accrual, stroke, and cognitive dysfunction 6.
• However, current guidelines neglect the specific management of hypertension in SLE patients, and more research is needed to understand the pathophysiological mechanisms underlying the development of hypertension in SLE 6.
• For malignant hypertension, combination therapy using multiple antihypertensive agents, such as thiazide diuretics, calcium channel blockers, ACE inhibitors, and ARBs, may be necessary to achieve adequate blood pressure control 7.

Antihypertensive Medications

• ACE inhibitors and ARBs exert cardioprotective effects that are independent of blood pressure reduction, making them suitable options for patients with ESRD and SLE 3, 5.
• Beta-blockers are also reasonable first-line agents for most patients, especially those with heart failure or reduced ejection fraction 7.
• Thiazide diuretics and calcium channel blockers may be used in combination with ACE inhibitors or ARBs to achieve adequate blood pressure control 7.
• Medications that are removed with dialysis may be preferred in patients who are prone to develop intradialytic hypotension 3.