From the Guidelines
Yes, both Angiotensin-Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs) can cause hyperkalemia as a side effect. These medications, which include drugs like lisinopril, enalapril, and ramipril (ACE inhibitors) and losartan, valsartan, and irbesartan (ARBs), can lead to elevated potassium levels in the blood because they reduce aldosterone production, a hormone that normally promotes potassium excretion by the kidneys 1. When aldosterone levels decrease, the kidneys retain more potassium, potentially leading to hyperkalemia.
Key Points to Consider
- The incidence of hyperkalemia with ACE inhibitors or ARBs monotherapy is less than 2%, but it increases to 5% with dual RAAS inhibition and to 5–10% when dual therapy is administered in patients with heart failure or chronic kidney disease 1.
- Patients taking these medications should have their potassium levels monitored regularly, especially when starting therapy or adjusting doses, as the risk of hyperkalemia is higher in patients with kidney disease, diabetes, advanced age, or those taking other medications that can increase potassium levels such as potassium-sparing diuretics, potassium supplements, or NSAIDs 1.
- If hyperkalemia develops, dose reduction or discontinuation of the medication may be necessary, along with dietary potassium restriction, and treatment with a K+ lowering agent should be initiated as early as possible to manage hyperkalemia 1.
Management of Hyperkalemia
- Life-threatening hyperkalemia requires immediate treatment with a combination of calcium carbonate and hyperosmolar sodium to stabilize the myocardial cell membrane, and insulin with or without glucose and/or beta adrenoceptor agonists to transfer K+ into the cells 1.
- Loop diuretics and potassium binders can be used to manage hyperkalemia, and the choice of treatment depends on the severity of hyperkalemia and the patient's underlying medical conditions 1.
From the Research
ACE Inhibitors and ARB Therapy
- Angiotensin-Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARB) are effective therapeutic agents used in various clinical scenarios, but their use can be associated with hyperkalemia, particularly in patients with chronic renal insufficiency 2, 3.
- The incidence of hyperkalemia associated with ACE inhibitors or ARB therapy varies, but up to 10% of patients may experience at least mild hyperkalemia 2.
Risk Factors for Hyperkalemia
- Important considerations when initiating ACEI or ARB therapy include obtaining an estimate of glomerular filtration rate and a baseline serum potassium concentration, as well as assessing whether the patient has excessive potassium intake from diet, supplements, or drugs that can also increase serum potassium 2, 3.
- Patients with chronic kidney disease are at a higher risk of developing hyperkalemia when using ACEI or ARB therapy 4, 5.
Comparative Risk of Hyperkalemia
- A comparative study found that treatment with ACEI is associated with both a higher incidence and greater degree of hyperkalemia than treatment with ARB in adjusted models, especially in patients with chronic kidney disease 4.
- Another study found that the use of ACE inhibitors or angiotensin receptor blockers is independently associated with an increased risk of developing hyperkalemia in chronic hemodialysis patients 5.
Monitoring and Management
- Serum potassium monitoring shortly after initiation of ACEI or ARB therapy can assist in preventing hyperkalemia 2, 3.
- If hyperkalemia does develop, prompt recognition of cardiac dysrhythmias and effective treatment to antagonize the cardiac effects of potassium, redistribute potassium into cells, and remove excess potassium from the body is important 2, 3.
- Careful potassium level monitoring is necessary in patients using concomitant spironolactone and ACE/ARB therapy, especially in older patients and those with heart failure 6.