Should I discontinue (DC) or decrease losartan (Losartan) 50mg in a patient with End-Stage Renal Disease (ESRD) on Hemodialysis (HD) who was not well controlled on nifedipine (Nifedipine)?

From the Guidelines

For a patient with End-Stage Renal Disease (ESRD) on hemodialysis who was not well controlled on nifedipine, you should consider decreasing the dose of losartan 50mg to 25mg daily, rather than discontinuing it, as losartan can provide cardiovascular protection and help manage blood pressure between dialysis sessions. Losartan, an Ang II receptor antagonist, is not contraindicated in patients with ESRD and can be beneficial in this population 1. However, it is essential to monitor the patient's blood pressure before and after dialysis sessions, as well as check potassium levels regularly, due to the increased risk of hyperkalemia and hypotension associated with losartan use in ESRD patients 1.

Key Considerations

• The patient's blood pressure should be monitored closely to avoid hypotension, particularly after dialysis sessions.
• Potassium levels should be checked regularly to prevent hyperkalemia.
• The timing of losartan administration is crucial; giving it after dialysis rather than before can help maintain its effectiveness while reducing adverse effects.
• If blood pressure remains uncontrolled or hyperkalemia develops despite dose reduction, consider switching to a different antihypertensive class with less renal impact.

Management

• Decrease losartan dose to 25mg daily and monitor patient's response.
• Adjust the timing of losartan administration to after dialysis sessions.
• Regularly check blood pressure, potassium levels, and assess for symptoms of hypotension.
• Consider alternative antihypertensive classes if necessary, such as calcium channel blockers or beta-blockers.

From the FDA Drug Label

5.3 Renal Function Deterioration Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system and by diuretics. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, or volume depletion) may be at particular risk of developing acute renal failure on losartan. Monitor renal function periodically in these patients Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on losartan

Key Considerations:

• The patient has End-Stage Renal Disease (ESRD) on Hemodialysis (HD), indicating severe renal impairment.
• Losartan may cause changes in renal function, including acute renal failure, especially in patients with pre-existing renal conditions.
• The drug label recommends monitoring renal function periodically and considering withholding or discontinuing therapy if a clinically significant decrease in renal function occurs.

Decision: Given the patient's severe renal impairment and the potential risks associated with losartan, it is prudent to consider discontinuing losartan 50mg. However, this decision should be made in consultation with the patient's healthcare team, taking into account their individual clinical circumstances and the potential benefits and risks of continuing or discontinuing losartan therapy 2.

From the Research

Patient Background

• The patient has End-Stage Renal Disease (ESRD) and is on Hemodialysis (HD)
• The patient was not well controlled on nifedipine
• The patient is currently on losartan 50mg

Considerations for Losartan in ESRD Patients on HD

• Losartan is an angiotensin II receptor blocker that can be used in patients with ESRD on HD 3
• Losartan is not removed during hemodialysis, and its pharmacokinetics are not substantially changed in patients with renal insufficiency 4
• The use of losartan in ESRD patients on HD has been shown to be well tolerated and effective in reducing blood pressure 5

Potential Risks and Benefits

• Losartan may cause hyperkalemia, anaphylactoid reactions with AN69 membranes, and aggravation of renal anemia 3
• Losartan has been shown to reduce morbidity and mortality by reducing mean arterial pressure, aortic pulse wave velocity, and aortic systolic pressure augmentation, as well as left ventricular hypertrophy (LVH) and probably reduction of C-reactive protein (CRP) and oxidant stress 3
• The risk of anaphylactoid reactions with losartan is lower than with ACE inhibitors, and losartan can be used in patients with a history of anaphylactoid reactions with ACE inhibitors and AN69 membranes 5

Decision on Losartan Dose

• There is no clear indication to discontinue losartan in this patient, as it has been shown to be effective and well tolerated in ESRD patients on HD 5
• The dose of losartan may need to be adjusted based on the patient's blood pressure response and tolerance to the medication 4
• It is recommended to monitor the patient's blood pressure, electrolyte levels, and renal function while on losartan therapy 3, 4, 5