Do I need to stop lisinopril (Angiotensin-Converting Enzyme Inhibitor) or chlorthalidone (Thiazide-like Diuretic) with chronic impaired renal function?

From the Guidelines

You should not stop lisinopril or chlorthalidone without consulting your healthcare provider first, as these medications often remain beneficial despite reduced kidney function, though they may require dose adjustments. For lisinopril (an ACE inhibitor), it can actually help protect kidney function in many patients with chronic kidney disease, though your doctor should monitor your potassium levels and kidney function regularly 1. Chlorthalidone (a thiazide diuretic) may become less effective as kidney function declines significantly, and your doctor might consider switching to a loop diuretic if your estimated glomerular filtration rate (eGFR) falls below 30 ml/min, as suggested by 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 1.

Some key points to consider when managing patients with chronic impaired renal function on these medications include:

• Monitoring potassium levels and kidney function regularly, especially when using ACE inhibitors like lisinopril 1
• Considering the switch to a loop diuretic if eGFR falls below 30 ml/min for patients on chlorthalidone 1
• Evaluating the patient's blood pressure control, degree of kidney dysfunction, potassium levels, and overall clinical condition to make informed decisions about medication adjustments 1
• Avoiding abrupt cessation of these medications to prevent uncontrolled blood pressure or worsening heart conditions 1

It's also worth noting that the ALLHAT study found no significant differences in end-stage renal failure between the chlorthalidone and lisinopril groups, suggesting that both medications can be effective in patients with chronic kidney disease, although more detailed information on renal function outcomes is needed 1. However, the most recent and highest quality guideline recommends continued use of these medications with appropriate monitoring and adjustments 1.

From the FDA Drug Label

1. 3 Impaired Renal Function Monitor renal function periodically in patients treated with lisinopril. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. 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, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure on lisinopril. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril [see Adverse Reactions (6. 1), Drug Interactions (7.4)].

Lisinopril and Chlorthalidone Use in Chronic Impaired Renal Function

• The FDA drug label for lisinopril recommends monitoring renal function periodically in patients with impaired renal function.
• Consider withholding or discontinuing lisinopril therapy in patients who develop a clinically significant decrease in renal function.
• There is no direct information in the provided drug labels regarding the need to stop chlorthalidone in patients with chronic impaired renal function.
• However, chlorthalidone has been found useful in edema due to various forms of renal dysfunction, including chronic renal failure 2.
• Clinical Decision: Monitor renal function closely in patients with chronic impaired renal function taking lisinopril or chlorthalidone. Consider adjusting or discontinuing therapy if a clinically significant decrease in renal function occurs. Consult the FDA drug label for lisinopril 3 and chlorthalidone 2 for more information.

From the Research

Stopping Lisinopril and Chlorthalidone with Chronic Impaired Renal Function

• There is no clear evidence to suggest that lisinopril (Angiotensin-Converting Enzyme Inhibitor) or chlorthalidone (Thiazide-like Diuretic) should be stopped in patients with chronic impaired renal function 4, 5, 6, 7, 8.
• In fact, studies suggest that these medications can be beneficial in patients with chronic kidney disease (CKD) and hypertension, as they can help to slow kidney function decline and improve blood pressure control 4, 6, 7.
• However, it is important to monitor patients with CKD closely for potential side effects, such as hyperkalemia, hypokalemia, and changes in serum creatinine levels, when using these medications 5, 6, 7, 8.
• The use of chlorthalidone in patients with advanced CKD has been shown to improve blood pressure control and reduce albuminuria, but may require close monitoring of electrolyte levels 6, 7.
• Lisinopril, an ACE inhibitor, may also be beneficial in patients with CKD, but may require dose adjustments and close monitoring of potassium levels, particularly in patients with end-stage renal disease (ESRD) 8.