When to discontinue Angiotensin Receptor Blockers (ARBs) regarding impaired renal function?

When to Discontinue ARBs Regarding Renal Function

ARBs should be discontinued when serum creatinine rises by more than 30% within 4 weeks of initiation or dose increase, in cases of uncontrolled hyperkalemia despite medical treatment, or when treating symptomatic hypotension in patients with advanced kidney disease (eGFR <15 ml/min per 1.73 m²). 1

Monitoring Guidelines for ARB Therapy

ARBs are cornerstone medications for patients with chronic kidney disease (CKD), particularly those with albuminuria. However, careful monitoring is essential to balance their benefits against potential risks:

• Check serum creatinine, potassium, and blood pressure within 2-4 weeks of initiating or increasing ARB dose 1
• Continue monitoring periodically, especially in patients with eGFR <60 ml/min/1.73 m² 1
• For patients on ARBs with advanced CKD, more frequent monitoring (every 1-3 months) is recommended 1

When to Continue ARBs Despite Declining Renal Function

ARBs should be continued in the following circumstances:

• When serum creatinine increases by ≤30% from baseline after initiation 1
• When eGFR falls below 30 ml/min/1.73 m² in patients already established on therapy 1, 2
• In patients with CKD and albuminuria, as these medications provide significant cardiovascular and renal protection 3

Research shows that continuing ARBs in patients with declining kidney function may be associated with cardiovascular benefits without excessive risk of end-stage kidney disease 3. Even declines in eGFR of up to 13% over 3 months after starting ARBs are associated with favorable long-term outcomes compared to no treatment 4.

When to Discontinue ARBs

ARBs should be discontinued in the following situations:

1. Significant creatinine elevation: When serum creatinine rises by >30% within 4 weeks of initiation or dose increase 1

2. Uncontrolled hyperkalemia: When serum potassium remains elevated despite medical treatment 1, 5

3. Symptomatic hypotension: When patients experience symptoms of low blood pressure that cannot be managed with dose adjustment 1

4. Advanced kidney failure: Consider reducing dose or discontinuing when treating uremic symptoms in patients with eGFR <15 ml/min/1.73 m² 1

5. High-risk situations: Temporarily discontinue ARBs during:

   • Serious intercurrent illness
   • IV radiocontrast administration
   • Major surgery
   • Other situations with high risk of acute kidney injury 2

6. Pregnancy: ARBs are contraindicated in pregnancy due to fetal toxicity 5

Common Pitfalls to Avoid

1. Premature discontinuation: Many clinicians discontinue ARBs too early due to minor, expected increases in creatinine. Remember that increases up to 30% are acceptable and do not indicate kidney injury 1.

2. Inadequate monitoring: Failure to check serum creatinine and potassium within 2-4 weeks after starting or increasing ARB dose can lead to missed opportunities to detect adverse effects 1.

3. Suboptimal dosing: Using lower than recommended doses of ARBs due to fear of worsening renal function. Studies show that higher doses provide better outcomes and are generally well-tolerated even in CKD 1, 6.

4. Inappropriate combination therapy: Avoid combining ARBs with ACE inhibitors or direct renin inhibitors, as this increases adverse effects without additional benefits 1.

By following these evidence-based guidelines for ARB management in patients with renal impairment, clinicians can maximize cardiovascular and renal protection while minimizing risks of adverse events.