Next Best Medication for CKD Patient with Uncontrolled Hypertension on Amlodipine and Hydrochlorothiazide
An ACE inhibitor (such as lisinopril) or ARB (such as losartan) should be added as the next best medication for a patient with CKD secondary to hypertensive nephropathy who is not meeting blood pressure target despite being on amlodipine and hydrochlorothiazide. 1, 2
Rationale for Adding an ACE Inhibitor or ARB
- ACE inhibitors and ARBs are specifically recommended for patients with CKD due to their renoprotective effects beyond blood pressure lowering 1, 2
- For patients with hypertension who are not meeting blood pressure targets on two classes of antihypertensive medications (in this case, a calcium channel blocker and a thiazide diuretic), adding a third class is recommended 1
- The International Society of Hypertension guidelines recommend an ACE inhibitor or ARB as a core component of antihypertensive therapy in patients with CKD 1, 2
Medication Selection Considerations
- Start with a low dose of ACE inhibitor (e.g., lisinopril 5-10 mg daily) or ARB (e.g., losartan 50 mg daily) and titrate as needed 3, 4
- ARBs may be better tolerated than ACE inhibitors as they don't cause cough, though both classes have similar efficacy 2, 5
- Monitor renal function and potassium levels after initiating therapy, as ACE inhibitors and ARBs can cause acute kidney injury or hyperkalemia in some patients 1
If Target BP Still Not Achieved
- If blood pressure remains uncontrolled after adding an ACE inhibitor or ARB, the next step would be to add a mineralocorticoid receptor antagonist (spironolactone 25-50 mg daily) 1, 2
- Alternative fourth-line options include eplerenone, amiloride, or doxazosin if spironolactone is not tolerated 1, 2
Monitoring Recommendations
- Check blood pressure within 3 months of medication changes to assess efficacy 1, 2
- Monitor renal function and electrolytes (particularly potassium) within 1-2 weeks of starting an ACE inhibitor or ARB 1
- Target blood pressure for CKD patients should be <130/80 mmHg according to current guidelines 2
Important Cautions
- Never combine an ACE inhibitor with an ARB as this combination increases adverse effects (hyperkalemia, syncope, acute kidney injury) without providing additional cardiovascular benefit 1
- Ensure patient adherence to all medications before adding new agents 2
- In patients with advanced CKD (GFR <30 mL/min), dose adjustment of lisinopril may be required 3
Special Considerations for CKD Patients
- The combination of a renin-angiotensin system blocker (ACE inhibitor or ARB), calcium channel blocker, and thiazide diuretic is considered a rational and effective combination for hypertension management 6
- While some studies have shown conflicting results regarding the superiority of ACE inhibitors over calcium channel blockers in non-diabetic nephropathies, current guidelines still recommend ACE inhibitors or ARBs as preferred agents in CKD 7, 8