When to Stop ARBs in Chronic Kidney Disease
ARBs should be discontinued in CKD patients when there is symptomatic hypotension, uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms when eGFR falls below 15 ml/min per 1.73 m².1
Indications for ARB Discontinuation
Absolute Indications for Discontinuation
- Symptomatic hypotension that compromises patient's quality of life or increases fall risk 1
- Uncontrolled hyperkalemia (serum potassium >6.5 mEq/L) that persists despite potassium-lowering interventions 1
- Advanced kidney failure (eGFR <15 ml/min per 1.73 m²) with uremic symptoms that may be exacerbated by ARB therapy 1
- Serum creatinine rise >30% within 4 weeks of initiation or dose increase 1
- Pregnancy or planning pregnancy (ARBs are contraindicated due to fetal risks) 1
Relative Indications (Consider Dose Reduction First)
- Moderate hyperkalemia (5.6-6.5 mEq/L) that can be managed with potassium-lowering strategies 1
- Acute kidney injury during hospitalization (temporary hold may be needed) 2
- Serum bicarbonate <22 mmol/L (associated with higher risk of discontinuation) 2
Management Algorithm Before Discontinuation
When faced with potential ARB discontinuation scenarios, follow this stepwise approach:
For hyperkalemia (K+ 5.0-6.5 mEq/L):
- Review concurrent medications that may contribute to hyperkalemia 1
- Implement dietary potassium restriction 1
- Consider adding or increasing diuretic therapy (thiazides are associated with lower risk of ARB discontinuation) 3, 2
- Consider potassium binders (sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate) 1, 3
- Only reduce ARB dose if above measures fail 1
For creatinine rise:
For advanced CKD (eGFR <30 ml/min per 1.73 m²):
Important Considerations
Benefits of Continuing ARBs in CKD
- ARBs provide significant renoprotection in CKD patients with albuminuria 1, 4
- ARBs slow CKD progression more effectively than other antihypertensive therapies 5
- Continuing ARBs even in advanced CKD (eGFR <30 ml/min per 1.73 m²) is recommended unless contraindicated 1
Monitoring Recommendations
- Check serum creatinine and potassium within 2-4 weeks after starting or changing ARB dose 1
- For stable patients on maintenance therapy, monitor every 3-6 months 1
- More frequent monitoring (every 1-2 weeks) may be needed in advanced CKD or after dose adjustments 1
Common Pitfalls to Avoid
- Premature discontinuation: Many clinicians discontinue ARBs too early due to minor, expected changes in creatinine or mild hyperkalemia 4
- Failure to attempt potassium management: Hyperkalemia can often be managed without ARB discontinuation 3
- Overlooking drug interactions: NSAIDs, potassium supplements, and potassium-sparing diuretics can worsen hyperkalemia 1, 2
- Inappropriate combination therapy: Never combine ARBs with ACE inhibitors or direct renin inhibitors 1
Special Situations
Diabetic CKD
- ARBs are strongly recommended for diabetic patients with CKD and albuminuria 1
- Consider adding SGLT2 inhibitor before discontinuing ARB in diabetic CKD patients with eGFR ≥20 ml/min per 1.73 m² 1
Heart Failure with CKD
- Greater tolerance for mild-moderate hyperkalemia (K+ 5.0-5.5 mEq/L) may be warranted due to cardiovascular benefits 1
- Consider potassium binders to maintain ARB therapy rather than discontinuation 1, 3