From the Guidelines
In this situation, it would be best to hold the trandolapril (an ACE inhibitor) while the patient is ill with acute pancreatitis, low-normal blood pressure, and reduced oral fluid intake. ACE inhibitors like trandolapril can exacerbate hypotension in volume-depleted states, which commonly occur during acute pancreatitis due to decreased oral intake, third-spacing of fluids, and potential vomiting. Additionally, ACE inhibitors can impair the kidney's ability to autoregulate blood flow when a patient is volume depleted, potentially leading to acute kidney injury. Atenolol (a beta-blocker) would be the preferred medication to continue as it generally causes less hemodynamic compromise in the setting of volume depletion. However, blood pressure should be monitored closely, and if hypotension worsens, both antihypertensives may need to be temporarily held. Once the patient's oral intake improves and they are adequately hydrated, trandolapril can be safely restarted. This approach helps balance the need to maintain some blood pressure control while minimizing the risk of hypotension and kidney injury during acute illness, as suggested by guidelines for managing heart failure and acute illness 1. Key considerations include:
- Monitoring fluid intake and output, vital signs, and clinical signs of congestion and perfusion 1
- Adjusting medications as necessary to maintain optimal blood pressure and volume status 1
- Avoiding nonsteroidal anti-inflammatory drugs, which can worsen kidney function and interact with ACE inhibitors 1
- Considering the potential interaction between aspirin and ACE inhibitors, although the evidence is not conclusive 1.
From the Research
Management of Hypertension in Acute Pancreatitis
- The patient is on atenolol and trandolapril for hypertension and is admitted for acute uncomplicated pancreatitis with low oral fluid intake.
- Given the patient's condition, it is necessary to consider which anti-hypertensive medication to hold to avoid potential complications.
- Trandolapril is an angiotensin-converting enzyme (ACE) inhibitor, and there is evidence suggesting a potential association between ACE inhibitors and pancreatitis 2.
- ACE inhibitors can cause significant ductal obstruction and fluid retention, which may trigger acute pancreatitis complicated by pseudocyst formation 2.
- Considering the patient's low oral fluid intake and the potential risks associated with ACE inhibitors, it may be best to hold trandolapril.
Considerations for Holding Anti-Hypertensive Medications
- Atenolol is a beta-blocker, and there is no direct evidence suggesting a link between beta-blockers and acute pancreatitis.
- The management of acute pancreatitis involves supportive care with fluid replacement, pain control, and controlled initiation of regular food intake 3, 4, 5, 6.
- Holding trandolapril may help minimize the risk of potential complications associated with ACE inhibitors in the context of acute pancreatitis 2.