Should a 69-year-old male patient with a history of diabetes, hypertension, Chronic Kidney Disease (CKD), Atrial Fibrillation (AFib), and dementia, taking Eliquis (apixaban), metoprolol, and digoxin, continue olmesartan or explore alternative medications for Impaired Renal Function and well-controlled blood pressure?

From the Guidelines

The patient should not continue olmesartan due to increased risk of kidney injury, and instead, consider alternative antihypertensive medication classes such as calcium channel blockers or diuretics. Given the patient's history of diabetes, hypertension, CKD, AFib, dementia, and current medications (Eliquis, metoprolol, digoxin), it is crucial to prioritize medications that minimize the risk of further kidney damage. The patient's current creatinine level of 1.71 indicates reduced kidney function, and continuing olmesartan, an angiotensin receptor blocker (ARB), could lead to further deterioration 1. Alternative options include calcium channel blockers like amlodipine (starting at 5mg daily) or diuretics like chlorthalidone (12.5mg daily), which may provide blood pressure control with less impact on kidney function. Some key points to consider when selecting an alternative medication include:

• The patient's age and comorbidities, which may affect the pharmacokinetics and pharmacodynamics of certain medications 1
• The potential for drug interactions with the patient's current medications, such as Eliquis, metoprolol, and digoxin
• The need for regular monitoring of kidney function, electrolytes, and blood pressure with any medication change
• The importance of considering the patient's other conditions, particularly atrial fibrillation and diabetes, when selecting an alternative medication. Overall, the decision to switch from olmesartan to an alternative antihypertensive medication should be based on a careful consideration of the patient's individual needs and medical history, with the goal of minimizing the risk of kidney injury and optimizing blood pressure control.

From the FDA Drug Label

7.1 Agents Increasing Serum Potassium Concomitant use of olmesartan with other agents that block the renin-angiotensin system, potassium-sparing diuretics (e.g., spironolactone, triamterene, amiloride), potassium supplements, salt substitutes containing potassium or other drugs that may increase potassium levels (e.g., heparin) may lead to increases in serum potassium. 7.3 Dual Blockade of the Renin-Angiotensin System (RAS) Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy

The patient is currently taking olmesartan and the question is about taking losartan, which is also an angiotensin II receptor antagonist.

• The patient should not take losartan because it would be a dual blockade of the RAS, which is associated with increased risks of hypotension, hyperkalemia, and changes in renal function.
• The patient's kidney function is already compromised with a GFR of 1.71, and taking losartan could further increase the risk of renal failure.
• The patient's PCP has already started them on olmesartan for high blood pressure, and the blood pressure is well-controlled.
• It is recommended to avoid combined use of RAS inhibitors 2.

From the Research

Patient's Current Medication and Condition

• The patient is currently taking Eliquis, metoprolol, digoxin, and was recently started on olmesartan by his PCP for high blood pressure.
• The patient has a history of diabetes, hypertension, chronic kidney disease (CKD), atrial fibrillation (AFib), and dementia.
• The patient's kidney function is at 1.71, and blood pressure is well-controlled.

Considerations for Continuing or Changing Medication

• According to 3, the combination of olmesartan, amlodipine, and hydrochlorothiazide was effective in lowering blood pressure and achieving blood pressure goals in patients with hypertension, diabetes, CKD, or chronic cardiovascular disease.
• 4 suggests that olmesartan medoxomil, either alone or in combination with other antihypertensive medications, is effective in reducing and stabilizing blood pressure.
• 5 states that olmesartan medoxomil is a valuable option for the treatment of adult patients with hypertension, including the elderly, due to its consistent antihypertensive efficacy and good tolerability profile.
• 6 reviews the effectiveness and safety of olmesartan-based therapy in targeting effective blood pressure control and achieving blood pressure goals, highlighting its value as a treatment option for adults with hypertension.
• 7 discusses the benefits of combining olmesartan with amlodipine, including greater blood pressure lowering and control, as well as effects beyond blood pressure lowering, such as beneficial effects on markers of inflammation and metabolic improvements.

Decision on Continuing or Changing Medication

• Based on the patient's current condition and medication, it may be beneficial to continue the patient on olmesartan, as it has been shown to be effective in lowering blood pressure and achieving blood pressure goals in patients with similar conditions 3, 4, 5, 6, 7.
• However, it is essential to monitor the patient's kidney function and adjust the medication as needed to ensure optimal blood pressure control and minimize potential adverse effects.