Telmisartan Use in CKD: eGFR Thresholds
Continue telmisartan (and other ARBs) even when eGFR falls below 30 ml/min/1.73 m², and only consider discontinuation when eGFR drops below 15 ml/min/1.73 m² in the setting of symptomatic hypotension, uncontrolled hyperkalemia despite medical management, or to reduce uremic symptoms. 1
No Specific eGFR Cutoff for Routine Discontinuation
The 2024 KDIGO guidelines explicitly state that ARBs (including telmisartan) should be continued in CKD patients even when eGFR falls below 30 ml/min/1.73 m². 1 There is no arbitrary eGFR threshold at which these medications must be stopped based solely on kidney function numbers.
When to Consider Dose Reduction or Discontinuation
Consider reducing the dose or discontinuing telmisartan only in these specific clinical scenarios: 1
- eGFR <15 ml/min/1.73 m² with uremic symptoms that may be reduced by stopping the ARB 1
- Symptomatic hypotension that cannot be managed by other means 1
- Uncontrolled hyperkalemia despite medical treatment (potassium binders, dietary modification, diuretics) 1
- Serum creatinine rise >30% within 4 weeks of initiation or dose increase 1
Key Management Principles
Hyperkalemia Management
Hyperkalemia associated with telmisartan should be managed by measures to reduce serum potassium levels (potassium binders, dietary restriction, diuretics) rather than automatically decreasing the dose or stopping the ARB. 1
Monitoring Requirements
Check blood pressure, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase, with frequency depending on current eGFR and potassium levels. 1
Dosing Strategy
Use the highest approved dose that is tolerated, as proven benefits in clinical trials were achieved using these doses. 1
Evidence Supporting Continuation at Low eGFR
Research demonstrates that telmisartan is effective and safe even in advanced CKD:
In patients with Stage 3-4 CKD (mean eGFR 19.7 ml/min/1.73 m²), telmisartan reduced the need for renal replacement therapy by 45% (47.2% vs 86.1%, relative risk 0.55) and slowed eGFR decline by 49.6% without increased adverse events. 2
Telmisartan was well-tolerated in patients with severe CKD (CrCl <30 ml/min/1.73 m²) and hemodialysis patients, with effective blood pressure control and minimal drug-related adverse events. 3
Common Pitfalls to Avoid
Do not automatically discontinue telmisartan when eGFR reaches 30 ml/min/1.73 m² - this is a common misconception. The guidelines explicitly support continuation below this threshold. 1
Do not stop telmisartan for hyperkalemia without first attempting medical management - use potassium binders, dietary modification, and diuretics before discontinuing this renoprotective medication. 1
Do not discontinue for a modest creatinine rise - only consider stopping if creatinine rises >30% within 4 weeks of initiation or dose change. 1