From the Guidelines
High renin hypertension patients typically respond best to medications that target the renin-angiotensin-aldosterone system (RAAS), with angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) being the most effective first-line treatments. The most effective medications include ACE inhibitors such as lisinopril (10-40 mg daily), ramipril (2.5-20 mg daily), or enalapril (5-40 mg daily), and ARBs like losartan (25-100 mg daily), valsartan (80-320 mg daily), or olmesartan (20-40 mg daily) 1. These medications are particularly effective because they counteract the excessive renin activity that drives blood pressure elevation in these patients. The high renin state leads to increased angiotensin II production, causing vasoconstriction and aldosterone release, which promotes sodium retention and volume expansion. By blocking this pathway at various points, these medications effectively lower blood pressure.
Some key points to consider when using these medications include:
- Starting with low doses and titrating upward to doses shown to reduce the risk of cardiovascular events in clinical trials
- Monitoring for potential side effects including hyperkalemia, especially when using ACE inhibitors or ARBs
- Assessing renal function regularly
- Avoiding use in patients with severe renal impairment, hyperkalemia, or other contraindications
- Considering alternative medications, such as direct renin inhibitors or beta-blockers, in patients who are intolerant to ACE inhibitors or ARBs
Overall, the use of ACE inhibitors and ARBs in high renin hypertension patients has been shown to reduce morbidity and mortality, and is a key component of evidence-based treatment for this condition 1.
From the FDA Drug Label
Although lisinopril was antihypertensive in all races studied, Black hypertensive patients (usually a low-renin hypertensive population) had a smaller average response to monotherapy than non-Black patients While the mechanism through which lisinopril lowers blood pressure is believed to be primarily suppression of the renin-angiotensin-aldosterone system, lisinopril is antihypertensive even in patients with low-renin hypertension Removal of angiotensin II negative feedback on renin secretion leads to increased plasma renin activity.
High renin hypertension patients respond to ACE inhibitors like lisinopril because it suppresses the renin-angiotensin-aldosterone system.
- The mechanism of action of lisinopril is believed to be primarily suppression of the renin-angiotensin-aldosterone system.
- Lisinopril is antihypertensive even in patients with low-renin hypertension.
- Removal of angiotensin II negative feedback on renin secretion leads to increased plasma renin activity 2.
From the Research
Treatment Options for High Renin Hypertension
High renin hypertension patients respond to various treatment options, including:
- Renin inhibitors, such as aliskiren, which block the generation of angiotensin I from angiotensinogen by inhibiting the active enzymatic site of renin 3
- Angiotensin-converting enzyme (ACE) inhibitors, which prevent the formation of angiotensin II 4, 5
- Angiotensin receptor blockers (ARBs), which block the action of angiotensin II on its receptor 4, 5
- Mineralocorticoid receptor antagonists, which block the action of aldosterone 6
Efficacy of Treatment Options
The efficacy of these treatment options has been studied in various clinical trials, with results showing:
- Aliskiren has a dose-related systolic/diastolic blood pressure lowering effect compared to placebo 7
- ACE inhibitors and ARBs have similar blood pressure lowering effects, with ACE inhibitors associated with a higher risk of cough and angioedema 4
- Direct renin inhibitors, such as aliskiren, have similar blood pressure reduction effects to ACE inhibitors and ARBs, but with more side effects 5
Choosing the Right Treatment Option
The choice of treatment option for high renin hypertension patients depends on various factors, including: