Block angiotensin II, with cough from bradykinin
Expansion
Indications: hypertension, heart failure with reduced ejection fraction, after myocardial infarction, diabetic and proteinuric kidney disease.
Adverse effects
- Dry cough, in up to 15 per cent, from bradykinin accumulation. ARBs do not cause it, which is the main reason to switch
- Hyperkalaemia
- First dose hypotension, particularly if volume deplete or on a diuretic
- Angioedema, which may occur years after starting and is commoner in patients of African ancestry
- Acute kidney injury, especially with bilateral renal artery stenosis
Why creatinine rises: angiotensin II constricts the efferent arteriole to maintain glomerular filtration. Blocking it dilates the efferent arteriole, so filtration pressure falls. A rise of up to 30 per cent is expected; more suggests renal artery stenosis or volume depletion.
Monitoring: check renal function and potassium before starting, 1 to 2 weeks after starting and after each dose increase.
Contraindications: pregnancy (renal dysgenesis and oligohydramnios), bilateral renal artery stenosis, previous angioedema, and aortic stenosis with caution.
Avoid the triple whammy: an ACE inhibitor plus a diuretic plus an NSAID, which is a common cause of acute kidney injury.