ACE inhibitor + A2 antagonist FYI

[howe928]

GUIDELINE 11: USE OF ANGIOTENSIN-CONVERTING ENZYME INHIBITORS AND ANGIOTENSIN RECEPTOR BLOCKERS IN CKD
2009 National Kidney Foundation, Inc., 30 East 33rd Street, New York, NY 10016, 1-800-622-9010


K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease
GUIDELINE 11: USE OF ANGIOTENSIN-CONVERTING ENZYME INHIBITORS AND ANGIOTENSIN RECEPTOR BLOCKERS IN CKD


ACE inhibitors and ARBs can be used in combination to
1. lower blood pressure or
2. reduce proteinuria (C) or
3. slow the progression of kidney disease by "class effect" mechanisms in addition to their antihypertensive and antiproteinuric effects.

Combination therapy with an ACE inhibitor and an angiotensin receptor blocker for diabetic nephropathy: a meta-analysis
In the short term, combination therapy with ACEI and ARB reduces 24-hour proteinuria to a greater extent than ACEI alone. The benefit also yields small effects on GFR, serum creatinine, potassium and blood-pressure.

Combination Therapy With an Angiotensin Receptor Blocker and an ACE Inhibitor in Proteinuric Renal Disease: A Systematic Review of the Efficacy and Safety Data : eClips Consult
Combination therapy also was associated with a significant decrease in proteinuria, at least in the short term.

http://image.thelancet.com/extras/01art11215web.pdf
Combination treatment safely retards
progression of non-diabetic renal disease compared with
monotherapy. However, since some patients reached the
combined primary endpoint on combined treatment, further
strategies for complete management of progressive nondiabetic
renal disease need to be researched.

http://www.nyrdtc.nhs.uk/docs/dud/DU...on_final_a.pdf
Routine use of ACE
inhibitor/ARB combination therapy is not recommended and should be reserved for patients with resistant congestive heart failure or renal disease, or severe unresponsive hypertension, following specialist advice.

http://www.nelm.nhs.uk/en/NeLM-Area/...eviews/499263/
The authors concluded that the combination of an angiotensin-converting enzyme inhibitor and an angiotensin receptor blocker was associated with a short-term decrease in proteinuria in adults with chronic proteinuric renal disease, and appeared safe. Overall, this was a well-conducted review and the authors' conclusions are likely to be reliable.

http://www.rcpe.ac.uk/journal/issue/...9_2/luyckx.pdf
This study therefore highlights the need for caution and
the monitoring of renal function in any patient receiving
combination ACEI and ARB therapy. The findings suggest
minimising the use of combination therapy in patients
with low-grade proteinuria and preserved renal function
in the presence of cardiovascular disease.

[Sofia]

I am sorry I still don't quite understand the message. Could you explain what your interest is in those references and what my interest should be?

[Raju]

Thanks - nice post howe928 - I found it useful.

[PHARMAC1ST]

When i was working at hospital i was given the question is there any use in giving an ARB and an ACE inhibitor together?

The answer was (abit long winded):

ACE = angiotensin I > angiotensin II (potent vasoconsitrictor) converted by ACE (angiotensin converting enzyme)

ARB = angiotensin receptor blockers prevent binding of angiotensin to receptors on the enzyme and therefore conversion from AI to AII

In theory we assume that inhibiting ACE would prevent the conversion from AI > AII 100% and we assume that ace inhibitors would inhibit all enzymes 100%.
However in reality that is not the case and in certain cases like resistant hypertension ( i am sure they have tried A + B or C + D (BP guidelines)) the addition of an ARB is beneficial as it increases the percentage of inhibition from AI to AII further lowering BP but should be done by a specialist.

I would query its use in community though and question whether other avenues have been looked at.

By the way Good info howe928