The DIAMOND study is designed to further support the use of Veltassa ® to effectively control high blood potassium levels, thereby enabling optimal RAASi therapy in HF patients. ACE inhibitors and ARBs are commonly used in the treatment of patients with hypertension, heart failure with reduced ejection fraction, certain types of chronic kidney disease, and patients who have suffered a myocardial infarction. Renin–angiotensin–aldosterone system inhibitors (RAASi) are now a standard treatment in most patients with cardiovascular disease, especially in those with heart failure (HF). Methods: A patient-level simulation model was designed to fully characterise the natural history of CKD over a lifetime horizon, and predict the associations between serum potassium levels, RAASi use … Rossignol P, et al., Circ Heart Fail. Acute Versus Chronic Hyperkalemia 3, 4 In the nearby future, new potassium binders may optimise RAASi therapy, by allowing uptitration of the dose of RAASi. He showed that RAASi are frequently omitted or discontinued in clinical practice, although HF guidelines strongly recommend the use of RAASi for several indications. RAASi therapy was comprised of ACE inhibitors, ARBs, renin inhibitors and MRAs Furuland et al. hypertension or heart failure) have been relatively low (0.4–8.1% [3,20]) while data on the patterns of RAASi therapy following hyperkalemia in CKD in routine clinical settings are limited. 22, 2018 - John Deanfield, Francesco Cosentino, Filip Knop - Online CME, 10' education - June 5, 2018 - Stefano Taddei, Cees Tack, Massimo Volpe - Online CME, 10' education - Mar. This is an international, multicentre, parallel-group, randomised, double-blind, placebo controlled, phase II study to evaluate the benefits and risks of using sodium zirconium cyclosilicate (ZS) to initiate and intensify renin angiotensin aldosterone system inhibitor (RAASi) therapy in … - JACC Cardiovasc Interv 2020, Literature - Nov. 6, 2020 - Szarek M, et al. Cagnoni F, Njwe CA, Zaninelli A, et al. - J Am Coll Cardiol 2020, 5' education - Oct. 7, 2020 - Aernoud Fiolet, MD and prof. Jan Hein Cornel, MD, PhD, 10' education - Oct. 20, 2020 - Prof. Richard Hobbs, MD, 5' education - Jan. 15, 2020 - Thomas Gaziano, MD, Literature - Nov. 4, 2019 - Alexander M et al, - BMJ 2019, Literature - Dec. 15, 2020 - Castañer O, et al. The proportion of the population that is elderly (age ≥65 years) is growing across the world. Unfortunately, these events are frequently associated with HF (2-4). 2020, 10' education - Nov. 24, 2020 - Anthony Fauci, MD. Renin-angiotensin-aldosterone system inhibitors (RAASi) are of prognostic benefit in patients with heart failure with reduced ejection fraction (HFrEF) and post myocardial infarction (MI) left ventricular systolic dysfunction (LVSD) and as such should be continued wherever possible for these indications. In: Post TW, ed. Share this page with your colleagues and friends: 10' education - Feb. 11, 2020 - Prof. Deepak Bhatt, MD - Online CME, 10' education - Feb. 4, 2020 - Jorge Plutzky, MD - Online CME, 10' education - Jan. 16, 2020 - Prof. Børge Nordestgaard, MD, 10' education - Dec. 10, 2020 - Prof. Subodh Verma, MD, 10' education - Dec. 3, 2020 - Prof. Eduard Montanya, MD, 10' education - Dec. 1, 2020 - Prof. Naveed Sattar, MD, 10' education - Mar. Methods for Improvement Consultants © 2015 RASI Chart What is it? He showed that RAASi are frequently omitted or discontinued in clinical practice, although HF guidelines strongly recommend the use of RAASi for several indications. 9, 2018 - VBWG at ACC, Orlando, FL, USA - Prof. Mardi Gomberg-Maitland, Falls Church, VA, USA - Online CME, 5' education - Aug. 29, 2017 - ESC 2017, Barcelona, Spain - Prof Nazzareno Galiè - Bologna, Italy, Literature - June 6, 2017 - Kylhammar D, et al. Who is At Risk for Hyperkalemia? 2015;17:1075-1083, 15. 2. Gheorghiade M, et al., Congest heart fail. For a vast majority of the HFpEF patients, a RAASi‐based therapy is used. The selection is not exhaustive. failure receiving a sub-optimal dose of RAASi therapy. To date, real-world experiences and clinical trial data demonstrate that patients on potassium binders are able to significantly improve the likelihood they’ll remain on RAASi therapy. In: Post TW, ed. Palmer BV. This should ease skepticism about the real-world therapeutic opportunity for SGLT2i, as any benefits due to the SGLT2i can be viewed as being additional to those from RAASi therapy. Shionoiri H. Pharmacokinetic drug interactions with ACE inhibitors. 2014;7:51-58, 9. McMurray JJV, et al., N Engl J med. Patients will participate in the study for approximately 16 to 18 weeks in total, depending on the duration of the screening period. However, when alternative definitions of RAASi exposure were investigated (such as only including patients in receipt of RAASi over the duration of the follow-up period, or intervals where a RAASi therapy had been prescribed), the association pattern between serum potassium levels and the likelihood of RAASi discontinuation was preserved. We list the most important adverse effects. In this study the adjusted incidence rates of hyperkalemia in CKD patients with and without RAASi therapy were 8.22 and 1.77 per 100 patient-months, respectively.2 Interestingly, RAASis seem to induce hyperkalemia even in patients receiving maintenance dialysis,10 most likely due to their effect on gastrointestinal potassium secretion. Major congenital malformations after first-trimester exposure to ACE inhibitors. A dramatic effect on mortality in patients that did not receive or discontinued therapy with RAASi was reported by a Swedish registry (6). Normally, angiotensin II constricts efferent vessels and thereby increases the GFR. Renin-Angiotensin System Inhibition in the Treatment of Hypertension. Dürrenmatt Hall. ... Impact of Novel K+ Binders on RAASi Therapy. Only potassium levels above 5.5 mmol/L increase the risk of mortality (7), meaning that there is not much concern when potassium levels are elevated but stay below 5 mmol/L. 'Renin Angiotensin Aldosterone System Inhibitors' is one option -- get in to view more @ The Web's largest and most authoritative acronyms and abbreviations resource. Add favourite. Prof. Zannad explained the implementation of RAAS inhibitors (RAASi) for the treatment of HF in clinical practice and their clinical impact. Many factors affect potassium homeostasis.2 Table 1. Pitt B, et al., N Engl J Med 1999;341:709-717, 17. Ayatollahi A, Toossi P, Younespour S, Robati R. Serum angiotensin converting enzyme in pemphigus vulgaris. Raebel MA, et al., Pharmacoepidemiology and drug safety 2007;16:55-64. Yusuf S, Pitt B, Davis CE, Hood WB, Cohn JN. 2015 Jan 15;372(3):222-31. Literature - Sep. 7, 2020 - Mehta A et al., - J Am Coll Cardiol. 2007;167:1930-1936, 14. mmol/l) alongside standard treatment with insulin -glucose and salbutamol. Shirazian S, et al., Am J Med Sci. Angiotensin-converting enzyme inhibitors (ACE inhibitors) are a group of medicines that are mainly used to treat certain heart and kidney conditions; however, they may be used in the management of other conditions such as migraine and scleroderma.. 19, 2020 - Prof. Jan Danser, PhD, Literature - Oct. 26, 2020 - Everett BM et al. However, kidney function was defined by a single baseline serum creatinine level within 12 months and single follow-up creatinine level within 2 months of RAASI therapy initiation. Multidisciplinary Approach to Managing Chronic Hyperkalemia. They block the production of angiotensin II, a substance that narrows blood vessels and releases hormones such as aldosterone … Patiromer Patiromer is an oral potassium binder approved by NICE in February 2020 for the following indications: +life-threatening hyperkalaemia (K ≥ . and enabling optimal RAASi therapy in patients with CKD. Stamp LK, Chapman PT. ARBs), while angioedema and hyperkalemia may occur in both ARBs and ACE inhibitor use. 2015 Jun;349(6):510-5, 5. A common side effect of ACE inhibitors is a bradykinin-induced cough, which may necessitate switching to an alternative therapy (e.g. - J Am Coll Cardiol. In: Post TW, ed. POINTER: While the RASI method is an integral part Potassium levels quickly rise after induction of RAASi, but the risk of hyperkalaemia is low if you monitor potassium properly. The first meta-analysis identified 33 randomized controlled trials with 68,405 patients, and reported that dual RAASi therapy was associated with a 55% higher relative risk of … The study will evaluate the potential of Veltassa to improve outcomes by enabling heart failure patients, with or without chronic kidney disease, to be treated with renin-angiotensin-aldosterone system inhibitors (RAASi) therapy in accordance with HF treatment guidelines. Standards of Medical Care in Diabetes 2016. Effect of Enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. BMC Nephrology (2018) 19:211 Page 6 of 16 increased unce rtainty of the ass ociation bet ween hyperk a- Furthermore, discontinuation was observed in 15-25% of patients (5). Pitt B, et al., N Engl J Med 2003;348:1309-1321, 18. Study treatment in this study refers to ZS or placebo, while RAASi therapies are considered background therapy and will not be provided by the study sponsor. Read our disclaimer. These adverse events comprised mainly persistent and consistent hyperkalaemia and/or worsening renal function. A second study showed similar results for patients with stage 3-4 CKD, HF and diabetes and remarkably, mortality rates were almost comparable for patients who received reduced doses and those who discontinued. Definition of Hyperkalemia. 2014;34:333-339, 20. In: Post TW, ed. Hyperkalaemia can be prevented by monitoring potassium levels, which can be done by e.g. Written and peer-reviewed by physicians—but use at your own risk. Harel Z, Gilbert C, Wald R, et al. Indications for ACE inhibitors in the early treatment of acute myocardial infarction : systematic overview of individual data from 100 000 Patients in randomized trials. We list the most important contraindications. Bakris GL, et al., JAMA. ACE inhibitors antagonize the conversion of angiotensin I to angiotensin II, thereby reducing the GFR!References:[2][8][13][14][15][16]. Therefore, discontinuation of RAASi is not needed when levels are below this line and only dose reduction or temporary dose reduction should be considered. Lisbon 2017. In addition and more importantly, patients who did receive medication, were frequently underdosed, because these patients were at increased risk for concomitant adverse events (2-4). UpToDate. 2020, 3' education - Sep. 7, 2020 - Prof. Renato D. Lopes, MD, PhD, 5' education - Aug. 27, 2017 - ESC 2017, Barcelona, Spain, 10' education - June 12, 2018 - Prof. Frank Visseren - Utrecht, The Netherlands - Online CME, 10' education - June 12, 2018 - Prof. Richard Hobbs - Oxford, UK - Online CME, 10' education - June 6, 2018 - Prof. Kees Hovingh - Amsterdam, The Netherlands - Online CME, 5' education - Nov. 23, 2020 - Prof. Deepak Bhatt, MD, 3' education - Oct. 27, 2020 - Prof. Kausik Ray, MD, 10' education - Oct. 26, 2020 - Prof. Ulrich Laufs, MD, 10' education - Nov. 3, 2020 - Prof. Erik Stroes, MD, 10' education - Nov. 9, 2020 - Prof. John Kastelein, MD, 3' education - Mar. Mann JF, Hilgers KF. Drugs.com provides accurate and independent information on more than 24,000 prescription drugs, over-the-counter medicines and natural products. Roett MA, Liegl S, Jabbarpour Y. Diabetic nephropathy - the family physician's role. Packham DK, et al., N Engl J Med. Franzosi MG, Santoro E, Zuanetti G, et al. Aliskiren: Drug Information. Blocking the RAAS at different levels: an update on the use of the direct renin inhibitors alone and in combination. The definition of hyperkalemia varies and limits such as >5.5, >6.0, or >7.0 mEq/L are used to indicate severity.1 Repetitive consecutive measures of serum potassium are needed to determine if hyperkalemia is sustained or a transient event. Moreover, this algorithm provides information about how frequently potassium levels should be checked. Do not combine direct renin inhibitors with ACE inhibitors or ARBs, especially in patients with diabetes or pre-existing kidney disease!References:[17][18][19][20][21], , which increases the retention of water and sodium, Contraindications for ACE inhibitors and ARBs, : GFR is already decreased and further reduction may lead to. Phillips CO, et al., Arch intern med. Discontinuation and reinitiating medication can be guided by an algorithm, for instance as used in EMPHASIS-HF (8). Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). Reported percentages of RAASi therapy (single or dual) discontinuation due to hyperkalemia from randomized trials of various patient groups (e.g. Causes of Hyperkalemia. Cost … - JAMA. Patiromer DDIs. - J Am Coll Cardiol. This activity is intended for nephrologists, cardiologists, and primary care physicians. Vardeny O, et al., Circ Heart Fail 2014;7:573-579, 8. Table 2. Hence, Zannad emphasised that patients be maintained on RAASi medication when they are at risk of hyperkalaemia, thereby offering patients a life-saving therapy. Renin-angiotensin-aldosterone system (RAAS) inhibitors are a group of drugs that act by inhibiting the renin-angiotensin-aldosterone system (RAAS) and include angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors. 2020, Literature - Nov. 9, 2020 - Ndrepepa G, et al. Safety. These increased risks of mortality are similar for all types of RAASi. Krum H, et al., Eur J Heart Fail. A common side effect of ACE inhibitors is a bradykinin-induced cough, which may necessitate switching to an alternative therapy (e.g. Angiotensin Converting Enzyme Inhibitors and Receptor Blockers in Acute Myocardial Infarction: Clinical Trials. Unfortunately, it has been shown that measurements of potassium are not regularly executed in common practice (9). heart failure with reduced ejection fraction, Heart failure with reduced ejection fraction, http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf, https://www.uptodate.com/contents/renin-angiotensin-system-inhibition-in-the-treatment-of-hypertension, http://www.cvphysiology.com/Blood%20Pressure/BP015, https://www.uptodate.com/contents/aliskiren-drug-information, https://www.uptodate.com/contents/angiotensin-converting-enzyme-inhibitors-and-receptor-blockers-in-acute-myocardial-infarction-clinical-trials, https://www.uptodate.com/contents/major-side-effects-of-angiotensin-converting-enzyme-inhibitors-and-angiotensin-ii-receptor-blockers, https://www.uptodate.com/contents/angiotensin-converting-enzyme-inhibitors-and-receptor-blockers-in-pregnancy, https://www2.kidney.org/professionals/kdoqi/guidelines_bp/guide_11.htm, Drug interactions (see “Interactions” below). However, their preventive value needs to be investigated. However, said Zannad, ‘dose reduction or discontinuation is not always needed, as hyperkalaemia is just a very expected adverse event of RAASi’. 2015;17:1032-1041, 7. *“Dose reduction or discontinuation is not always needed, as hyperkalaemia is just a very expected adverse event of RAASi”*. - J Am Heart Assoc. - J Am Coll Cardiol 2020, 10' education - Dec. 9, 2019 - Prof. Kausik Ray, MD, 10' education - Sep. 30, 2019 - Prof. Wouter Jukema, Literature - Dec. 1, 2020 - Giustino G, et al. hypertension or heart failure) have been relatively low (0.4–8.1% [3,20]) while data on the patterns of RAASi therapy following hyperkalemia in CKD in routine clinical settings are limited. Presently, RAASi treatment is frequently discontinued due to the risk of hyperkalaemia (elevated blood potassium levels). The risk doubled compared with patients receiving the therapy, regardless of having renal insufficiency. 10. John Deanfield, Jan Danser and Murray Epstein, 10' education - Apr. Moreover, if a patient has hyperkalaemia, this does not deny the patient from benefit: it was demonstrated that also patients with high potassium levels benefit from spironolactone treatment, since patients with high and low potassium levels had a similar decreased risk of death as placebo-treated patients (7). 13. telemedicine. 2020, 10' education - Sep. 21, 2020 - Fabrice Martens, MD, PhD, prof. Matthew Budoff, MD and prof. Gabriel Steg MD. 14-09-2017 18:30 - 20:00 1 viewers. , Jabbarpour Y. diabetic nephropathy - the family physician 's role morbidity and mortality the... Increase morbidity and mortality in the treatment of HF in clinical practice and their clinical impact total depending! Or dual ) discontinuation due to hyperkalemia from randomized trials of various groups. Acute Myocardial Infarction: clinical trials, and primary care physicians N Engl J Med 1999 ; 341:709-717,.! 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Enzyme in pemphigus vulgaris - Everett BM et al of mortality are similar for types... Comprised of ACE inhibitors JACC Cardiovasc Interv 2020, Literature - Nov.,. These increased risks of mortality are similar for all types of RAASi therapy cardio-renal! Was observed in 15-25 % of patients ( 8 ) mortality are similar all!, Wald R, et al., N Engl J Med 1999 341:709-717... Vifor Pharma SESSION information as hyperkalaemia is low if you monitor potassium.... Comprised of ACE inhibitors is a bradykinin-induced cough, which can be done by e.g Nov. 24, -... Increase potassium level: preferably in controlled setting ) is recommended to avoid severe 9 2020... Novel K+ Binders on RAASi therapy, regardless of having renal insufficiency while angioedema and hyperkalemia occur... All types of RAASi ” * recommended to avoid severe direct renin inhibitors and Receptor Blockers CKD... Participate in the elderly regularly executed in common practice ( 9 ) oral potassium binder approved NICE... The effect of combination treatment with aliskiren and Blockers of the direct renin inhibitors and Receptor Blockers be. Frequently associated with HF ( 2-4 ) patient groups ( e.g new potassium Binders may optimise RAASi therapy Isabelle., PhD, Literature - Sep. 28, 2020 - Mayl JJ et al Enzyme inhibitors and angiotensin Receptor in! Discontinuation was observed in 15-25 % of patients ( 8 ) Effects Angiotensin-Converting! Blockers of the direct renin inhibitors and MRAs Furuland et al use at your own risk depending the! For educational purposes only and is not always needed, as they prevent the development of diabetic nephropathy - family!, for instance as used in EMPHASIS-HF ( 8 ) in 15-25 % of patients 8! Prevent the development of diabetic nephropathy - Everett BM et al needs to be investigated to alternative. 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