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renin-angiotensin-aldosterone system inhibitor (RAAS inhibitor)

Includes: - ACE inhibitors - ARBs - aldosterone antagonists Indications: - treatment of hypertension - benefit in patients with heart failure - renal protective in patients with diabetes mellitus - RAAS inhibitors that cross the blood-brain barrier* may be linked to less memory decline - treatment of heart failure - mineralocorticoid receptor antagonists improve outcomes in heart failure with preserved (HFpEF), reduced (HFrEF), & mildly reduced ejection fraction [7] * ACE inhibitors that cross the blood-brain barrier - captopril, fosinopril, lisinopril, perindopril, ramipril, trandolapril * ARBs that cross the blood-brain barrier - telmisartan, candesartan Adverse effects: - increases in serum creatinine after start of a RAAS inhibitor associated with adverse cardiorenal outcomes, even below guideline recommended threshold of a 30% increase for stopping treatment [3] - concentric hypertrophy of renal arterioles possible leading to renal vascular damage [4] Laboratory: - serum creatinine & serum potassium - within 120 days prior to therapy initation* - at least twice within 10 days after therapy initiation* - at least three times days 11-90 after therapy initiation* * recommendations for patients with heart failure [2] Mechanism of action: - pharmaceutical agents that inhibit the renin-angiotensin-aldosterone axis. Notes: - among patients with mean eGFR of 12 mL/min/1.73 m2 continuation vs discontinuation of RAS inhibitor made little difference in eGFR [6]

Interactions

drug interactions drug adverse effects (more general classes)

Related

renin-angiotensin-aldosterone axis renin-angiotensin-aldosterone system inhibitor contraindications

Specific

aldosterone receptor antagonist (aldosterone antagonist) angiotensin II receptor antagonist (ARB) angiotensin II receptor type 2 & 4-inhibiting antihypertensive angiotensin II receptor type 2 & 4-stimulating antihypertensive angiotensin-converting enzyme (ACE) inhibitor finerenone (Kerendia) renin inhibitor

General

vasodilator agent

References

  1. Weir MR, Rolfe M. Potassium homeostasis and renin-angiotensin-aldosterone system inhibitors. Clin J Am Soc Nephrol. 2010 Mar;5(3):531-48. PMID: 20150448
  2. Cooper LB et al. Consistency of laboratory monitoring during initiation of mineralocorticoid receptor antagonist therapy in patients with heart failure. JAMA 2015 Nov 10; 314:1973 PMID: 26547470
  3. Schmidt M et al. Serum creatinine elevation after renin-angiotensin system blockade and long term cardiorenal risks: Cohort study. BMJ 2017 Mar 9; 356:j791 PMID: 28279964 Free full text http://www.bmj.com/content/356/bmj.j791
  4. Pass W Memory benefit seen with antihypertensives crossing blood-brain barrier. Internal Medicine News. 2021. June 21. https://www.mdedge.com/internalmedicine/article/241878/neurology/memory-benefit-seen-antihypertensives-crossing-blood-brain
  5. Zoler ML ACE Inhibitors, ARBs Link With Kidney Damage in Small Study. Medscape. Feb 4, 2022 https://www.medscape.com/viewarticle/967898 - Watanabe H, Martini AG, Brown EA et al Inhibition of the renin-angiotensin system causes concentric hypertrophy of renal arterioles in mice and humans. JCI Insight. 2021;6(24):e154337 https://insight.jci.org/articles/view/154337
  6. Bhandari S, Mehta S, Khwaja A Renin-Angiotensin System Inhibition in Advanced Chronic Kidney Disease. N Engl J Med. 2022. Nov 3. PMID: 36326117 https://www.nejm.org/doi/full/10.1056/NEJMoa2210639
  7. Jhund PS, Talebi A, Henderson AD et al Mineralocorticoid receptor antagonists in heart failure: an individual patient level meta-analysis. Lancet. 2024 Aug 30:S0140-6736(24)01733-1. PMID: 39232490 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01733-1/fulltext