Do I need regular check-ups or tests while taking an angiotensin-converting enzyme (ACE) inhibitor?

Blood Pressure Monitoring and Check-up Frequency

Patients started on an angiotensin-converting enzyme (ACE) inhibitor should return for a follow-up appointment monthly until blood pressure control is met.^1,2 The 2017 American College of Cardiology (ACC) and American Heart Association (AHA) hypertension guidelines found strong evidence to support the recommendation of promoting other strategies to improve control of blood pressure in patients on antihypertensive therapy to include the use of home blood pressure monitoring, team-based care, and telehealth strategies [Strong Recommendation (Level A)].² The evidence in these studies demonstrated the benefits of a combination of home blood pressure monitoring, telehealth, and team-based (e.g., nurse case manager, pharmacist, doctor) care over just office-based follow-up.^3-7 At the follow-up check-up, the doctor will measure blood pressure and assess for adverse effects.^1,2 Patients with more severe hypertension (≥160 systolic blood pressure or ≥100 diastolic blood pressure) or complicating comorbid conditions, such as heart failure (HF), diabetes, or chronic kidney disease (CKD), need more frequent visits.² Serum potassium and creatinine should be tested at least once or twice a year.¹ Once the blood pressure goal is met and stable, visits can be at three- to six-month intervals.

Renal Function Monitoring Details

Periodic renal function monitoring is recommended for patients taking ACE inhibitors.^8-18 Drugs that inhibit the renin-angiotensin system (RAS), such as ACE inhibitors, can cause changes in renal function including acute renal failure. Patients whose renal function may depend on the activity of the RAS include those with renal artery stenosis, CKD, severe HF, or volume depletion. They may be at higher risk of developing oliguria, progressive azotemia, or acute renal failure when taking an ACE inhibitor. Doctors should consider withholding or discontinuing treatment in patients who develop a clinically significant decrease in renal function on an ACE inhibitor.

The 2014 Eighth Joint National Committee (JNC8) guidelines recommend that adults with CKD should include an ACE inhibitor or an angiotensin receptor blocker (ARB) as part of their antihypertensive treatment to improve kidney outcomes [Moderate recommendation (Grade B)].¹⁹ The 2017 ACC/AHA Hypertension Guidelines recommend that adults with CKD should include an ACE inhibitor as part of their antihypertensive treatment to improve kidney outcomes [Moderate recommendation (Level B-R)].² Since use of an ACE inhibitor will commonly increase serum creatinine and may produce other metabolic effects such as hyperkalemia, people with CKD require monitoring of electrolyte and serum creatinine levels.¹⁹

Serum Potassium Monitoring Details

Manufacturers recommend monitoring serum potassium periodically in patients receiving an ACE inhibitor.^{8-10,12-18,20-22} Drugs that inhibit the RAS can cause hyperkalemia.^8-18,20-23 Patients at risk of developing hyperkalemia include those:

• with renal insufficiency
• with diabetes mellitus
• who also use potassium-sparing diuretics, potassium supplements, and/or potassium-containing salt substitutes

A 2010 meta-analysis reviewed 39 studies for the effects on serum potassium levels of ACE inhibitors, ARBs, aldosterone receptor antagonists, and direct renin inhibitors, alone and in combination, in patients with hypertension, HF, or CKD.²⁴ In patients on ACE inhibitor monotherapy with hypertension and no risk factor for hyperkalemia, the incidence of hyperkalemia was very low (≤2%). Patients with risk factors, such as HF or CKD, had a higher incidence of hyperkalemia (5% to 10%).

A 2003 meta-analysis of 354 randomized double-blind placebo-controlled trials of hypertension treatment with thiazides, beta blockers, ARBs, calcium channel blockers, and ACE inhibitors looked at the rate of side effects at the standard dose.²³ The study found potassium increased by 4%, or 0.16-mmol/L, with ACE inhibitors (95% confidence interval [0.08 – 0.23-mmol/L], 15 trials, 20 treatment arms).

A 1998 study of 1,818 outpatients using ACE inhibitors found 194 (11%) developed hyperkalemia (defined as a potassium level higher than 5.1-mmol/L).²⁵ The study concluded that while mild hyperkalemia was common, subsequent severe hyperkalemia was uncommon in patients younger than 70 years with normal renal function.

Hypotension

Hypotension rarely occurs in patients with uncomplicated hypertension treated with ACE inhibitors alone, but patients may report lightheadedness, especially in the first few days of treatment.^8-18,20-22

Manufacturers recommend that patients at risk of excessive hypotension be started on an ACE inhibitor under medical supervision and followed for the first two weeks of treatment or whenever the dose of the ACE inhibitor and/or diuretic is increased.^8-18,20-22 Patients at risk of excessive hypotension include those who:

• have HF with systolic blood pressure below 100 mm Hg
• have ischemic heart disease
• have cerebrovascular disease
• have hyponatremia
• are on high dose diuretic therapy
• are undergoing renal dialysis
• have severe volume- and/or salt-depletion.

Examples of patients at risk for volume and/or salt-depletion include those who^8-18,20-22:

• take water pills (diuretics)
• are on a low-salt diet
• take other medicines that affect your blood pressure
• get sick with vomiting or diarrhea
• do not drink enough fluids

^References

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