188.8.131.52 Angiotensin-II receptor antagonists (AIIRAs/ARBs)
Diabetic nephropathy in type II diabetes mellitus
- Refer to NICE NG136
- Monitoring requirements are the same for ACE inhibitors and ARBs.
- ACE inhibitors and ARBs are contra-indicated in pregnancy and should be avoided in patients who become pregnant.
- The combination of an ACE inhibitor and ARB may cause increased adverse events and is not usually recommended. Refer to MHRA advice.
- Occasionally in heart failure and under secondary care supervision only, candesartan may intentionally be combined with an ACE inhibitor (in patients meeting CHARM-added inclusion criteria).
- For the prescribing of sacubitril/valsartan (Entresto) see 184.108.40.206 under prescribing notes.
- Patients taking ACE inhibitors or ARBs should be informed that they are at an increased risk of acute kidney injury if they develop an illness associated with hypovolaemia and hypotension. ACE inhibitors and ARBs should be stopped temporarily. Refer to ‘sick day guidance’ for further information.
- As elderly patients are at particular risk of renal impairment, renal function should be monitored pre-treatment in patients taking ARBs. Regular U&E checks may be needed after initiation.
- The use of ACE inhibitors or ARBs in the setting of severe aortic stenosis or outflow tract obstruction is controversial with care needed to avoid precipitating hypotension. While recent small studies suggest potential benefits, such use is best guided by secondary care
- Caution is required in patients who may have renovascular disease. ARBs should be used with caution in patients with renal artery stenosis.