My hypertensive patient needs hemodialysis. How dialyzable are common antihypertensives?

Among antihypertensives, most commonly used angiotensin converting enzyme inhibitors (ACE-Is) such as captopril, enalapril, lisinopril, and benazepril are at least partially removed by hemodialysis; ramipril and fosinopril are not appreciably removed.1,2

In contrast, none of the commonly used angiotensin receptor blockers such as losartan, valsartan, and irbesartan are removed by hemodialysis.

Among β-blockers and combined α- and β-blockers, atenolol and metoprolol are removed by hemodialysis while carvedilol, bisoprolol, propranolol and labetalol are not.

Many other antihypertensives such as calcium channel blockers, α-blockers, clonidine, and hydralazine are not appreciably removed by hemodialysis, while isosorbide dinitrate appears to be.

Of interest, a 2015 retrospective cohort study found that initiation of high- dialyzability β-blockers (atenolol, acebutolol, or metoprolol) was associated with a higher risk of death in the following 180 days compared to that of low-dialyzability  β-blockers (bisoprolol or propranolol), suggesting that perhaps we should be more selective in our choice of β-blockers in this patient population.2 In contrast, no significant difference in all-cause mortality was noted among older patients receiving ACE-Is with high vs low dialyzability potential.3

 

References

  1. Inrig JK, Antihypertensive agents in hemodialysis patients: A current perspective. Semin dial 2010;23:290-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3061334/pdf/nihms206964.pdf
  2. β-Blocker dialyzability and mortality in older patients receiving hemodialysis. J Am Soc Nephrol 2015;26:987-96. https://www.ncbi.nlm.nih.gov/pubmed/25359874
  3. Weir MA, Fleet JL, Dixon SN, et al. Angiotensin converting enzyme inhibitor dialyzability and outcomes in older patients receiving hemodialysis. Blood Purif 2015;40:232-42.  https://www.ncbi.nlm.nih.gov/pubmed/26382240   

Contributed in part by Andrew Lundquist, MD, PhD, Mass General Hospital, Boston, MA.

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My hypertensive patient needs hemodialysis. How dialyzable are common antihypertensives?

Which is more effective in managing rapid ventricular rate in atrial fibrillation, diltiazem or metoprolol?

Overall, diltiazem may be more effective than metoprolol in the acute management of AFib with RVR without increased side effects based on a few small but randomized double-blind studies.

A systematic review1 based on 2 trials2,3 comparing IV diltiazem with IV metroprolol in patients with atrial fibrillation seen in emergency departments has reported better acute rate control with IV diltiazem (RR 1.8 [95% CI, 1.2-1.6]).  In these studies, the onset of rate control was faster and the percentage decrease in ventricular rate at each time point was higher with IV diltiazem.  In general, 0.25 mg/kg of IV diltiazem (max 25 mg) and 0.15 mg/kg of IV metoprolol (max 10 mg) were used.

Exclusion criteria in these studies included severe congestive heart failure, hypotension, acute coronary syndrome, and use of either class of drugs within the past five days.

References

  1. Martindale JL, deSouza IS, Silverberg M et al.. Beta-blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review. Eur J Emerg Med 2015;22: 150-154. https://www.ncbi.nlm.nih.gov/pubmed/25564459
  2. Demircan C, Cikriklar H, Engindeniz Z, et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J 2005;22: 411-414. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726824/pdf/v022p00411.pdf 
  3. Fromm C, Suan SJ, Cohen V, et al. Diltizem vs metoprolol in the management of atrial fibrillation or flutter with rapid ventricular rate in the emergency department. J Emerg Med 2015;49:175-82. https://www.ncbi.nlm.nih.gov/pubmed/25913166

Contributed by William L. Hwang, MD, Mass General Hospital, Boston, MA.

Which is more effective in managing rapid ventricular rate in atrial fibrillation, diltiazem or metoprolol?