Discontinuation of ACE inhibitor or ARB in Chronic Kidney Disease
ACE inhibitors or ARBs should not be routinely discontinued solely due to baseline CKD. Dose reduction or discontinuation should be considered when specific adverse effects occur, including symptomatic hypotension, uncontrolled hyperkalemia, or excessive loss of kidney function after treatment initiation or dose increase. [1]
Medication Discontinuation Triggers
Discontinuation of an ACE inhibitor or ARB (or dose reduction when appropriate) is recommended for the following clinical situations:
- Symptomatic hypotension. [1]
- Uncontrolled hyperkalemia despite treatment of hyperkalemia. [1]
- Marked kidney function decline with guideline-defined magnitude of creatinine rise after initiation or dose increase. [1]
- Reduction of uremic symptoms while treating kidney failure in advanced CKD (eGFR <15 mL/min/1.73 m²), using a temporary discontinuation strategy. [1]
Kidney Function Decline Criteria
ACE inhibitor or ARB therapy should be continued unless serum creatinine rises by more than 30% within 4 weeks after initiation or an increase in dose. [1]
Hyperkalemia Criteria
ACE inhibitor or ARB therapy should be stopped when serum potassium increases to 6.0 mmol/L or more. [2]
Monitoring Timeframe Around Initiation or Dose Increase
Serum creatinine and potassium should be monitored early after starting or increasing ACE inhibitor or ARB therapy, because creatinine rise exceeding 30% within 4 weeks is a discontinuation consideration. [1]
Pregnancy-Related Discontinuation
ACE inhibitor and ARB therapy should be discontinued when pregnancy occurs or when pregnancy is being considered. [1]
Practical Sequencing of Actions
In the setting of adverse effects, ACE inhibitor or ARB dose reduction or discontinuation should be implemented after confirmation of the adverse condition and completion of medical treatment for hyperkalemia when hyperkalemia is the limiting toxicity. [1]
Restart Strategy After Temporary Discontinuation for Advanced CKD
In advanced CKD with temporary interruption to reduce uremic symptoms, ACE inhibitor or ARB therapy discontinuation is used to allow resolution of hemodynamic reductions and symptoms to facilitate kidney failure preparation, with resumption after the temporary period per clinical course. [1]