Welcome to que digo conversations in. Nephrology this episode is titled approaches to rassi optimization for disclosure information. Please go to que digo dot org, slash podcasts. Here's your host dr. Roberto Pourquoi. Filho. Hello and welcome to the cadyville conversations in biology. I am dr. Roberto Pavilion, senior research scientist. Just at the arbor research
collaborative. Health professor of medicine at the pontifical Catholic University of Montana on the program, with me today to discuss, approaches to the optimization of raining, and the tensing of those turn system. In addition is dr. Patrick row. Single doctor rosie. No is a nephrologist. Vascular medicine specialist. So certainly the perfect gas for our topic today. Patrick welcome to the program. Thank you very much for Berto. Delighted to be here.
That's okay. It looks like as ears go by therapies that inhibit the renin-angiotensin system or rassi as I'll refer to this from now on the continue to be important tools in the management of patients with CKD. See you in the real world. Listen, struggle to align with recommendation. What is your approach to rassi optimization or SEO titration is indeed desirable throughout the quadrant? The Continuum as universally emphasized by International guidelines.
This is true in chronic kidney disease patients without without hypertension as emphasized Again by the latest 221 que digo guidelines on blood pressure Management in CKD. For instance, stating that resi s Inhibitors or are bees should be administered using the highest approved dose. That is tolerated to achieve the benefits described because the proven benefits were achieved in Trials using these doses. This is also true in patients with heart failure on reduced,
ejection fraction. That's confirmed by the latest. European Cardiology guidelines published in August to 21. Importantly, CKD must redefine us egfr below 60 million per minute per 1.73. M2 is a highly prevalent condition in patients. With acute on chronic heart failure, approximately one-third recording to a meta-analysis published some Years Ago by cave in demand in the European. Aldrin are in 2013 of 57 studies. Comprising, more than 1 million patients.
In both settings, especially in elderly patients on in patients with diabetes, hyperkalemia was found the true world or toward rescue optimization in the art. Fair setting, we on orders? We plotted that hyperkalemia is one of the main triggers of received, no news, underdosing on discontinuation. Thereby leading to deep rib, our patients for this category, no protective agent. It's on partly mediating, The observed association between hyperkalemia on two outcomes.
Intel urinal patients, looking at the conversations in the biology and Cardiology seems like the community has finally decided to approach the problem or hyperkalemia. In a more proactive approach, don't you think so? Yes, indeed. So, let us 221. Can you go guide lines and blood pressure Management in CKD stated that I procured in your associate We use of recipe can often be managed by measures to reduce the serum potassium levels, rather than decreasing the dose of stopping resi.
On that potassium. Restriction discontinuation of potassium supplements, certain salt substitutes on hyperkalemic, drugs, adding potassium, wasting diuretics and or potassium. Binders in CKD. Patients receiving receipt, we develop hyperkalemia. The letter can be controlled with newer or potassium, binders in many. A patients with the effects that Pharisee can be continued as a recommended dose.
Furthermore, the latest 2021 is here for your guylines stated that administration of the catering agents, fetch your mother or sodium zirconium Sacra silicate, may allow any uncertainty reduction system inhibitor initiation or up titration in the literature. Proportion of patients. That's really interesting. Patrick, so you were an experienced clinician and you probably treat patients with these therapies a lot. Not in a daily basis.
Can you provide the nor audience with your approach to monitoring measures impatient studying and long-term Russell therapies? Well, it is universally acknowledged that creatinine and potassium must be adequately. Monitored in cked on or off for your patience. Why the proper monitoring was unfortunately reported to be poor after mineral particular receptor. Antagonist.
Initiation in heart failure, patients both in the US and in Europe. The latest 221 cadigal guidelines on blood pressure Management in CKD stated that changes in blood pressure serum creatinine, turn potassium should be checked within two to four weeks of initiation or increasing the dose of resi. C, depending on the current
differ on serum potassium. Furthermore, in patients at risk for iplock alinea, measuring serum potassium before on at one to two weeks after initiation, of recipe is recommended. Patients should also be monitored for symptomatic. Hypotension. I broke a linear on serum creatinine within two to four weeks after initiating or changing the dose of the drug with the time interval depending on Baseline blood pressure, serum creatinine, some potassium
on, only the shorter time. Interval is indicated, is a baseline serum creatinine is I or some potassium is already a normal, or is, there is a history of I Academia or an acute rise in some creatinine with blood pressure lowering or raising as far as the easiest federal guidelines concern. So let us is Jeffrey. Guidelines repeatedly stated that in advisor on reduce ejection fraction. Firstly after s Inhibitors are be initiation.
Recheck, blood chemistry. In other words urea be un creatinine, potassium one to two weeks after initiation on one to two weeks. After final dose titration, monitor blood, chemistry for monthly thereafter, The syrup potassium monitoring is warranted in patients. Treated with an Metacritic, restore antagonist, check blood chemistry are torn on for weeks after starting increasing those on that 8 and 12 weeks 69 on 12 months, four months he's after.
So don't the close protection, monitoring is warranted under potassium, lowering agents for those just joining us. This is que digo conversations in virology, I'm dr. Gilberto topography And I'm speaking with dr. Patrick real signal on approaches to Rossi optimization, Patrick, the guidelines are providing a clear message in terms of the importance of keeping patients on this life-saving therapies. However, it's not really an easy
task to optimize patients. And this requires a diversity of strategies different phases of treatment acute, or chronic hospital or ambulatory. Can you provide some tips on how to optimize that? Therapies. Well Roberto it should be emphasized that as yet no monitoring regime and has been prospectively. Evaluated in patients initiating a potassium boring agent for the treatment of I Britannia in editorial. Bertram. Didn't I published a couple of
years ago? In pharmacological research, 2017 we are ever suggested the following regimen based upon the experience in initiating. These agents in the pivotal clinical trials. On our own experience on resi under etic management, as a basis for discussion on further prospective evaluation. First serum potassium should be
measured before. Initiation of potassium boring agent on should be above 50 minimal per liter on a known immunized, blood sample in patients without life-threatening, I practically Nia, it will be prudent to repeat the measurement on to confirm that their own potassium, is truly above. Five me. Immortality before initiating, your potassium roaring agent one, should also measure some magnesium bicarbonate on access when I'll function with the egfr.
Second after initiating, you put a silver ring. Agent serum potassium should be measured within 48 to 72 hours on repeated at one week. If at one rig, the sun protection remains above five, millimoles per liter consideration. Should be given to increasing the dose of the potassium. Boring agent on tour.
Check some potassium? No, l. And one week later, Once the same potential is below 5 minimal pollinator, it would appear reasonable to based upon the experience in the pivotal Trials of procurement on a sec to measure some potassium at one month on then every three to six months at regular follow-up. Visits. Importantly, any time that the change in electrolyzed Staters is suspected such as during an episode of diarrhea.
The or vomiting or after each recipe or directly to change some potassium and creatinine should be remeasured on the monitoring sequence. Repeated, I'm sure that there are different Regional realities and really the, the fragmentation of care and problems with the communication between Specialties that take care of the patients is really difficult. Don't you think why do you think is Of chemical education is exist, especially between Cardiology Nephrology emergency medicine.
Why. Roberto in my view is the workload is certainly a measure or do Lashley along with some inconsistencies between Nephrology and Cardiology guidelines. For instance, regarding thresholds to discontinue, don't die traitor. SE in the presence of a rational function on or I truck anemia, and I'm fully agree with that. Patrick Well, any final advice
to clinicians sure. Please don't hesitate to titrate for a see as much as you can which monitoring creatinine and potassium closely and be ready to introduce a new petition binder to enable resi as repeatedly. Demonstrated whispered. Shermer, for instance, in the on betrayal, I was involved in the steering committee in patients with Advanced, chronic kidney disease on resistant hypertension. A tumor compared to Placebo, enables a more persistent shoes of the steroidal.
Emery spironolactone, the primary endpoint of this Phase 2 trial. Well, that, take away in mind, I want to thank my guest, dr. Patrick Rocio for joining me and discussed the different approaches to Rossi optimization. Patrick was great having you on the program, my pleasure rattle, I am Doctor Who bear to people are feeling to access this and other episodes in the series. Series please. Visit KD V Dot org slash podcast. Thanks for listening.
This episode was provided by KD go and supported by V4 Pharma. Series please. Visit KD V Dot org slash podcast. Thanks for listening. This episode was provided by KD go and supported by V4 Pharma.