Prescribing 2 medications in the same class?

[autimom4ever]

Hi all.

I am a FNP working at a family practice and I was seeing a patient of my co-midlevel provider.

The patient has HTN and was on Lotrel 5/20 prior to coming to the practice.

According to his notes, her BP wasn't under control, so he added Lisinopril/HCTZ 20/25. This was 6 months ago.

She came in 2 weeks ago and saw him c/o a dry cough for approx 5 months. He sent her for a chest x-ray which was clear.

She came in today and I saw her for the first time. Continued dry cough.
Exam was benign.

I explained to her the possiblity of the dry cough coming from the ace inhibitor. She thought the Lotrel was a medication for cholesterol.

I changed her medication to Diovan HCT 80/25 and told her to stop the Lisinopril / HCTZ and the Lotrel.

Here are my questions (I have researched all day to get some of these answers):

1. Is it ok to be prescribed two different ace inhibitors? (Isn't there a high
risk of hyperkalemia with doing so?)
2. If I am trying to rule out the ACE cough and her BP was stable on the two meds, should I put her back on the Norvasc portion of the Lotrel?
3. I have also read the lowering the dose of the ACE may reduce the likelihood of the cough. Since she was on Lotrel prior to coming to the practice without the cough, should I just keep her on that with the Diovan HCT and is it safe for her to be on an ARB and an ACE at the same time?

Thanks ahead of time...

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[dragonfly99]

first of all, good case. And good pickup on the possible ACE-I cough. Great case actually...hope some of the med students, interns and maybe some NP students are reading this.
I'm an internist recently out of residency not too long ago. I'll try to answer your questions as best I can.
1) You are correct. Not optimal to be giving two ACE-I at once. Really no reason to do that - it just confuses the issue and costs the patient more if you give them 2 beta blockers, 2 ACE-I, etc. when I looked up the dose of ACE-I combination product he had the patient on initially, the patient was only on about 1/2 the max dose of the ACE-I. Then he added another combination med that also had ACE-I in it (also at just a medium dose). If I had been seeing that patient, I would have just bumped up the dose of that original combination product, probably adding the HCTZ (since patient wasn't on a diuretic initially). No reason to double up on ACE-I. Not sure the risk of hyperkalemia would have been high in this patient, since her total ACE-I dose still wasn't that high (does that make sense?). Also usually people don't get hyperkalemic when you give them ACE-inhibitors, unless they have renal artery stenosis. Some cardiologists will actually give lisinopril 40mg PO bid for HTN (though the usual dose is 40mg once/day) though others will tell you you don't get any more antihypertensive effect above 40mg once/day (go figure).

 

[dragonfly99]

Question 2:
Nothing wrong with amlodipine for HTN. It's probably pretty cheap too? I'd have to check. I guess if it were me I'd be tempted to max out the combination product you've put her on before adding another med....particularly if you are close to getting control with just what you've got her on now (say, the BP is 145/85 on the combo product you have her on...I'd just bump up to the next dose).

 

[dragonfly99]

question #3:
Hmm. There's not really an absolute contraindication to using ARB plus ACE-I together. If you do a drug interaction checker it will tell you there is increased risk of hyperkalemia, but like I said, the hyperkalemia pretty usually happens in your old vasculopathic patients with renal artery stenosis. However, I would argue against using 2 different combination pills in this patient. If you do that you are effectively giving her 4 different drugs - ACE-I, ARB, HCTZ and calcium blocker. You are just making your life and the patient's too complicated. I'll bet you can get control with one combo pill, +/- a third agent (noncombo agent). That's an interesting ? about whether lowering the dose back will get rid of the cough. I never even bother with that...if they cough with an ACE-I then I just switch to an ARB (unless it's just way to expensive or something). You are smart, though - it might have been the increase in total ACE-I dose that led to the cough.

HTN is a pain isn't it? Just make your life easy. Titrate up this new combo pill you put the patient on (the one w/out ACE-I). If HTN isn't controlled in a couple of weeks, keep titrating. If still not, then add a 3rd agent (calcium blocker OK if your combo pill is ARB+thiazide). You didn't say if the patient is diabetic or not? If she is, then you definitely want either an ACE-I and/or ARB to lower risk of development of diabetic nephropathy.

 

[astropilot]

On average, it takes 3 anti-HTN meds to get HTN under control.

In using both ARB with ACE-I, this is indicated in diabetic proteinuria and CHF that is not well controlled with BB, ACE-I, Spirinolactone, loop diuretics alone. Usin an ARB will reduce mortality by itself or in conjuction of ACE-I (CHARM).

. .
.The problem with the use of ACE-I or ARBs is that many have CRI and ACE-I or ARBs can make it ..worse. For ARI, ACE-I should be held in men at a Creatinine of 2.5 and women, 2.0. .