Hyperkalemia constitutes a constraint for implementing renin-angiotensin-aldosterone inhibition: the widening gap between mandated treatment guidelines and the real-world clinical arena
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Abstract
<p class="first" id="d2824040e127">Recent studies have reported a large gap between
the forceful and assertive recommendations
in the guidelines and real-world practice in the use of renin-angiotensin-aldosterone
inhibitors (RAASi) therapies. A comprehensive, retrospective analysis of a large database
of electronic medical records (>7 million patients) was undertaken to evaluate
3 pivotal
concerns: (i) whether RAASi are being prescribed according to treatment guidelines,
(ii) what happens to RAASi prescriptions after hyperkalemia events, and (iii) what
the clinical outcomes are in patients whose RAASi are discontinued or who are prescribed
at doses lower than the guidelines recommend. The results indicate that a substantial
gap exists between guideline recommendations and real-world prescribing patterns for
RAASi. Among patients with cardiorenal comorbidities for which RAASi are recommended
by the guidelines, more than one-half were prescribed lower-than-recommended doses,
and approximately 14% to 16% discontinued RAASi therapy. RAASi prescribing patterns
may be altered by the development of hyperkalemia. Moderate-to-severe hyperkalemia
events were followed by down-titration or discontinuation of RAASi therapy in nearly
one-half of all patients on maximal dose and by discontinuation in nearly one-third
of patients on submaximal dose. This analysis highlights the challenge behind RAASi
prescribing decisions, balancing the risk of provoking hyperkalemia with the benefits
to reducing cardiorenal morbidity and mortality. Patients who are known to derive
the greatest benefit from these drugs (chronic kidney disease patients with concomitant
diabetes mellitus or heart failure) are the same patients who are at highest risk
of developing hyperkalemia. These observations constitute a “call to action” to develop
newer treatment modalities to lower serum potassium and to achieve and sustain normokalemia
long-term.
</p>