Optimising an ACEI (16)

An 83 year old woman attends the GP surgery for a blood pressure review.

Blood pressure has been high for a while (systolic ~160).  She was taking ramipril 1.25mg and diltiazem HCL 360 mg OD.  She had been taking bendrofluazide but this was stopped during a recent hospital admission due to hypokalaemia.   BP a couple of weeks ago is still very high with values of 218/93 and 200/100. Consequently, I initially increased her ramipril 10 days ago to 2.5mg OD.  Her BP this week is 210/78 and repeat U+Es were ok, so I increased the dose again to 5mg.

She is sytemically well other than for a recent altered bowel and mild weight loss for which she has been referred to colorectal.

I was planning to increase ramipril to 10mg as tolerated but I am not sure how quickly I should be increasing the dose.   I am concerned about her high BP and also concerned about increasing the dose too quickly due to her age.  I also wonder if she requires any further investigation in view of her significant proteinuria?

What further information would you seek before giving your opinion?

See more of the history or available results?

Urine  ACR 467 and PCR 259.  No haematuria.  Her eGFR is 50 and stable.

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You’re doing all that I’d do. The proteinuria level is technically above the recommended referral threshold (PCR 100), but at her age I’d be unlikely to go on to do a biopsy unless she was actually nephrotic or had deteriorating function.   In view of the proteinuria, maximising ACEi would be my first step too.   This can be done quickly (days to weeks) provided BP and renal f(x) are monitored.

 If her eGFR drifts down or there is an increase in proteinuria then it would be worth referring her to the renal clinic. That said, you can allow up to around a 20% rise in creatinine around the time of institution of ACE inhibition.


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