Table 2 Precautions for administering RAS inhibitors to patients with renal dysfunction, and measures to take in case of elevated serum potassium levels [2]

From: Blood pressure control in patients with chronic kidney disease: comparison between JSH2025 and other international guidelines

<Precautions>

• If possible, start with the minimum dose (or half the dose) before administering diuretics

• Perform electrolyte and renal function tests (BUN, serum Cr, serum potassium, etc.) within 2–4 weeks

• Continue the treatment (regularly monitor electrolytes and renal function) if an increase of serum Cr within 30% of baseline (or 1.0 mg/dL), or if serum potassium remains below 5.5 mEq/L

• If there is a further increase, refer to a nephrologist (collaboration is important)

<Measures to take when serum potassium levels rise during administration of RAS inhibitors>

• Ensure adequate fluid intake, followed by administration of diuretics (thiazide diuretics, loop diuretics)

• Restrict potassium intake

• Take action to prevent constipation

• Administration of potassium binders (cost-effectiveness is important: expensive medications should be reserved for emergencies)

• Review concomitant medications (some potassium binders may have reduced efficacy when used with magnesium- or aluminum-containing antacids or laxatives)

• Correction of acidosis

• Reduce or discontinue the causative drug and promptly refer to a nephrologist.

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