June 5th, 2014

An Adverse Event on Lisinopril: What Do You Say to Your Patient?

This post is the third in our series “What Do You Say to Your Patient?” In this series, we ask members to share with us how they interpret a complex or controversial issue for patients. To review earlier posts, click here.

The following scenario stems from the recommendations from the JNC8 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults

Your patient is a 65-year-old woman with a BP of 150/90 mm Hg on hydrochlorothiazide (HCTZ) 25 mg. She is overweight and has obstructive sleep apnea but uses her continuous positive airway pressure machine every night. She is asymptomatic and keen to get her BP under control. You start her on lisinopril 10 mg once a day.

One week later you get a basic metabolic panel to assess renal function. Her potassium level is 6.8 mEq/L and her creatinine level is 2.1 mg/dL (up from 1.3 mg/dL at baseline).

In light of the increased postassium level, you refer the patient to the emergency department. She is treated for hyperkalemia and discharged the following day with a creatinine level of 1.8 mg/dL and a normal potassium level. She is discharged on HCTZ 25 mg only. Renal artery imaging did not show any renal artery disease.

She follows up with you in clinic one week later.

In this case, the patient has had a known adverse event. When you see her again, what do you say?

Do you apologize? 

Do you tell her that this can happen and was not her fault? 

Do you acknowledge that you were following guidelines? 

How do you approach discussing the next medicine that you will consider starting for her BP?


3 Responses to “An Adverse Event on Lisinopril: What Do You Say to Your Patient?”

  1. I am writing my thoughts regarding these patients. These patients previously been identified as creatinine level 1.3 mg. This value is at the upper limit. Probably earlier in these patients, renal function may be impaired. If the cause of renal impairment may be uncontrolled hypertension. Lisinopril are given in low doses. Elevation of potassium in these patients and the cause of the deterioration of renal function can not be used lisinopril. This drug is widely used in the world. I believe it is a very useful drug. Perhaps patients receiving the drug lisinopril, other drugs that impair renal function, such as herbal medicines and pain relievers may be used to excess. These patients were using previously hydrochlorothiazide. When using Lisinopril, patients may be dehydrated status. In this situation could lead to side effects of ACE inhibitors. First of all, causes that may impair renal function in this patient is necessary to investigate. Nevertheless, if intended to be used as a factor lisinopril possibility of bilateral renal artery stenosis should be investigated in detail.

    Rather than apologize to the patient, explaining the situation in detail, may have to continue with other drugs to treat hypertension. Unlike the last guidelines, to protect the patient’s kidney function, blood pressure should be reduced below 130/80 mmHg I believe.

    Treatment plan, to prevent electrolyt disturbances, hydrochlorothiazide every other day and together with a Ca antagonist may be advised to take. E.g., diltiazem or verapamil. If you get full control of blood pressure, the other Ca antagonists can be given such as Lacidipine or lercadipine.

  2. Jean-Pierre Usdin, MD says:

    Thank you for this challenge.
    Dr Altunkan is probably right the patient had infraclinical dehydratation due to 25 mg of HCTZ before Lisinopril treatment.
    I personnally never start à the maximum dosage of a drug because sometimes lower doses may be sufficient (in this case it is not urgent to go on so quickly) and if you have strong side effect -like in this case- you will definitly distroy an effective drug which could be used at lower ranges.
    Fortunatly a blood control was done after one week which is short, my habit is to check after one month…so if I did so it would be catastrophic in this case!
    I will not apologize but I understand the patient could be upset and gone to see another cardiologist.
    I hope her attending physiscian will not blame me in fact.

    If I understood well she had an evaluation of her kidney arteries (by Ultrasonography I suppose depending of the impaired renal function)
    So my future choice concerning anti hypertensive will be calcic inhibitors hoping that no oedema will come.
    As far as Sleep Apnea is concern, I would recommend to check the machine and eventually to do 24 hour recording of blood pressure, only to rule out a technical problem and se if deeper pattern is present or not.
    What about her weight and her diet salt control?
    Best regards and thanks for all these intersting topics and discussions

  3. I agree with Dr.Usdin’s thoughts. A week later to check the patient very interesting. Moreover, also made ​​of biochemistry. That’s what I’d call to check this patient a month later. To call to check in early, perhaps might have been problems in patients. We do not know exactly what it is.

    I wouldn, rather than sending the patient to another doctor, if she wishes, I would continue to follow-up and treatment.

    Before starting drug treatment, 24-hour blood pressure monitoring would be appropriate to do. In addition, echocardiography for left ventricular hypertrophy would need to be done. Also, it was important to know the initial values ​​of the electrolyte, CrCl and proteinuria. After this process would be much better administration of medication.

    This case is very good to discuss. I would like to thank Dr.Ryan.