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Abstract
Objectives To examine adherence to serum creatinine and potassium monitoring and discontinuation guidelines following initiation of treatment with ACE inhibitors (ACEI) or angiotensin receptor blockers (ARBs); and whether high-risk patients are monitored.
Design A general practice-based cohort study using electronic health records from the UK Clinical Practice Research Datalink and Hospital Episode Statistics.
Setting UK primary care, 2004–2014.
Subjects 223 814 new ACEI/ARB users.
Main outcome measures Proportion of patients with renal function monitoring before and after ACEI/ARB initiation; creatinine increase ≥30% or potassium levels >6 mmol/L at first follow-up monitoring; and treatment discontinuation after such changes. Using logistic regression models, we also examined patient characteristics associated with these biochemical changes, and with follow-up monitoring within the guideline recommendation of 2 weeks after treatment initiation.
Results 10% of patients had neither baseline nor follow-up monitoring of creatinine within 12 months before and 2 months after initiation of an ACEI/ARB, 28% had monitoring only at baseline, 15% only at follow-up, and 47% both at baseline and follow-up. The median period between the most recent baseline monitoring and drug initiation was 40 days (IQR 12–125 days). 34% of patients had baseline creatinine monitoring within 1 month before initiating therapy, but <10% also had the guideline-recommended follow-up test recorded within 2 weeks. Among patients experiencing a creatinine increase ≥30% (n=567, 1.2%) or potassium level >6 mmol/L (n=191, 0.4%), 80% continued treatment. Although patients with prior myocardial infarction, hypertension or baseline potassium >5 mmol/L were at high risk of ≥30% increase in creatinine after ACEI/ARB initiation, there was no evidence that they were more frequently monitored.
Conclusions Only one-tenth of patients initiating ACEI/ARB therapy receive the guideline-recommended creatinine monitoring. Moreover, the vast majority of the patients fulfilling postinitiation discontinuation criteria for creatinine and potassium increases continue on treatment.
- NEPHROLOGY
- GENERAL MEDICINE (see Internal Medicine)
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Footnotes
Twitter Follow Kathryn Mansfield @AnimaSophia
Contributors LAT conceived the study idea and acquired data permissions. MS, KEM and LAT designed the study. MS and KEM performed data management and established the cohort. MS, KEM and LAT reviewed the literature. The analyses were carried out by MS. All authors participated in the discussion and interpretation of the results. MS organised the writing and wrote the initial drafts. All authors critically revised the manuscript for intellectual content and approved the final version. MS is the guarantor.
Funding MS was supported by the A.P. Møller Foundation for the Advancement of Medical Science, Snedkermester Sophus Jacobsen & Hustru Astrid Jacobsens Fond, and Christian og Ottilia Brorsons Rejselegat for yngre videnskabsmænd og–kvinder. HTS was supported by the Program for Clinical Research Infrastructure (PROCRIN) established by the Lundbeck Foundation and the Novo Nordisk Foundation. KB holds a Sir Henry Dale Fellowship jointly funded by the Wellcome Trust and the Royal Society (grant number 107731/Z/15/Z). LAT and KEM are funded by a Wellcome Trust intermediate clinical fellowship to LAT (101143/Z/13/Z).
Disclaimer None of these funding sources had a role in the design, conduct, analysis or reporting of the study.
Competing interests None declared.
Ethics approval London School of Hygiene and Tropical Medicine Ethics Committee (Approval number 6536) and the Independent Scientific Advisory Committee (ISAC) for Medicines and Healthcare Products Regulatory Agency (Approval number 16_025).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.