Aliskiren plus ACEI or ARB May Increase Hyperkalemia Risk

Combining the direct renin inhibitor aliskiren with an angiotensin-converting inhibitor (ACEI) or an angiotensin receptor blocker (ARB) may lead to an increased risk of hyperkalemia, reports a meta-analysis in the British Medical Journal.

A systematic review identified 10 randomized trials comparing aliskiren combined with ACEIs or ARBs versus ACEIs or ARBs alone. Data on 4814 patients were pooled for meta-analysis, focusing on the risk of hyperkalemia and acute kidney injury. Most of the trials compared aliskiren plus ARB versus ARB monotherapy.

Patients receiving aliskiren plus either an ACEI or an ARB were at increased risk of hyperkalemia: relative risk 1.58, compared with ACEI or ARB alone. Treatment with aliskiren alone was also associated with an increased rate of hyperkalemia: relative risk 1.67. The rates of acute kidney injury were similar among the various treatments.

Recent studies have raised concerns about the safety of dual inhibition of the renin-angiotensin system, leading to cautions about using ACEIs and ARBs together. With the rising use of aliskiren, it’s important to determine whether it has similar safety problems in combination with other drugs.

The new analysis suggests that combining aliskiren with an ACEI or an ARB may increase the risk of hyperkalemia. Further studies of the clinical role and safety of using aliskiren in combination therapy are needed. Until then, the authors urge careful monitoring of serum potassium in patients receiving combinations of renin-angiotensin system blockers [Harel Z, et al. The effect of combination treatment with aliskiren and blockers of the renin-angiotensin system on hyperkalemia and acute kidney injury: systematic review and meta-analysis. BMJ 2012; 344:e42].

March 2012 (Vol. 4, Number 3)