I think most of you who follow the blog know I spend most of my time dealing with polypharmacy and geriatrics. I’m going to use the example of ACE Inhibitors in CHF to demonstrate my point. Every now and then, I will see patients who have a history of CHF and are not on an ACE Inhibitor.
With issues of falls, low blood pressure, renal impairment, electrolyte imbalances and so on in the elderly, it is a tough decision sometimes whether or not to start or restart an ACE inhibitor. For someone who has significant hypertension and no issues with falls, good kidney function, that decision to start an ACE inhibitor in CHF is certainly a little bit easier.
I do want to caution you about using ACE/ARB Inhibitors in CHF patients (and really any compelling indication for blood pressure medications). The problem I’ve seen a handful of times particularly in our patients with long term CHF is that they may have been on an ACE/ARB before. They may not have tolerated it in the past and if you ever come across a long term CHF patient, be very diligent in digging into their past history.
I once had a nursing home resident who was started on an ACE Inhibitor twice and it resulted in hyperkalemia twice. What happened was this patient switched providers, and following the “guidelines” an ACE was added.
The major point I want you to take away is that if something seems fishy, be sure to thoroughly investigate the patient history if you are going to start a new medication or recommend starting a new medication.
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