Antihypertensive combination, double the effect! Hypotensive + kidney protection!

Recently, I often have friends with kidney disease ask me to talk about the combination of blood pressure medications. After all, 60% of kidney friends are accompanied by high blood pressure, and the more severe the condition, the higher the blood pressure, which is often not solved by one antihypertensive drug.

Moreover, in recent years, a variety of new drugs have emerged that can also be used as antihypertensive drugs, and it is indeed time to combine new and old drugs to talk about it in a unified manner.

The traditional first-line antihypertensive drugs have 4 types of ABCD:

A: ACEI/ARB - Pril/sartan

B: β receptor blockers – lol

C: CCB – Dipine drugs

D:Diuretic——利尿剂

In the past two years, new drugs such as linozin drugs and finerenone have also been introduced.

Among them, drug A has been the absolute king of antihypertensive drugs for kidney disease since it came out more than 40 years ago, and there is no one. Although in recent years, there have been new drugs that have overwhelmed drug A in terms of kidney protection, but in terms of blood pressure, the prescription amount of drug A still stands out in the nephrology department, and all combinations must be considered.

Today, let's take stock of various blood pressure reduction combinations and see which one suits us.

The most worry-free combination of blood pressure reduction: A+C

The representative drug is Bebot, an valsartan amlodipine tablet, which is a compound preparation composed of valsartan + amlodipine, and the antihypertensive effect is one and two tablets.

Why is the combination of valsartan + amlodipine the most worry-free?

Sartan is the least side effect of all antihypertensive drugs and has additional kidney-protective effects in addition to lowering blood pressure. Among them, valsartan is suitable for the condition of many patients with kidney disease, and is one of the antihypertensive drugs with the largest number of prescriptions in nephrology.

Dipine is the most common class of all antihypertensive drugs, there are almost no contraindications, if there are contraindications, hypotensive patients can not use, but hypotensive patients need to use antihypertensive drugs? Basically, all patients can use it, and the most commonly used antihypertensive drugs for patients with dying life and organ failure in the ICU are dipine. There is a not-so-nice saying in the academic world: "Calcium antagonists (dipine drugs) can be used until death." "It shows that doctors still trust such drugs in extremely dangerous situations. Among them, amlodipine is one of the antihypertensive drugs with the largest number of prescriptions in general practice in the world.

The largest number of nephrology prescriptions + the largest number of general prescriptions supports the applicable population of the combination of valsartan + amlodipine, covering the largest number of kidney patients. If kidney friends want to combine and save their minds, 1 tablet of Bebot per day is about the same.

Similarly, the exchange of valsartan for other sartans, prilis drugs, or amlodipine for other dipines is similar. Not necessarily the most beneficial, but the most secure, the combination of pulli/sartan + dipine focuses on a peace of mind.

Of course, if you're not looking for the most peace of mind, but the maximization of benefits, you may need to choose a combination for your specific condition to seek greater benefits.

The most effective combination for the elderly: pril / sartan + diuretics

Because most of the elderly have diuretic insufficiency, the application of diuretic antihypertensive drugs has obvious effects. Combined with the kidney-protective effect of pril/sartan, it has become the most effective combination for the elderly.

Kidney friends with a fast heart rate are most suitable: pril/sartan + lol

Both the magnitude of lowering blood pressure and the protective effect of target organs are weaker than other first-line antihypertensive drugs, so the "2022 Chinese Clinical Practice Guidelines for Hypertension" kicked Lol out of the ranks of first-line antihypertensive drugs.

What is not so certain is whether Lol is useful in lowering heart rate, and whether it can reduce the risk of cardiovascular disease? Therefore, pril/sartan + lol is a weak recommendation and can be considered for patients with a fast heart rate.

The emaciated camel is bigger than the horse, and although Lohr has taken a back seat in some countries, it is still in the first line in some countries, in the middle of the first and second lines. Compared with antihypertensive drugs that have been almost eliminated, such as adrenergic receptor antagonists (such as reserpine), α receptor antagonists (zorazines), etc., Lol still has a higher priority for consideration.

Kidney friends with rapid kidney damage are most suitable: pril/sartan + Lizin

Isn't it talking about a combination of antihypertensive drugs? How to mix in a hypoglycemic drug?

Although the detachin drugs are hypoglycemic drugs, they have become drugs for the treatment of a variety of diseases with a variety of effects. It also has a certain antihypertensive effect, and the average systolic blood pressure (high pressure) is reduced by about 5mmHg, catching up with some antihypertensive drugs that are not very high blood pressure lowering.

Moreover, the kidney-protective effect of Lycosin is twice that of pril/sartan. On average, pril/sartan slows the decline in kidney function (glomerular filtration rate) by a factor of 2 and the rate of decline by a factor of 4.

Therefore, if you have high protein in the urine and rapid progression of kidney function, and you urgently need to protect kidney function in addition to lowering blood pressure, you need to give priority to the combination of prilis/sartan + liozin.

In addition, Lenozin has a large role in anti-heart failure, a moderate effect on weight loss, and a small role in uric acid lowering.

Patients with very high blood pressure and rapid renal impairment are best suited for: pril/sartan + finerenone

Finerenone has been introduced as a treatment for diabetic kidney disease in the past two years, which is used to slow down the decline of kidney function in patients with diabetes nephrium.

It's just that its target, aldosterone, is itself a hypotensive target. All aldosterone antagonists can be used as antihypertensive drugs, and another aldosterone antagonist on the mainland, spironolactone (spironolactone), is itself a diuretic antihypertensive drug.

Therefore, although finerenone has not been approved for the treatment of hypertension, as an aldosterone antagonist, it is also old for antihypertensive use. And there is a high probability that it will be a drug for the treatment of primary kidney disease, and the ongoing kidney treatment trial is likely to be successful.

Kidney friends with heart failure or severe renal failure: Replace drug A with sacubitril-valsartan

Sacubitril valsartan, a cocrystal of sacubitril + valsartan, belongs to angiotensin receptor neprilysin inhibition (ARNI), and is also a drug A. However, among the ARNI drugs, sacubitril-valsartan is currently the only seedling, which is marketed as an anti-heart failure drug, and also has renal protective effects and antihypertensive effects.

Why should it be replaced by severe kidney failure? Because valsartan, a priri/sartan drug, has a small drawback: it will reduce kidney function.

Why does a drug that protects kidney function reduce kidney function?

Because the glomerular blood vessels in patients with kidney disease are narrow, the entrance and outlet are narrow, resulting in less blood flow, high pressure, and accelerated kidney damage.

Pril/sartan, on the other hand, dilates the outlet, allowing blood to flow out smoothly in the glomeruli, reducing pressure and slowing down kidney damage.

So here comes the problem: such a narrow blood vessel, hard pressure can not press out much function, this reduces the pressure, reduces the kidney work, the kidney is more relaxed, longer life, but the kidney function is lower.

Therefore, drug A will generally increase the blood creatinine by about 20%, which is reversible, and mild kidney failure does not need to worry about the creatinine increase by 20%.

However, patients with severe renal failure may find it difficult to accept an upward adjustment of creatinine, and they are not willing to raise it a little, and a 20% increase may lead to entering the dialysis room in advance. Although better kidneys mean longer dialysis years and longer lifespans, no one wants to dialysis earlier to increase the "painful life".

And Shakubaqu makes up for this small shortcoming.

Because sacubitril can dilate the entrance of the glomerular blood vessels, so that the blood is smooth from inflow to out, it also reduces the pressure on the kidneys, and the increased blood flow does not delay the kidneys to filter blood (kidney function), and does not increase blood creatinine.

In the glomeruli, lowering blood pressure and protecting kidney function are a contradiction: high pressure is beneficial to the current kidney function and impairs the future kidney function, and low pressure is conducive to the future kidney function and damages the current kidney function, which can be rectified in patients with severe renal failure.

Among the three class A drugs, only sacubitril-valsartan can improve the hemodynamics of the glomeruli, and take into account the protection of blood pressure and full-cycle renal function.

Therefore, sacubitril-valsartan is suitable for patients with severe renal failure, that is, blood creatinine above 265μmol/L. Guidelines recommend that patients with serum creatinine above 265 micromol/L switch to sacubitril/valsartan with sacubitril-valsartan.

In short, all antihypertensive combinations are preferentially based on drug A. However, drug A is not mandatory, and it is contraindicated in some patients with pregnancy, renal artery stenosis, hyperkalemia, liver damage, and cholestasis, and other antihypertensive combinations need to be prioritized.

For reasons of space, the blood pressure reduction combination is introduced here first. If you still have kidney problems, you can leave a message.