Which medications are used in the treatment of renovascular hypertension (RVHT)?

Updated: Dec 01, 2020
  • Author: Rebecca J Schmidt, DO, FACP, FASN; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Answer

Hypertensive patients should receive antihypertensive medication. In children with severe hypertension, it may be necessary to initiate medical treatment before a definitive diagnosis is obtained.

RVHT is often refractory to medical treatment. Because current approaches to renal artery dilation and surgical revascularization yield excellent results, these procedures are generally considered the treatments of choice in preference to life-long antihypertensive medication that does not achieve optimal blood pressure control. However, attempts to control the patient’s blood pressure in preparation for surgical intervention should always be made. In particular, it is advisable to defer surgery until manifestations of malignant hypertension are relieved.

All classes of antihypertensive medications are used to treat RVHT; however, the most effective therapy is with an angiotensin-converting enzyme (ACE) inhibitor, which minimizes the ischemia-induced rise in angiotensin production. Because hypertension may be dependent on angiotensin II, antihypertensives that inhibit renin or angiotensin II are used widely.

An ACE inhibitor markedly decreases blood flow through the stenotic kidney; thus, in patients with a solitary kidney or bilateral renovascular disease, blood pressure may fall rapidly, with an ensuing deterioration in renal function. Although this deterioration usually is reversible upon discontinuance of the medication, ACE inhibitors are generally avoided until definitive therapy has been attempted. There has been less clinical experience with angiotensin receptor blockers (ARBs), but these agents appear to be as effective as ACE inhibitors in experimental models.

Certainly, any patients with RVHT who are treated with ACE inhibitors or ARBs should have their serum creatinine levels monitored, and therapy should be discontinued if their creatinine levels rise significantly. In patients without hemodynamically significant renal artery disease, a serum creatinine increase of up to 35% above baseline with an ACE or an ARB is considered acceptable and is not a reason to withhold treatment unless hyperkalemia develops.

Both beta blockers and diuretics also are used, the latter often in conjunction with ACE inhibitors. Diuretics enhance sodium and water diuresis, thereby eliminating the volume-mediated component of RVHT. Calcium channel blockers may provide equally good control of hypertension while presumably causing less impairment of the function of the ischemic kidney than ACE inhibitors do. Nitroprusside and phenoxybenzamine are useful in the short-term management of malignant hypertension before surgery.

The selective aldosterone inhibitor eplerenone is also available for the treatment of hypertension. This agent selectively blocks aldosterone at the mineralocorticoid receptors in both epithelial tissues (eg, kidney) and nonepithelial tissues (eg, heart, blood vessels, and brain), thereby decreasing blood pressure and sodium reabsorption. The adult dosage is 50 mg/day orally, which may be increased after 4 weeks to a dosage not exceeding 100 mg/day. Contraindications include the following:

  • Documented hypersensitivity
  • Hyperkalemia
  • Coadministration with drugs causing increased serum potassium levels
  • Moderate-to-severe reduction in renal function (ie, creatinine clearance less than 30 mL/min)

Because eplerenone is a cytochrome P-450 (CYP450) 3A4 substrate, potent CYP3A4 inhibitors (eg, ketoconazole) increase serum levels of the drug about 5-fold, whereas less potent CYP3A4 inhibitors (eg, erythromycin, saquinavir, verapamil, and fluconazole) increase serum levels about 2-fold. Grapefruit juice increases serum eplerenone levels by about 25%.

Coadministration of eplerenone with potassium supplements, salt substitutes, or drugs known to increase serum potassium (eg, amiloride, spironolactone, triamterene, ACE inhibitors, and ARBs) and increases the risk of hyperkalemia. Eplerenone may cause hyperkalemia, headache, or dizziness. Caution is advised in patients with hepatic insufficiency.


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