Palemer BF: Managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. N Eng J Med 2004;351(6):585-92.
Hyperkalemia develops in about 10% of outpatients within 1 year after angiotensin-converting enzyme (ACE) and angiotensin receptor blocker (ARB) drugs are prescribed. Hyper-kalemia occurs more often in patients who have risk factors such as diabetes, congestive heart failure, or impaired renal function. It is uncommon in patients without risk factors, and these comprised most of the subjects in controlled trials. Often, the very patients who benefit most from the renal-protective effects of ACE and ARB drugs are those who develop hyper-kalemia. An initial approach is to avoid, if possible, other drugs that predispose to higher potassium levels by interfering with the release of renin or with the function of the cortical colleting tubule such as nonsteroidal anti-inflammatory drugs, beta-blockers, and potassium-sparing diuretics. Other approaches to reduce hyperkalemia caused by ACE and ARB drugs include ingestion of a low-potassium diet, use of diuretics, and use of sodium bicarbonate to correct metabolic acidosis. If the serum potassium is 5.6 mmol/L or more, the ACE or ARB drug dosage can be lowered. If this is ineffective, serum potassium may need to be discontinued.