Chronic kidney disease (CKD) is increasing in prevalence in the United States. Therapies that can retard the progression of CKD are needed to prevent the morbidity and mortality associated with reduced renal function. Although multiple studies published in the past 10 years have supported the combination use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) to decrease proteinuria and delay disease progression, it is our position that combinations of ACE inhibitors and ARBs should be used with great caution in patients with CKD. We do not dispute that ACE inhibitors or ARBs used as monotherapy can decrease proteinuria and retard progression of renal disease. However, in combination, the risks of adverse effects, including hyperkalemia, hypotension, and worsening renal failure, could outweigh the purported benefits of dual blockade. Until more studies are conducted on the safety of dual renin-angiotensin blockade on the average patient in the community who has CKD, the simultaneous use of ACE inhibitors and ARBs should be discouraged in primary care.
Ku E, Park J, Vidhun J, Campese V. The Hazards of Dual Renin-Angiotensin Blockade in Chronic Kidney Disease. Arch Intern Med. 2009;169(11):1015-1018. doi:10.1001/archinternmed.2009.128