Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin–angiotensin system blockade: a UK general practice-based cohort study
Objectives To examine adherence to serum creatinine and potassium monitoring and discontinuation guidelines following initiation of treatment with ACE inhibitors (ACEI) or angiotensin receptor blockers (ARBs); and whether high-risk patients are monitored.Design A general practice-based cohort study...
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BMJ Publishing Group
2017-01-01
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| Series: | BMJ Open |
| Online Access: | https://bmjopen.bmj.com/content/7/1/e012818.full |
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| author | Henrik Toft Sørensen Liam Smeeth Dorothea Nitsch Morten Schmidt Laurie A Tomlinson Krishnan Bhaskaran Kathryn E Mansfield |
| author_facet | Henrik Toft Sørensen Liam Smeeth Dorothea Nitsch Morten Schmidt Laurie A Tomlinson Krishnan Bhaskaran Kathryn E Mansfield |
| author_sort | Henrik Toft Sørensen |
| collection | DOAJ |
| description | Objectives To examine adherence to serum creatinine and potassium monitoring and discontinuation guidelines following initiation of treatment with ACE inhibitors (ACEI) or angiotensin receptor blockers (ARBs); and whether high-risk patients are monitored.Design A general practice-based cohort study using electronic health records from the UK Clinical Practice Research Datalink and Hospital Episode Statistics.Setting UK primary care, 2004–2014.Subjects 223 814 new ACEI/ARB users.Main outcome measures Proportion of patients with renal function monitoring before and after ACEI/ARB initiation; creatinine increase ≥30% or potassium levels >6 mmol/L at first follow-up monitoring; and treatment discontinuation after such changes. Using logistic regression models, we also examined patient characteristics associated with these biochemical changes, and with follow-up monitoring within the guideline recommendation of 2 weeks after treatment initiation.Results 10% of patients had neither baseline nor follow-up monitoring of creatinine within 12 months before and 2 months after initiation of an ACEI/ARB, 28% had monitoring only at baseline, 15% only at follow-up, and 47% both at baseline and follow-up. The median period between the most recent baseline monitoring and drug initiation was 40 days (IQR 12–125 days). 34% of patients had baseline creatinine monitoring within 1 month before initiating therapy, but <10% also had the guideline-recommended follow-up test recorded within 2 weeks. Among patients experiencing a creatinine increase ≥30% (n=567, 1.2%) or potassium level >6 mmol/L (n=191, 0.4%), 80% continued treatment. Although patients with prior myocardial infarction, hypertension or baseline potassium >5 mmol/L were at high risk of ≥30% increase in creatinine after ACEI/ARB initiation, there was no evidence that they were more frequently monitored.Conclusions Only one-tenth of patients initiating ACEI/ARB therapy receive the guideline-recommended creatinine monitoring. Moreover, the vast majority of the patients fulfilling postinitiation discontinuation criteria for creatinine and potassium increases continue on treatment. |
| format | Article |
| id | doaj-art-d6e2330dbb4148b8ac3cf406840d7239 |
| institution | Kabale University |
| issn | 2044-6055 |
| language | English |
| publishDate | 2017-01-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | BMJ Open |
| spelling | doaj-art-d6e2330dbb4148b8ac3cf406840d72392025-02-01T20:00:16ZengBMJ Publishing GroupBMJ Open2044-60552017-01-017110.1136/bmjopen-2016-012818Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin–angiotensin system blockade: a UK general practice-based cohort studyHenrik Toft Sørensen0Liam Smeeth1Dorothea Nitsch2Morten Schmidt3Laurie A Tomlinson4Krishnan Bhaskaran5Kathryn E Mansfield6Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark3 Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK1Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UKregistrarDepartment of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK2 London School of Hygiene and Tropical Medicine, London, UK1 London School of Hygiene & Tropical Medicine, London, UKObjectives To examine adherence to serum creatinine and potassium monitoring and discontinuation guidelines following initiation of treatment with ACE inhibitors (ACEI) or angiotensin receptor blockers (ARBs); and whether high-risk patients are monitored.Design A general practice-based cohort study using electronic health records from the UK Clinical Practice Research Datalink and Hospital Episode Statistics.Setting UK primary care, 2004–2014.Subjects 223 814 new ACEI/ARB users.Main outcome measures Proportion of patients with renal function monitoring before and after ACEI/ARB initiation; creatinine increase ≥30% or potassium levels >6 mmol/L at first follow-up monitoring; and treatment discontinuation after such changes. Using logistic regression models, we also examined patient characteristics associated with these biochemical changes, and with follow-up monitoring within the guideline recommendation of 2 weeks after treatment initiation.Results 10% of patients had neither baseline nor follow-up monitoring of creatinine within 12 months before and 2 months after initiation of an ACEI/ARB, 28% had monitoring only at baseline, 15% only at follow-up, and 47% both at baseline and follow-up. The median period between the most recent baseline monitoring and drug initiation was 40 days (IQR 12–125 days). 34% of patients had baseline creatinine monitoring within 1 month before initiating therapy, but <10% also had the guideline-recommended follow-up test recorded within 2 weeks. Among patients experiencing a creatinine increase ≥30% (n=567, 1.2%) or potassium level >6 mmol/L (n=191, 0.4%), 80% continued treatment. Although patients with prior myocardial infarction, hypertension or baseline potassium >5 mmol/L were at high risk of ≥30% increase in creatinine after ACEI/ARB initiation, there was no evidence that they were more frequently monitored.Conclusions Only one-tenth of patients initiating ACEI/ARB therapy receive the guideline-recommended creatinine monitoring. Moreover, the vast majority of the patients fulfilling postinitiation discontinuation criteria for creatinine and potassium increases continue on treatment.https://bmjopen.bmj.com/content/7/1/e012818.full |
| spellingShingle | Henrik Toft Sørensen Liam Smeeth Dorothea Nitsch Morten Schmidt Laurie A Tomlinson Krishnan Bhaskaran Kathryn E Mansfield Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin–angiotensin system blockade: a UK general practice-based cohort study BMJ Open |
| title | Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin–angiotensin system blockade: a UK general practice-based cohort study |
| title_full | Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin–angiotensin system blockade: a UK general practice-based cohort study |
| title_fullStr | Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin–angiotensin system blockade: a UK general practice-based cohort study |
| title_full_unstemmed | Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin–angiotensin system blockade: a UK general practice-based cohort study |
| title_short | Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin–angiotensin system blockade: a UK general practice-based cohort study |
| title_sort | adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin angiotensin system blockade a uk general practice based cohort study |
| url | https://bmjopen.bmj.com/content/7/1/e012818.full |
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