Potassium NSAIDs

ACE-I, indicates angiotensin converting-enzyme inhibitor BP, blood pressure CNS, central nervous system GI, gastrointestinal INR, international normalization ratio K+, potassium NSAID, non-steroidal anti-inflammatory drug SSRI, selective serotonin receptor inhibitor TCA, tricyclic antidepressant. 

POTASSIUM NSAIDs T risk of hyperkalaemia Additive effect 5 For signs and symptoms of hyperkalaemia, see Qinical Features of Some Adverse Drug Interactions, Hyperkalaemia... 

The hypotensive effects of most antihypertensive dru are increased when administered with diuretics and other antihypertensives. Many dnigp can interact with the antihypertensive drugs and decrease their effectiveness (eg, antidepressants, monoamine oxidase inhibitors, antihistamines, and sympathomimetic bronchodilators). When the ACE inhibitors are administered with the NSAIDs, their antihypertensive effect may be decreased. Absorption of the ACE inhibitors may be decreased when administered with the antacids. Administration of potassium-sparing diuretics or potassium supplements concurrently with the ACE inhibitors may cause hyperkalemia. When the angiotensin II receptor agonists are administered with... 

Potassium-sparing diuretics may cause hyperkalemia, especially in patients with chronic kidney disease or diabetes, and in patients receiving concurrent treatment with an ACE inhibitor, ARB, NSAID, or potassium supplement. Eplerenone has an increased risk for hyperkalemia and is contraindicated in patients with impaired renal function or type 2 diabetes with proteinuria. Spironolactone may cause gynecomastia in up to 10% of patients, but this effect occurs rarely with eplerenone. 

ACE inhibitors decrease aldosterone and can increase serum potassium concentrations. Hyperkalemia occurs primarily in patients with chronic kidney disease or diabetes and in those also taking ARBs, NSAIDs, potassium supplements, or potassium-sparing diuretics. 

Drugs that may interact include digoxin, potassium preparations, ACE inhibitors, and NSAIDs. 

Drugs that may be affected by NSAIDs include the following Aminoglycosides, anticoagulants, ACE inhibitors, beta blockers, cyclosporine, dextromethorphan, digoxin, dipyridamole, hydantoins, lithium, loop diuretics, methotrexate, penicillamine, potassium-sparing diuretics, sympathomimetics, theophylline, thiazide diuretics. 

In combination with potassium-sparing diuretics severe hyperkalaemia may occur. The elimination of lithium is prolonged. Non-steroidal anti-inflammatory drugs (NSAIDs) may reduce the antihypertensive effect of ACE inhibitors. 

Hyperkalemia due to a decrease in aldosterone secretion is rarely found in patients with normal renal function, but it is relatively common in those with CHF and in the elderly. Hyperkalemia is more frequent in patients with renal impairment, diabetes, and in those receiving either K+ or potassium K+-sparing diuretics, heparin or non-steroidal anti-inflammatory drugs (NSAIDs). 

ACE INHIBITORS, ANGIOTENSIN II RECEPTOR ANTAGONISTS NS AIDs 1. t risk of renal impairment with NSAIDs and ACE inhibitors 2. t risk of hyperkalaemia with ketorolac 1. Additive effect 2. Ketorolac causes hyperkalaemia, and ACE inhibitors can 1 renal function 1. Monitor renal function and BP closely. Benefits often outweigh risks for short-term NSAID use 2. Ketorolac is only licensed for short-term control of perioperative pain. Monitor serum potassium daily... 

POTASSIUM-SPARING DIURETICS ANALGESICS-NSAIDs Risk of hyperkalaemia with NSAIDs Renal insufficiency caused by NSAIDs can exacerbate potassium retention by these diuretics Monitor renal function and potassium closely... 

HEPARINS ANALESICS - NSAIDs 1. Risk of prolonged bleeding when ketorolac is co-administered with dalteparin (but not enoxaparin), and intravenous diclofenac is given with heparins 2. t risk of hyperkalaemia when ketorolac is given with heparin 1. Uncertain 2. Heparin inhibits aldosterone secretion, causing hyperkalaemia 1. Avoid co-administration 2. Monitor potassium levels closely... 

NSAIDs PROGESTOGENS t risk of hyperkalaemia Drospirenone (component of the Yasmin brand of combined contraceptive pill) is a progestogen derived from spironolactone that can cause potassium retention Monitor serum potassium weekly until stable, and then every 6 months... 

Diuretics NSAIDs cause sodium retention and reduce diuretic and antihypertensive efficacy risk of hyperkalaemia with potassium-sparing diuretics increased nephrotoxicity risk (with indomethacin, ketorolac). 

Triamterene (Dytac) is a potassium-sparing diuretic which has an action and use similar to that of amiloride. The diuretic effect extends over 10 h. Gastrointestinal upsets occur. Reversible, nonoliguric renal failure may occur when triamterene is used with indomethacin (and presumably other NSAIDs). 

Acute renal failure, e.g. cuninoglycosides, cisplatin Nephrotic syndrome, e.g. penicillamine, gold, cap-topril (only at higher doses than now recommended) Chronic renal failure, e.g. NSAIDs Functional impairment, i.e. reduced ability to dilute and concentrate urine (lithium), potassium loss in urine (loop diuretics), acid-base imbalance (acetazolamide). 

The interaction between potassium-sparing diuretics and NSAIDs is well documented (SED-14, 674). The major complications are deterioration of renal function and hjrper-kalemia. The risk associated with the non-selective COX-2 inhibitors is unknown. However, three patients had hyperkalemia (8.5, 5.4, and 5.1 mmol/1) after developing acute renal insufficiency while taking these drugs (8). 

NSAIDs. The CSM remarked that the release characteristics of the system might expose certain areas of the bowel to higher concentrations of indometacin than usual. It was also noted that the formulation contained potassium bicarbonate, a known bowel irritant (26). 

Potassium-sparing diuretics All NSAIDs Potassium retention and hyperkalemia Avoid combination monitor plasma potassium concentration... 

Abbreviations NSAID = nonsteroidal anti-inflammatory drugs, PG = prostaglandin, RBF = renal blood flow, GFR = glomerular filtration rate,HTN = hypertension, DM = diabetes mellitus, = potassium, RAA = renin-angiotensin- aldosterone, CHF = congestive heart failure, AGE = angiotensin-converting enzyme, SLF = systemic lupus erythematosis. 

Indomethacin appears to be the NSAID most frequently associated with the development of hyperkalemia, including patients without apparent risk factors [54]. In addition to the known effects of NSAIDs on potassium delivery to the distal tubule and their inhibi-... 

As noted above, hyperkalemia often complicates the NSAID-induced acute renal deterioration. However, the severity of hyperkalemia can be disproportionate to the degree of renal impairment. Tan et al. [56] have reported a patient who had a serum potassium level of 6.2 mEq/L in spite of only mildly abnormal renal function. In this patient, plasma renin and aldosterone levels were suppressed and failed to respond to furo-semide or postural changes. Urinary prostaglandin Ej was also suppressed. Discontinuation of indomethacin resulted in normalization of potassium, prostaglandin Ej, and a rebound of renin and aldosterone. 

NSAID-induced acute renal decompensation is a pharmacologically predictable phenomenon that possesses a dose-dependent component. In a triplecrossover study of 12 females with mild renal failure, ibuprofen (800 mg three times daily) was discontinued in 3 pahents after 8 days because of worsening renal function (> 133 pmol/L - > 1.5 mg/dl increase in serum creahnine) or hyperkalemia (potassium > 6 mmol/ml). When these 3 pahents were rechallenged at a 50% lower dose of ibuprofen, two developed evidence of acute renal deteriorahon [45]. 

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