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• An important rationale for sequential prescription of medication for congestive heart failure
  oscar,m jolobe
  Published on: 10 March 2023

• Published on: 10 March 2023

  An important rationale for sequential prescription of medication for congestive heart failure

  • oscar,m jolobe, retired geriatrician British Medical Association

  The occasional, and unforeseen occurrence of drug-related interstitial nephritis is, arguably, an important justification for sequencing the initiation of drug treatment for congestive heart failure or for hypertension.
  Given the fact that interstitial nephritis has been reported after medication with captopril[1], losartan[2], valsartan[3], and empagliflozin[4],[5],, respectively, the challenge of identifying the culprit medication is made much easier if drugs belonging to those subclasses are introduced sequentially. Two examples justify that approach:-
  In one hypertensive patient empagliflozin had been prescribed as an add-on therapy to long-standing medication with losartan, bisoprolol, amlodipine, sitagliptin, and aspirin. Pre empagliflozin serum creatinine was 0.9 mg/dl. Post empgliflozin serum creatinine peaked at 9.22 mg/dl. Renal biopsy showed stigmata of acute interstitial nephritis. Empagliflozin was discontinued, and the patient was managed with haemodialysis and corticosteroid therapy. She improved and was eventually weaned off haemodialysis[4].
  The second example was a hypertensive patient who had been taking enalapril, dilriazem, and atoravastatin for more than 2 years. Pre-empagliflozin serum creatinine was 60 mcmol/l. After empagliflozin was initiated as add-on therapy serum creatnine increased to 381 mcmol/l. Renal biopsy showed stigmata of acute interstitial nephritis. Renal function improved after withdrawal of empagliflozi...

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  The occasional, and unforeseen occurrence of drug-related interstitial nephritis is, arguably, an important justification for sequencing the initiation of drug treatment for congestive heart failure or for hypertension.
  Given the fact that interstitial nephritis has been reported after medication with captopril[1], losartan[2], valsartan[3], and empagliflozin[4],[5],, respectively, the challenge of identifying the culprit medication is made much easier if drugs belonging to those subclasses are introduced sequentially. Two examples justify that approach:-
  In one hypertensive patient empagliflozin had been prescribed as an add-on therapy to long-standing medication with losartan, bisoprolol, amlodipine, sitagliptin, and aspirin. Pre empagliflozin serum creatinine was 0.9 mg/dl. Post empgliflozin serum creatinine peaked at 9.22 mg/dl. Renal biopsy showed stigmata of acute interstitial nephritis. Empagliflozin was discontinued, and the patient was managed with haemodialysis and corticosteroid therapy. She improved and was eventually weaned off haemodialysis[4].
  The second example was a hypertensive patient who had been taking enalapril, dilriazem, and atoravastatin for more than 2 years. Pre-empagliflozin serum creatinine was 60 mcmol/l. After empagliflozin was initiated as add-on therapy serum creatnine increased to 381 mcmol/l. Renal biopsy showed stigmata of acute interstitial nephritis. Renal function improved after withdrawal of empagliflozin and initiation of corticosteroid therapy[5].
  Comment
  In both cases[4],[5] the culprit medication was more easily identifiable because medications belonging to subclasses that were potential candidates for the role of causative agents for interstitial nephritis, namely, losartan[4] and enalapril[5] , respectively, were already in place by the time empagliflozin was introduced.
  I have no conflict of interest
  References
  [1]Smith WR., Neill J., Cushman WC., Butkus DE
  Captopril-associated acute interstitial nephritis
  Am J Nephrol 1989;9:230-235
  [2]Weinert LS., Triches CB., Laitao B et al
  Losartan-induced acute interstitial nephritis
  REV HCPA 2007;27:61-64
  [3]Chen T., Xu P-c., Hu S-y et al
  Severe acute interstitial nephritis induced by valsartan A case report
  Medicine 2019;98;6
  [4] Bnaya A., Itzkowitz E., Atrash J., Abu-Alfeilat M., Shavit L
  Acute interstitial nephritis related to SGLT-2 inhibitor
  Postgrad Med J 2022;98:740-741
  [5] Ryan R., Choo S., Willows J et al
  Acute interstitial nephritis due to sodium-glucose-co-transporter 2 inhibitor empagliflozin
  Clinical Kidney Journal 2021;14:1020-1022

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  Conflict of Interest:
  None declared.

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