ACE inhibitors, ARBs, mineralocorticoid receptor antagonists and SGLT2 inhibitors all lower intraglomerular pressure, producing an early eGFR fall that is usually haemodynamic and reversible. A fall of up to about 30% within the first weeks is generally acceptable if potassium is safe and the patient is not volume-depleted. A larger fall, rising potassium or continued decline should prompt a check for dehydration, NSAIDs, renal artery stenosis or intercurrent illness before stopping the drug.
- Recheck creatinine and potassium 1–2 weeks after starting or up-titrating.
- Accept an eGFR fall of up to about 30% if potassium is under control.
- Look for a cause — volume depletion, NSAIDs, contrast — before stopping for a larger fall.
- Restart once the cause is corrected; the long-term benefit is large.
Why it matters
Premature discontinuation after an expected dip is one of the commonest ways patients lose cardiorenal protection.
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