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REPLY
Renal Insufficiency and Heart Failure Therapy
Michael G. Shlipak, MD, MPH
6 April 2004 | Volume 140 Issue 7 | Page 584
IN RESPONSE:
I greatly appreciate Dr. Spital's thoughtful comments on my review and regarding the choice of ACE inhibitor in patients with renal dysfunction. He is correct that fosinopril may be the ideal ACE inhibitor in this setting because it has the greatest hepatobiliary elimination (1, 2). Therefore, if discontinuation is required in response to an adverse event, fosinopril should have a more rapid elimination than other ACE inhibitors. However, because studies have not compared clinical outcomes among the ACE inhibitors, and fosinopril has not been evaluated in a heart failure survival trial, I cannot strongly endorse fosinopril as the optimal ACE inhibitor for patients with heart failure and renal insufficiency. Future studies comparing adverse events in this setting among the various ACE inhibitors would be useful contributions to the literature.
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Author and Article Information
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From Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, CA 94121.
1. Hoyer J, Schulte KL, Lenz T. Clinical pharmacokinetics of angiotensin converting enzyme (ACE) inhibitors in renal failure. Clin Pharmacokinet. 1993;24:230-54. [PMID: 8462229].[Medline]
2. White CM. Pharmacologic, pharmacokinetic, and therapeutic differences among ACE inhibitors. Pharmacotherapy. 1998;18:588-99. [PMID: 9620109].[Medline]
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[ABSTRACT][Full Text]
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