Clinical Experience With IV Angiotensin II Administration: A Systematic Review of Safety

Abstract

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Safe Use of Vasopressin and Angiotensin II for Patients with Circulatory Shock

“…Although this review described few ADRs with angiotensin II, the results should be interpreted cautiously because only 115 patients included had shock, and the results from ATHOS-3 were not incorporated. 45 Importantly, despite the ADRs noted, dropouts and/or discontinuations due to adverse effects were numerically less frequent in ATHOS-3 with angiotensin II than placebo (angiotensin II 14.1% vs placebo 21.5%, risk difference À7.4%, 95% confidence interval À15.8 to 0.9%, p=0.11), 31 suggesting that ADRs with angiotensin II often do not occur during treatment and should be closely monitored after infusion cessation.…”

“…Because of the short half‐life of angiotensin II, this ADR can be mitigated by more rapid down‐titration of angiotensin II infusions in hyper‐responders than was used in the ATHOS‐3 study, or lower initial doses could be utilized. Moreover, patients with asthma or bronchospasm were excluded from ATHOS‐3 because angiotensin II has been associated with bronchospasm and should be avoided in these patients . Lastly, a large systematic review described the safety of angiotensin II use in 31,218 participants.…”

“…Although data support the existence of a relative vasopressin deficiency in patients with hypovolemic (hemorrhagic) shock secondary to trauma, the published studies of AVP use in this shock state are small and conflicting, 50, 51 and the results of a recently completed study of AVP as salvage therapy in patients with traumatic hemorrhagic shock (Vasopressin in Traumatic Shock [VITRIS] trial, NCT00379522) are awaited. Furthermore, because of their potential to reduce CO, AVP and angiotensin II should be avoided in patients with cardiogenic shock and should be used with extreme caution in patients with septic shock complicated by left heart failure with reduced ejection fraction . Finally, there seems to be a benefit when these agents are started in patients with less severe shock, whether defined as lower catecholamine doses, 2, 7 lower lactate concentrations, 7, 25 or time from shock onset …”

“…Moreover, patients with asthma or bronchospasm were excluded from ATHOS-3 because angiotensin II has been associated with bronchospasm and should be avoided in these patients. 45 Lastly, a large systematic review described the safety of angiotensin II use in 31,218 participants. Although this review described few ADRs with angiotensin II, the results should be interpreted cautiously because only 115 patients included had shock, and the results from ATHOS-3 were not incorporated.…”

Vasoactive Agent Use in Septic Shock: Beyond First‐Line Recommendations

“…Additionally, further safety data on angiotensin II is warranted. In one meta‐analysis, the drug appeared to be well tolerated with minimal adverse effects (albeit this study did not include data from the ATHOS‐3 study). However, the U.S. product labeling for angiotensin II warns of increased thrombotic events (rates of 12.9% with angiotensin II vs 5.1% with placebo in the ATHOS‐3 trial), thrombocytopenia, and infection risk, among others .…”