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

Abstract

Circulatory shock is a medical emergency that requires rapid intervention to optimize patient outcomes. Although catecholamine vasopressors are considered life‐sustaining therapy, they are associated with adverse reactions, and vasopressin and angiotensin II may be used to minimize these adverse effects. However, vasopressin and angiotensin II are also associated with adverse reactions that must be known to the clinician to mitigate risk for patients. This review focuses on the known adverse drug effects of vasopressin and angiotensin II while offering potential solutions to minimize harm with these agents. Future directions with vasoactive medication safety including optimization of the electronic medical record, clinical decision support, prediction analytics, and precision medicine for patients with circulatory shock are also discussed.

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

“…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 . As with vasopressin use, if and when angiotensin II is administered, hemodynamic response should be monitored, and if a positive hemodynamic response does not occur after the initiation of angiotensin II, alternative therapies should be considered.…”

“…Chronic ACEI and ARB use may also have significant effects in patients with sepsis who receive angiotensin II. Due to potential upregulation of angiotensin I receptors in patients receiving chronic ACEIs, an exaggerated increase in MAP may occur when giving angiotensin II . However, downregulation of angiotensin I receptors in patients receiving ARBs may result in a diminished response to angiotensin II initiation, an effect shown in a small subgroup analysis of the ATHOS‐3 trial .…”

“…Due to potential upregulation of angiotensin I receptors in patients receiving chronic ACEIs, an exaggerated increase in MAP may occur when giving angiotensin II. 69 However, downregulation of angiotensin I receptors in patients receiving ARBs may result in a diminished response to angiotensin II initiation, an effect shown in a small subgroup analysis of the ATHOS-3 trial. 67 Unfortunately, there is a need for further published data evaluating these scenarios to determine the true clinical effects of chronic ACEIs and ARBs in patients who receive angiotensin II.…”

Innovations in Medication Safety: Services and Technologies to Enhance the Understanding and Prevention of Adverse Drug Reactions

“…Muensterman and colleagues review the literature on the use of predictive analytics to assist with early warning of patients at risk for QT c ‐interval prolongation . Clinical decision support can be applied to new drugs to assist with identifying candidates for treatment and as an early warning tool when safety is a concern but the full scope of possible ADRs is not understood until postmarketing surveillance is available …”

“…22 Clinical decision support can be applied to new drugs to assist with identifying candidates for treatment and as an early warning tool when safety is a concern but the full scope of possible ADRs is not understood until postmarketing surveillance is available. 23 Innovations in medication safety expand beyond the hospital to include long-term care facilities and community settings as well. The Centers for Medicare and Medicaid Services recently updated the requirement of participation for long-term care facilities, and the changes include an emphasis on the safe and effective use of medications, which is an opportunity to advance pharmacy services.…”