Both cause potassium retention; combined use increases risk of life-threatening hyperkalemia
Management: Monitor serum potassium closely if used together. Common cardiac combination but requires monitoring.
NSAIDs reduce prostaglandin-mediated renal blood flow, potentially blunting ACE inhibitor efficacy and increasing nephrotoxicity
Management: Monitor renal function closely. Ensure adequate hydration.
ACE inhibitors + loop diuretics can cause excessive hypotension and prerenal azotaemia
Management: Standard cardiac combination. Start ACE inhibitor at low dose. Monitor renal values and blood pressure.
Methimazole treatment unmasks pre-existing CKD (previously masked by hyperthyroidism-induced hyperfiltration). Adding ACE inhibitor further reduces GFR.
Management: Monitor BUN/creatinine at 2 and 4 weeks after starting methimazole. Adjust methimazole dose to maintain mild hyperthyroidism if CKD is severe.
Trilostane reduces aldosterone + ACE inhibitor reduces aldosterone: combined potassium-retaining effect.
Management: Monitor serum potassium. Clinically used combination in Cushing's dogs with concurrent heart disease — requires monitoring.
NSAID opposes ACE inhibitor renal hemodynamic protection by reducing prostaglandin-dependent afferent arteriolar vasodilation.
Management: Monitor BUN/creatinine at 5-7 days. Ensure hydration. Common combination in geriatric dogs with OA + heart disease — requires monitoring.
NSAID + ACE inhibitor: reduced renal prostaglandin effect opposes ACE inhibitor renal protection.
Management: Monitor renal function when combining. Ensure adequate hydration.
Potassium Citrate
moderateACE inhibitors reduce aldosterone (potassium-retaining). Adding potassium supplementation increases hyperkalemia risk.
Management: Monitor serum potassium at 3-5 days. Reduce supplement if K+ >5.5 mEq/L.
Dual RAAS blockade (ARB + ACE inhibitor): additive blood pressure reduction and potassium retention. Used therapeutically for refractory proteinuria but requires monitoring.
Management: Used intentionally for severe proteinuria when single agent insufficient. Monitor blood pressure, potassium, and renal function at 3-5 days and 14 days.