Peak Development for ...

Medication Administration

Vol. 15 Issue 12
December 2014

Antihypertensive Agents:
Renin Inhibitors (Aliskiren)
Peak Development Resources
P.O. Box 13267
Richmond, VA 23225
Phone: (804) 233-3707
Fax: (804) 233-3705
Email: editor@peakdev.com

Peak Development for Medication

Administration and Competency
Assessment Tool for Medication
Administration are components of
a site license for the Peak
Development Resources
Competency Assessment System
for Medication Administration
and may be reproduced for this
individual facility only. Sharing
of these components with any
other freestanding facility within
or outside the licensees corporate
entity is expressly prohibited.

The information contained in

Peak Development for Medication
Administration is intended only as
a guide for the practice of
licensed nursing personnel who
administer medications. Every
effort has been made to verify the
accuracy of the information
herein. Because of rapid changes
in the field of drug therapy, the
reader is advised to consult the
package insert, facility pharmacist
or patients physician for relevant
information. This is particularly
important for new or seldom used
drugs. Use of professional
judgment is required in all patient
care situations. It is the readers
responsibility to understand and
adhere to policies and procedures
set forth by the employing
institution. The editor and
publisher of this newsletter
disclaim any liability resulting
from use or misuse of
information contained herein.
Copyright 2014

After completion the learner should be able to:

1. Identify appropriate indications for use of
renin inhibitors.
2. Relate general characteristics of renin
inhibitors to specific patient situations.
3. Apply nursing process considerations for
renin inhibitors to specific patient situations.
Hypertension
Hypertension is a serious public health issue
in the US, affecting 78 million, or 1 in 3, adult
Americans. Of those affected by hypertension,
almost 20% are not aware that they have the
disease. Close to 50% of Americans with
documented hypertension do not have their
blood pressure controlled to target levels. Also
figuring into this public health dilemma is the
enormous financial burden of this disease. The
American Heart Association (AHA) estimates the
direct and indirect costs of hypertension in the
US at $51 billion.
The American Heart Association considers
blood pressure normal if the systolic reading is
below 120 mm/Hg, and the diastolic reading is
below 80 mm/Hg. Hypertension is defined as a
sustained systolic blood pressure of 140 mm/Hg
or greater, or diastolic blood pressure of 90 mm/
Hg or greater. Systolic readings from 120139
or diastolic readings from 8089 are termed
prehypertension.
Consequences of untreated chronic
hypertension include coronary artery disease,
MI, stroke, congestive heart failure, kidney
disease, and peripheral vascular disease. Over
90% of persons with hypertension exhibit the
primary or essential type, meaning the cause of
hypertension is unknown. Risk factors for
hypertension include African American race,
family history of hypertension, obesity, sedentary
lifestyle and a diet high in sodium.
One of the primary physiologic factors in
blood pressure regulation is the reninangiotensin-aldosterone system (RAAS). The

main function of the RAAS is to regulate blood

pressure at times when the body needs it, such
as in response to hypovolemia, low renal blood
flow, or reduced blood pressure. When renal
perfusion decreases or the sympathetic nervous
system is stimulated, special cells in the kidney
secrete renin, an enzyme that stimulates the
formation of angiotensin I. Angiotensin I in the
blood stream is then converted to angiotensin II
by angiotensin converting enzyme (ACE).
Angiotensin II is a potent vasoconstrictor that
increases blood pressure and stimulates release
of aldosterone from the adrenal cortex.
Aldosterone causes retention of sodium and
water, further increasing blood pressure. When
blood pressure rises, release of renin is
suppressed, ending further action of the RAAS.
Several classes of antihypertensive drugs
affect the RAAS to manage blood pressure,
such as ACE inhibitors and angiotensin receptor
blockers (ARBs). The newest drug class is the
direct renin inhibitor, of which aliskiren
(Tekturna) is the first and only member.
ACE inhibitors interrupt the RAAS to lower
blood pressure by blocking the action of
angiotensin converting enzyme, and ARBs act
by blocking the action of angiotensin II. In
contrast, aliskiren interrupts the RAAS at an
earlier point, by direct blocking of renin activity at
the receptor sites. This results in lower ACE and
angiotensin II levels, compared to the other drug
classes.
Indications
Aliskiren is approved for the treatment of
hypertension, alone or in combination with other
antihypertensive drugs, such as calcium channel
blockers or ARBs. Aliskiren is available in
various combinations with hydrochlorothiazide,
amlodipine, and valsartan.
Pharmacodynamics
Aliskiren directly inhibits the activity of
renin at receptor sites. While this results in

increased renin plasma levels, the ability of renin to activate the

RAAS is decreased. This decreases levels of angiotensin I and
II and reduces blood pressure.
Pharmacokinetics
Absorption: Poorly absorbed after oral administration;
absorption is reduced when taken with high-fat meals.
Distribution: Moderately protein-bound; unknown whether the
drug is found in breast milk
Metabolism: Undergoes hepatic metabolism; long half-life of at
least 24 hours
Elimination: Excreted unchanged by the kidneys
Major Interactions
Cyclosporine and itraconozole: Concurrent administration
can significantly increase aliskiren levels; aliskiren should not
be administered with either drug.
Other drugs affecting the RAAS: Administration of ARBs or
ACE inhibitors with aliskiren may increase the risk of
hypotension, hyperkalemia and renal damage.
NSAIDs: Concurrent administration increases the risk of
acute renal failure, hyperkalemia and decreased antihypertensive effect of aliskiren.
Adverse Effects/Toxicity
Common adverse effects include dizziness, headache,
diarrhea, cough, fatigue, rash, back pain and hyperkalemia.
Kidney stones, acute renal failure, seizures, anaphylaxis and
angioedema have also been reported.
Precautions/Contraindications
Aliskiren should not be used during pregnancy, and carries
a boxed warning about the risk of fetal injury and death with
exposure to the drug. Hypotension may occur in patients with
hypovolemia or sodium depletion these conditions should be
corrected before starting the drug. Combination therapy with
ACE inhibitors or ARBs is contraindicated in patients with
diabetes, due to increased risk of renal damage, hyperkalemia
and hypotension. It should also be avoided in patients with renal
impairment and GFR <60 ml/min.
Nursing Process
Assessment
Determine baseline status: Accurate baseline blood
pressure measurements should be documented, based on
several readings at different times. Thorough assessment of
other aspects of the patients cardiovascular system should also
be performed, including heart rate, pulse quality and rhythm,
and ECG.
Identify risk factors: A thorough history should be taken to
identify conditions that may be affected by adding aliskiren to
the medication regimen, such as diabetes, renal impairment,
current antihypertensive drugs or allergies.

Age-specific considerations: FDA pregnancy category D.

Aliskiren should be discontinued as soon as possible if
pregnancy occurs. The drug should be used in nursing mothers
only if the benefits outweigh the risks. Decreased dosage in the
elderly is not required, but this population may be at increased
risk for renal impairment and dizziness, predisposing to falls.
Planning and Analysis
The desired therapeutic outcome of antihypertensive
therapy is to reduce blood pressure and prevent long-term
complications of chronic hypertension.
Intervention
Medication administration: Aliskiren is administered orally,
in tablet form. It may be taken with or without meals, but this
should be consistent, since food affects absorption. Dosing is
usually once daily, and is adjusted based on patient response.
Observe for therapeutic effects: Monitor blood pressure
and other cardiovascular indicators regularly during therapy.
The Joint National Committee hypertension guidelines (JNC 8)
recommend a reduction and stabilization of blood pressure to
below 140/90 for all patients aged 18-59 years, and for patients
60 years and older with diabetes or chronic kidney disease. For
patients 60 years and older without diabetes or chronic kidney
disease, a goal of below 150/90 is recommended.
Observe for adverse effects: Monitor for effects such as
hypotension, dizziness and hyperkalemia (irregular or slow
pulse, weakness or tingling). Monitor lab values such as renal
function and potassium levels.
Patient/Family teaching: Education should include:
Take drug exactly as prescribed, at the same time each day.
Take drug with meals or on an empty stomach consistently.
Change positions slowly until drug effects are known.
Do not use potassium supplements or salt substitutes
containing potassium unless advised by the physician.
Continue taking drug as prescribed, even when feeling well,
as hypertension typically does not cause signs or symptoms.
Avoid pregnancy while taking the drug.
Do not take other medications without physician approval.
Notify physician if weakness, edema, persistent dizziness,
decreased urine output or other serious effects occur.
Also, emphasize that medication is only one aspect of
therapy for hypertension. Institute teaching plans for lifestyle
changes associated with diet, achievement of normal body
weight, smoking cessation, stress management, and regular
exercise.
Evaluation
Support and education from the nurse and other healthcare
professionals can provide the patient with the necessary tools to
make healthy choices regarding diet, exercise, and medication
management for effective control of hypertension.

Peak Development for Medication Administration

Antihypertensive Agents: Renin Inhibitors (Aliskiren)

Page 2

Peak Development for ...

Medication Administration
Competency Assessment Tool

Vol. 15 Issue 12
December 2014

Antihypertensive Agents:
Renin Inhibitors (Aliskiren)
NAME:

DATE:

UNIT:

Directions: Place the letter of the one best answer in the space provided.
_____1. According to current guidelines of the American Heart Association, a patient whose blood pressure is
consistently 122/78 has:
A. hypotension
B. pre-hypertension
C. hypertension
D. normal blood pressure
_____2. Most cases of hypertension have an identifiable cause, such as renal disease.
A. True
B. False
_____3. Risk factors for hypertension include all of the following EXCEPT:
A. family history of hypertension
B. African-American race
C. sedentary lifestyle
D. underweight
_____4. The renin-angiotensin-aldosterone system (RAAS) may be activated when which of the following occurs:
A. hypotension
B. hypovolemia
C. reduced renal blood flow
D. all of the above
_____5. Aliskiren acts by:
A. directly blocking the action of renin
B. blocking the receptor sites for angiotensin II
C. stimulating renin receptor sites to form angiotensin l
D. inhibiting the action of angiotensin converting enzyme

_____6. Aliskiren in combination with an ACE inhibitor or angiotensin receptor blocker (ARB) is contraindicated in:
A. patients with cardiovascular disease
B. diabetic patients
C. patients over the age of 60
D. all patients, since this combination of drugs should not be used
_____7. Aliskiren carries a black box warning due to risk of:
A. severe hypotension and falls
B. renal damage
C. fetal injury or death
D. liver failure
_____8. Patients taking aliskiren are most likely to develop which of the following electrolyte disturbances:
A. hyperkalemia
B. hypokalemia
C. hypernatremia
D. hyponatremia
_____9. The nurse should instruct patients starting on aliskiren to take the drug:
A. with meals
B. on an empty stomach
C. either with meals or on an empty stomach, but do so consistently
D. whenever they desire, as food has no effect on drug absorption
_____10. Mrs. Bailey is a 65 year old woman with no chronic health problems other than hypertension. According to
the current Joint National Committee hypertension guidelines, her antihypertensive medication should be
managed to reach a target blood pressure below:
A. 130/80
B. 140/90
C. 150/90
D. 160/100

Competency Assessment Tool

Antihypertensive Agents: Renin Inhibitors (Aliskiren)

Page 2

Peak Development for ...

Medication Administration

Month: December 2014

Issue: Antihypertensive Agents:
Renin Inhibitors (Aliskiren)

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December 2014
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