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Angiotensin is a peptide endocrine hormone and an important part of the renin-angiotensin-aldosterone system, an inter-related endocrine system important in volume and blood pressure control. Angiotensinogen, an alpha-globulin, and the peptide prohormone is synthesized primarily by the liver and circulates in plasma. Angiotensin II (AT-II) has recently received FDA approval for use in patients in shock. This activity reviews the indications, contraindications, activity, adverse events, and other key elements of AT-II therapy in the clinical setting as relates to the essential points needed by members of an interprofessional team managing the care of patients presenting with shock. Objectives: Identify the indications approved for II in the therapeutic setting. Review the dose forms and dosing parameters for angiotensin II. Summarize monitoring, contraindications, and toxicity for angiotensin II. Outline interprofessional team strategies for improving care coordination and communication to advance appropriate clinical outcomes with angiotensin II therapy to treat shock and drive optimal patient results. Access free multiple choice questions on this topic.

The pharmacologic effect of this drug is to raise blood pressure. An overdose of the drug could result in hypertension. Careful monitoring and titration of the drug should prevent this effect, but in the even that it occurs, the short plasma half-life of angiotensin II means that this toxicity is easily reversible, and no antidote or further treatment should be required. The potential for thromboembolic events in patients treated with angiotensin II dictates the need for DVT prophylaxis during treatment.

Angiotensin II is often useful in the management of unresponsive shock vs. the traditional inotropic agents. However, healthcare workers, including the ICU nurse, intensivist, cardiologist, infectious disease specialist, pharmacist, and internist, need to be fully aware of the drug's potential toxicity. The patient requires monitoring in an ICU setting with an interprofessional team. The drug should be infused in large veins, preferably central veins, as it has the potential to cause severe vasoconstriction of the peripheral vessels; this is the responsibility of the nursing staff. Because of the potential for both arterial and venous thromboembolic events, all treated patients should receive concurrent deep vein thrombosis (DVT) prophylaxis, which the pharmacist can help drive appropriate agent selections and verify dosing and medication reconciliation. All patients need to have their renal function monitored while the patient is on angiotensin II. One significant caveat to the use of this agent is the lack of mortality benefit with this agent. The ATHOS 3 trial did not report any mortality improvement; this study was not powered to prove the mortality benefit. Small case studies indicate that angiotensin II can raise blood pressure, but it often does not improve survival in patients with shock. The argument for the use of this agent is that clinicians wait till it is very late in the clinical process before initiating this agent, leading to mortality. The hypothesis of angiotensin II deficiency states that the condition, as reflected by elevated renin levels, can be used to identify patients where this agent may potentially be more effective, justifying its early use in the vasoplegic shock state. However, renin testing is not done in routine labs and is a send-out test for most hospitals, with results delayed for days. The cost of angiotensin II is another concern in its widespread adoption. Daily therapy with this agent is approximately three thousand dollars, which, when compared to norepinephrine, is many times more expensive. Use of this medication requires complex decision making requiring an interprofessional team, including clinicians, specialists, nursing, and pharmacy, necessary for successful treatment with angiotensin II. [Level V]