Key result
A prolonged 48-hour washout period of azilsartan prevented severe refractory hypotension during general anesthesia in a patient with moderate-to-severe renal impairment, whereas a 24-hour washout did not.
Why the study?
Impaired renal function prolongs the half-life of azilsartan, raising questions about whether the recommended 24-hour preoperative washout period sufficiently avoids severe refractory hypotension during general anesthesia.
Does a 48-hour washout period of azilsartan prevent severe refractory hypotension during general anesthesia in patients with renal impairment?
Case Report (n=1)
No
Does a 48-hour washout period of azilsartan prevent severe refractory hypotension during general anesthesia in patients with renal impairment?
In patients with significant renal impairment taking azilsartan, the standard 24-hour preoperative washout period may be insufficient to prevent severe refractory hypotension during general anesthesia, suggesting a longer washout period is needed.
May warrant caution with standard azilsartan washout in renal impairment; leaves open need for prospective confirmation.
Angiotensin receptor blockers (ARBs) are widely used to treat hypertension, but severe refractory hypotension during general anesthesia is a well-known complication associated with the continuation of ARBs during the perioperative period. It has therefore been recommended that ARBs be withheld for 24 hours before induction of general anesthesia. However, impaired renal function affects the pharmacokinetics of each ARB differently. The half-life of azilsartan is prolonged in accordance with the degree of renal impairment. Herein, we describe a patient with chronic kidney disease grade 3B who experienced severe refractory hypotension after induction of general anesthesia requiring administration of dopamine following inadequate responses to ephedrine and phenylephrine despite a 24-hour azilsartan washout period. When the same patient underwent general anesthesia for a subsequent surgery, azilsartan was withheld for 48 hours before induction, resulting in mild intraoperative hypotension that responded adequately to phenylephrine. Severe refractory hypotension during general anesthesia cannot always be avoided by holding azilsartan for 24 hours in patients with significant renal impairment. Therefore, a longer washout period may be preferable for patients regularly taking azilsartan who also have concurrent substantial renal impairment.
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Hojo et al. (2021) conducted a case report in Refractory hypotension during general anesthesia in a patient with renal impairment taking azilsartan (n=1). Prolonged azilsartan washout period (48 hours) vs. 24-hour washout period was evaluated on Intraoperative refractory hypotension. A prolonged 48-hour washout period of azilsartan prevented severe refractory hypotension during general anesthesia in a patient with moderate-to-severe renal impairment, whereas a 24-hour washout did not.
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