ACE Inhibitor and Beta Blocker, Nephrologist recommendations Options

[Linda B]

Hi,
I saw the nephrologist today. My endo sent me to him because my last GFR was low. The doctor I saw just came out of research and is going back into practice. With his research, he was able to REVERSE KIDNEY DISEASE and get patients OFF DIALYSIS.

He changed my ACE inhibitor from 10 mg Ramipril once a day to 10 mg Quinapril twice a day. He said it is the Quinapril that reversed kidney disease.

He also added a Beta Blocker, Metroprolol Tartrate 25 mg twice a day because my BP and pulse were high. My BP varies - I never know if it will be high or normal when a Doctor checks it. Not sure if I have white collar syndrome or not. But my pulse is ALWAYS high. He did not like that. He said it is much healthier to get it down. He said that some doctors do not prescribe BETA Blockers for diabetics because it masks the symptoms of lows, but since I have my CGMS he was not concerned.

So we will see. This doctor has wonderful credentials, and I believe that he has reversed kidney disease. Since I don't have any real issue yet (other than a GFR that varies from 48 to 68), I am happy to follow whatever he suggests to preserve my kidney function.

The only disappointing thing was that he was not familiar at all with insulin pumps. I had to explain the whole thing to him. But since he has been researching kidney disease I will not hold it against him.

Is anyone else on the combination of Beta Blocker and ACE inhibitor?

Linda B.

[Manxman]

<div class='quotetop'>

(Linda B @ Dec 6 2012, 01:47 PM) </div><div class='quotemain'>Hi,
I saw the nephrologist today. My endo sent me to him because my last GFR was low. The doctor I saw just came out of research and is going back into practice. With his research, he was able to REVERSE KIDNEY DISEASE and get patients OFF DIALYSIS.

He changed my ACE inhibitor from 10 mg Ramipril once a day to 10 mg Quinapril twice a day. He said it is the Quinapril that reversed kidney disease.

He also added a Beta Blocker, Metroprolol Tartrate 25 mg twice a day because my BP and pulse were high. My BP varies - I never know if it will be high or normal when a Doctor checks it. Not sure if I have white collar syndrome or not. But my pulse is ALWAYS high. He did not like that. He said it is much healthier to get it down. He said that some doctors do not prescribe BETA Blockers for diabetics because it masks the symptoms of lows, but since I have my CGMS he was not concerned.

So we will see. This doctor has wonderful credentials, and I believe that he has reversed kidney disease. Since I don't have any real issue yet (other than a GFR that varies from 48 to 68), I am happy to follow whatever he suggests to preserve my kidney function.

The only disappointing thing was that he was not familiar at all with insulin pumps. I had to explain the whole thing to him. But since he has been researching kidney disease I will not hold it against him.

Is anyone else on the combination of Beta Blocker and ACE inhibitor?

Linda B.

Just a suggestion, Linda--

Be very careful and alert for unexpected low BG's that show up with absolutely no symptoms (other than pump alarms from your CGM). Beta blockers, and Metoprolol specifically, have the side effect of eliminating low BG awareness. My own low BG symptoms that I had had for 49 years just disappeared entirely while I was using Metoprolol, and resulted in an open fracture of my left tibia and fibula, and due to hospital negligence, the open fracture gave me lifetime osteomyelitis (an incurable infection of the tibia).

My Cardiologist has me on a Calcium Channel Blocker instead of the Beta Blocker because of the high danger that the Beta Blockers pose for me. And, under the care of my Nephrologist over the last 20 years, I have been on several different ACE inhibitors, currently taking Ramipril, 10 mg. AM & PM. After 63 years, my urinary protein levels are those of a non-Diabetic.

Obviously, disastrous side effects that are possible with some drugs do not affect everyone the same way. However, my PCP as well as my Cardiologist both avoid prescribing Beta Blockers to their Diabetic patients specifically because of their usual bad effects on low BG awareness. I was not made aware of these side effects by the doctor who prescribed the medication for me, and that led to the resulting severe complications. With this forewarning, you may not suffer the same problems. Good luck!!!

[Linda B]

Just a suggestion, Linda--

Be very careful and alert for unexpected low BG's that show up with absolutely no symptoms (other than pump alarms from your CGM). Beta blockers, and Metoprolol specifically, have the side effect of eliminating low BG awareness. My own low BG symptoms that I had had for 49 years just disappeared entirely while I was using Metoprolol, and resulted in an open fracture of my left tibia and fibula, and due to hospital negligence, the open fracture gave me lifetime osteomyelitis (an incurable infection of the tibia).

My Cardiologist has me on a Calcium Channel Blocker instead of the Beta Blocker because of the high danger that the Beta Blockers pose for me. And, under the care of my Nephrologist over the last 20 years, I have been on several different ACE inhibitors, currently taking Ramipril, 10 mg. AM & PM. After 63 years, my urinary protein levels are those of a non-Diabetic.

Obviously, disastrous side effects that are possible with some drugs do not affect everyone the same way. However, my PCP as well as my Cardiologist both avoid prescribing Beta Blockers to their Diabetic patients specifically because of their usual bad effects on low BG awareness. I was not made aware of these side effects by the doctor who prescribed the medication for me, and that led to the resulting severe complications. With this forewarning, you may not suffer the same problems. Good luck!!!

Thanks, Dave.
I am a little worried, to be honest. The nephrologist had never seen a pump or a CGM, and I'm concerned that I did not explain well enough that I can't count on the CGM to catch every low. I took one pill this evening, but I think I may call him tomorrow and discuss this concern before I take too many of them. I read that once on them you have to 'wean' off of them. I also was a little relunctant to change my ACE inhibitor and add the Beta Blocker at the same time. If I do have side effects, I won't know what they are from.

Have you ever been on the Quinipril? This doctor says it works better than Ramipril to protect kidneys, that even at low doses it actually reverses kidney damage (although I don't have any yet either). He was not able to achieve the same effect with Ramipril even at higher doses.

Linda B.

[Arlene S.]

Thanks, Dave.
I am a little worried, to be honest. The nephrologist had never seen a pump or a CGM, and I'm concerned that I did not explain well enough that I can't count on the CGM to catch every low. I took one pill this evening, but I think I may call him tomorrow and discuss this concern before I take too many of them. I read that once on them you have to 'wean' off of them. I also was a little relunctant to change my ACE inhibitor and add the Beta Blocker at the same time. If I do have side effects, I won't know what they are from.

Have you ever been on the Quinipril? This doctor says it works better than Ramipril to protect kidneys, that even at low doses it actually reverses kidney damage (although I don't have any yet either). He was not able to achieve the same effect with Ramipril even at higher doses.

Linda B.

Linda,

I've been on Quinapril for many years (even before it went generic--the brand name is Accupril) an I never had a problem with it masking lows. Two years ago when I went in for kidney surgery my cardiologist put me on Bystolic (a Beta Blocker) and it was fine but it was very expensive. I asked her if there was another drug that is just as effective and she put me on Metoprolol Succinate and after two weeks I had to go back to be checked to make sure it was working as well as the Bystolic and it is. But I also take the generic of Norvasc (a calcium channel blocker). I take the Quinapril and Metoprolol in the morning and the Norvasc at night.

[bkh]

Linda, ask your endo for a second opinion on the beta blocker prescribed by your new nephrologist. If the endo has misgivings, they should be able to discuss it and come to an agreement about your treatment.

[Manxman]

Thanks, Dave.
I am a little worried, to be honest. The nephrologist had never seen a pump or a CGM, and I'm concerned that I did not explain well enough that I can't count on the CGM to catch every low. I took one pill this evening, but I think I may call him tomorrow and discuss this concern before I take too many of them. I read that once on them you have to 'wean' off of them. I also was a little relunctant to change my ACE inhibitor and add the Beta Blocker at the same time. If I do have side effects, I won't know what they are from.

Have you ever been on the Quinipril? This doctor says it works better than Ramipril to protect kidneys, that even at low doses it actually reverses kidney damage (although I don't have any yet either). He was not able to achieve the same effect with Ramipril even at higher doses.

Linda B.

Linda,

I had not heard of Quinapril before reading your post, but I have been on Captopril as far back as 25 years. My doctor switched me to Ramipril about 8 years ago. I will see my Nephrologist next in February and will discuss the benefits of Quinapril over Ramipril at that time.

My normal levels of protein in urine isn't the same thing as having no kidney problems at all after 63 years of Diabetes. I retain too much potassium, and must reduce food sources containing it as well as take a medication that helps the kidneys filter it out. I also retain too much uric acid which causes gout, and take another med that helps the kidneys get rid of excess uric acid.

It looks as if I need to repeat my previous statement- Beta Blockers in general, and Metoprolol specifically, are known to reduce and/or eliminate the symptoms of low BG.

Again, good luck in your discussions with your Nephrologist. It seems a little odd that your new guy would be so unfamiliar with modern Diabetes treatment. Most Nephrologists acquire a lot of their patients through the influence of Diabetes, and become very competent Diabetes specialists in addition to their main specialty. But as you said, he came from research and started treating patients after his earlier career.

[Linda B]

Linda,

I've been on Quinapril for many years (even before it went generic--the brand name is Accupril) an I never had a problem with it masking lows. Two years ago when I went in for kidney surgery my cardiologist put me on Bystolic (a Beta Blocker) and it was fine but it was very expensive. I asked her if there was another drug that is just as effective and she put me on Metoprolol Succinate and after two weeks I had to go back to be checked to make sure it was working as well as the Bystolic and it is. But I also take the generic of Norvasc (a calcium channel blocker). I take the Quinapril and Metoprolol in the morning and the Norvasc at night.

Hi Arlene,

Do you have any problem recognizing that you are low? Do you still feel funny? I cannot count on my CGM to tell my I'm low - it often has too much of a lag time. I was going to call the nephrologist this AM and say I cannot take a pill that will mask my low symptoms, but if that doesn't happen with everyone, then maybe I shouldn't worry about it. It seems scary, though. I definitely often feel low before the CGM gives me a warning. I guess I could increase my low threshhold so that the CGM alarms sooner, but that would mean more fingersticks to check, not sure it's worth it. Also, he put me on 10 mgof Metoprolol twice a day - what dose do you take?


Linda

[JohnG]

I have never taken Ramipril....my brother does, I guess it's a popular drug, taken as a prophylactic to preserve kidneys.

My GFR will get down into the 20's some weeks, kinda scarey. Some of the anti viral drugs they put me on after my transplant actually cause kidney damage
and extremely high Potassium levels and low Magnesium....a low Potassium diet is the pits...no tomatoes, beans, Avocado,orange, most fruit,spinach,
most anything green, Milk, soy, halibut, tuna, cod, snapper, turkey, no seeds, bran, and peanut butter Boohoo...;-(
I must also drink 3 liters of water a day to keep my Kidneys detoxed.....it's harder than you think to drink all that water.. If I drink to much of it after 6:00pm
then I'm up all night so it does not give me much time to chug it all down.

I take (PRINIVIL, ZESTRIL) 5 MG and AMLODIPINE (NORVASC) 5 MG for high BP which is caused by PROGRAF (TACROLIMUS) another one of my meds.

I took Nadolol (Corgard) for 15+ years as a prophylactic , it is a non-selective beta blocker that masks low BG symptoms, I cannot see any difference after
they took me off of it, I still can't tell when my BG is low....no difference...;-)

[Linda B]

I called the nephrologist, and just flat out asked if he would have put me on the beta blocker if I did not have CGM. I explained that the sensor is 15 - 20 minutes delayed, does not catch every low, and so I MUST know if I am going low. He said not to bother with the beta blocker then. He did not suggest an alternative.

Hopefully the change in ACE inhibitor and increase to twice a day will help my rapid heartbeat.

Linda B.

[Manxman]

I called the nephrologist, and just flat out asked if he would have put me on the beta blocker if I did not have CGM. I explained that the sensor is 15 - 20 minutes delayed, does not catch every low, and so I MUST know if I am going low. He said not to bother with the beta blocker then. He did not suggest an alternative.

Hopefully the change in ACE inhibitor and increase to twice a day will help my rapid heartbeat.

Linda B.

Hi Linda,

It looks as if you will avoid some serious risks by your directness with your new doctor. Good! I just sent you a very detailed PM that may further clarify the Beta blocker issue (and I hope that the story doesn't scare you too badly).

Stay well-

Dave

[Arlene S.]

Hi Arlene,

Do you have any problem recognizing that you are low? Do you still feel funny? I cannot count on my CGM to tell my I'm low - it often has too much of a lag time. I was going to call the nephrologist this AM and say I cannot take a pill that will mask my low symptoms, but if that doesn't happen with everyone, then maybe I shouldn't worry about it. It seems scary, though. I definitely often feel low before the CGM gives me a warning. I guess I could increase my low threshhold so that the CGM alarms sooner, but that would mean more fingersticks to check, not sure it's worth it. Also, he put me on 10 mgof Metoprolol twice a day - what dose do you take?
Linda

Hi Linda,

i feel my lows and I've been on Quinapril for at least 10 years. One of the symptoms of Ace Inhibitors is a cough and I've never had that either. Of my BP pills Norvasc is the only one that has caused problems (that I know of) and that is ankle swelling but my cardiologist's nurse practitioner suggested that I take it at night and that has helped. As Metoprolol I take 50 mg once a day. I've never seen 10 mg pills. 25 mg is the lowest dose of Metoprolol Succinate ER. You might be taking a different drug.

Until 2010 I was doing just fine on one BP drug--Quinapril. The others were added because of my surgery.

[Linda B]

Hi Linda,

i feel my lows and I've been on Quinapril for at least 10 years. One of the symptoms of Ace Inhibitors is a cough and I've never had that either. Of my BP pills Norvasc is the only one that has caused problems (that I know of) and that is ankle swelling but my cardiologist's nurse practitioner suggested that I take it at night and that has helped. As Metoprolol I take 50 mg once a day. I've never seen 10 mg pills. 25 mg is the lowest dose of Metoprolol Succinate ER. You might be taking a different drug.

Until 2010 I was doing just fine on one BP drug--Quinapril. The others were added because of my surgery.

OOPS - You are right, the Metoprolol is 25 mg twice a day. THAT is the the one that is supposed to suppress the symptoms of lows, not the Quinapril. The reason he wanted me on the Beta Blocker was because my BP and pulse were both high when I was there, although he admitted that it could be 'white coat syndrome'. He DID mention that the Metoprolol might mask my low symptoms, and said that he wasn't worried because I use CGMS. It didn't register until I read Manxman's message how serious it could be if I became hypo unaware.
I see him again in a month. In the meantime I am tracking my BP and pulse myself. I will bring those numbers with me when I see him next time. It is my pulse that I am a little worried about. It was 99 at his office, 100 the first time I checked yesterday, and 79 the second time I checked yesterday.

Linda B.

[Arlene S.]

OOPS - You are right, the Metoprolol is 25 mg twice a day. THAT is the the one that is supposed to suppress the symptoms of lows, not the Quinapril. The reason he wanted me on the Beta Blocker was because my BP and pulse were both high when I was there, although he admitted that it could be 'white coat syndrome'. He DID mention that the Metoprolol might mask my low symptoms, and said that he wasn't worried because I use CGMS. It didn't register until I read Manxman's message how serious it could be if I became hypo unaware.
I see him again in a month. In the meantime I am tracking my BP and pulse myself. I will bring those numbers with me when I see him next time. It is my pulse that I am a little worried about. It was 99 at his office, 100 the first time I checked yesterday, and 79 the second time I checked yesterday.

Linda B.

The one I take is ER (extended release); prior to that I was taking Bystolic which I started two years ago. Beta blockers have not masked my hypo symptoms so far. I wore a monitor about twenty years ago to determine if I had "white coat syndrome" and I certainly did. However a few years later it was determined that because of my diabetes I should be put on an ACE inhibitor.

[Linda B]

I wanted to give an update on my medications.

I decided to try the beta blocker based on several discussions I had with friends and also on Arlene's posts. I also checked with my endo who said that it was OK to take it, just to be sure to test often and to call the nephrologist if I found that I became hypo unaware. I started with just 1 25mg pill per day and found I still recognized my lows. I then added the second pill because I noticed that my pulse was higher later in the day. I WAS able to recognize lows with no problem.

I was thrilled with my lower BP readings and the lower pulse rate, but the drug was causing intestinal gassiness that was annoying.

Yesterday when I saw my primary doctor, he was fine with me taking the beta blocker, and offered to write me a script for the extended release version with the hope that it might be easier on my intestines. He said that about 5% of people have gastrointestinal problems with beta blockers. I started the extended release version this AM and so far so good. I'm hoping if it releases smaller amounts of the drug during the day it might not cause so much gassiness.

Thank you to everyone for encouraging me to give the beta blocker a try.

Linda B.