RAAS
The Kidneys release this enzyme to convert Angiotensinogen from the Liver?
Renin
How often are Medicare Pt. D reviews?
They are updated infrequently based on a strict annual review cycle
This class lowers circulating aldosterone levels rather than just blocking its downstream effects
ASI
How does aldosterone binding to MR receptors inside kidney cells raise blood pressure?
By creating Sodium-Potassium Pumps
This class of drugs includes lisinopril and works by blocking conversation of Angiotensin i to Angiotensin ii
Ace Inhibitor
What does the Liver release to combine with Renin to create Angiotensin 1
Angiotensin
Describe the 6 step Route a prescription take to get from Doctor to Patient
Prescription, Benefit Investigation, Requirement Submission, Payer Decision, pharmacy processing, patient pick up
One of the most common Side effects of this class is gynecomastia
MRA
Aldosterone is a mineralocorticoid hormone that regulates the concentrations of what?
Sodium and Potassium
Amlodipine is part of this class that lowers BP by relaxing vascular smooth muscle
Calcium Channel Blocker
How does Angiotensin ll increase blood pressure?
Vasoconstriction
What requests can an HCP make to help their patients on Medicare better access a prescribed drug?
Formulary Exception and Tiering Exception
This feedback effect may occur with MRA’s, leading to increased circulating aldosterone levels despite receptor block
Aldosterone Escape
Long term aldosterone excess contributes to fibroses and remodeling in this organ, increasing risk of Heart Failure
The Heart
What is the Most common side effect of Ace Inhibitors?
Ace Cough
What signals the kidney to release renin?
Low blood pressure
In a 4‐ to 5‐tier commercial plan formulary, which tier is typically used for nonpreferred, non‐specialty brand‐name drugs?
Tier- 3
MRA’s block Aldosterone in the _____ while ASI’s stop production in the ______?
Kidney and Adrenal Gland
Aldosterone enters principal cells located in which structures?
Collecting Ducts whithin the Kidney
Explain the Mechanism of Action for MRA’s
Blocks the Effect of Aldosterone at its receptor in the distal nephron
Describe how the RAAS pathway is activated and how it stimulates Aldosterone Production
Kidney, Renin, Angiotension(liver), Angio i, Angio Converting Enzyme, Angio 2, Adrenal Gland, Aldosterone signals to Kidney to increase Sodium and Water reabsorption which increases BP and BV
A Case By Case Coverage request in which a prescriber submits clinical documentation demonstrating that the plans covered alternatives are not medically appropriate for the patient and therefore the non formulary drug is medically necessary
Medical Exception
When a rep says “could targeting aldosterone directly, be a different approach,” but the provider says MRAs already target aldosterone directly.
How would you respond?
MRAs do have an impact on aldosterone, but they don’t target aldosterone directly. They work at the receptor level—by blocking aldosterone from binding to the mineralocorticoid receptor (MR).18 This can actually cause an increase in aldosterone, which we know can lead to inflammation and fibrosis of the heart, vasculature and kidneys, leading to end-organ damage.
This electrolyte imbalance caused by aldosterone excess can lead to muscle weakness and cardiac arrhythmias
Hypokalemia
In a patient with an eGFR >45 whose BP goal is not achieved, when would it be appropriate to start an MRA?
Patient is in ACE/ARB, CCB, and Diuretic