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Vasopressor (Angiotensin II Receptor Agonist)

Angiotensin II (Human)

Brand names: Giapreza

Adult dose

Dose: Start at 20 nanogram/kg/min IV; titrate to MAP target ≥75 mmHg; usual range 1.25–80 nanogram/kg/min; max 80 nanogram/kg/min
Route: Intravenous infusion
Frequency: Continuous infusion, titrated to haemodynamic response

Clinical pearls

  • Licensed for distributive shock (primarily septic shock) as adjunct to catecholamines and other vasopressors
  • ATHOS-3 trial: angiotensin II significantly increased MAP >75 mmHg vs placebo in catecholamine-resistant septic shock
  • VTE prophylaxis with anticoagulant heparin is strongly recommended during treatment — high thromboembolic risk
  • May be particularly beneficial in patients with relative RAAS deficiency or high renin/low Ang II states
  • Specialist/ICU use only — requires central venous access and continuous haemodynamic monitoring
  • NICE TA553 (2019): recommended as option for refractory distributive shock requiring high-dose vasopressors

Contraindications

  • No absolute contraindications in septic shock if benefits outweigh risks
  • Thrombotic risk — avoid or use with caution in patients with active thrombus or at very high VTE risk without anticoagulation

Side effects

  • Thromboembolic events (DVT, PE) — significantly increased; anticoagulant prophylaxis recommended
  • Tachycardia
  • Hypertension
  • Peripheral ischaemia (vasoconstriction)

Interactions

  • Other vasopressors/inotropes — additive vasopressor effects; adjust doses accordingly
  • ACE inhibitors — may reduce angiotensin II metabolism (angiotensin converting enzyme degrades Ang II); increased and prolonged effect
  • Anticoagulants — VTE prophylaxis/treatment strongly recommended concurrent with angiotensin II

Monitoring

  • Continuous invasive arterial blood pressure monitoring
  • Heart rate and cardiac output
  • Mean arterial pressure (MAP — target ≥75 mmHg or individualised)
  • VTE signs
  • Peripheral perfusion (ischaemia)

Reference: BNF; NICE TA553 (Angiotensin II for treating refractory distributive shock, 2019); ATHOS-3 trial (NEJM 2017); Surviving Sepsis Campaign Guidelines (2021); https://bnf.nice.org.uk/drugs/angiotensin-ii/. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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