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Do not coadminister with aliskiren in patients with diabetes mellitus or with renal impairment ie, GFR Use caution in congestive heart failure CHF, surgery or anesthesia, volume depletion consider lower dosage. Risk of hypotension, especially in patients with volume or salt depletion secondary to salt restriction or prolonged diuretic treatment; initiate treatment in such patients under close medical supervision and consider starting at a lower dose. Avoid use in patients with ascites resulting from cirrhosis or refractory ascites; monitor blood pressure and renal function closely if use cannot be avoided. Dual blockade of the renin-angiotensin system with angiotensin-receptor blockers ARBs, angiotensin-converting enzyme ACE inhibitors, or aliskiren is associated with increased risk of hypotension, hyperkalemia, and altered renal function including acute renal failure in comparison with monotherapy; closely monitor blood pressure. Children Can cause fetal harm when administered to a pregnant woman; use of drugs that act on renin-angiotensin system during second and third trimesters of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death. Most epidemiologic studies examining fetal abnormalities after exposure to antihypertensive use in the first trimester have not distinguished drugs affecting the renin-angiotensin system from other antihypertensive agents.

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