From the Guidelines
Combining ACE inhibitors with angiotensin II receptor blockers (ARBs) and combining beta-blockers with thiazide diuretics should be avoided due to increased risks of adverse effects. The combination of ACE inhibitors and ARBs can significantly increase the risk of adverse effects such as dangerously low blood pressure, high potassium levels (hyperkalemia), and kidney damage without providing substantial additional benefits for blood pressure control 1. Similarly, the combination of beta-blockers and thiazide diuretics is associated with an increased risk of developing diabetes and should be avoided unless required for other reasons 1. Both of these combinations are not recommended by current guidelines due to the lack of clinical evidence supporting their use and the potential for harm. Instead, using either an ACE inhibitor or an ARB along with a different class of blood pressure medication, such as a calcium channel blocker or diuretic, provides better blood pressure control with fewer risks 1. Additionally, combining a blocker of the renin-angiotensin system, a calcium antagonist, and a diuretic at effective doses may be necessary for some patients to achieve blood pressure control 1. It is essential to consult with a healthcare provider to determine the best treatment strategy for individual patients. The most recent and highest quality studies support avoiding these combinations to minimize risks and optimize blood pressure control 1. In clinical practice, it is crucial to prioritize the safety and efficacy of treatment strategies, and avoiding these combinations is a key aspect of providing high-quality care for patients with hypertension.
From the FDA Drug Label
- 4 Dual Blockade of the Renin-Angiotensin System (RAS) Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, syncope, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy In most patients no benefit has been associated with using two RAS inhibitors concomitantly In general, avoid combined use of RAS inhibitors.
The two blood pressure medicines that should not be combined are:
- Angiotensin receptor blockers (such as losartan) and ACE inhibitors (such as lisinopril) This combination is associated with increased risks of hypotension, hyperkalemia, and changes in renal function compared to monotherapy 2 3.
From the Research
Blood Pressure Medicines to Avoid Combining
- Angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) should not be combined, as this can increase the risk of adverse renal outcomes, including renal dysfunction and hyperkalemia 4, 5
- The combination of ACE inhibitors and ARBs may be useful in certain situations, such as proteinuric renal disease, but the risks and benefits of this combination should be carefully considered 5, 6
Alternative Treatment Options
- Calcium channel blockers (CCBs) may be considered as an alternative to ACE inhibitors or ARBs in certain situations, such as angina pectoris or isolated systolic hypertension in the elderly 7, 8
- Diuretics and beta-blockers are generally preferred as first-line therapy for hypertension, unless there are specific indications for alternative agents 7, 8
Important Considerations
- The use of ACE inhibitors, ARBs, and CCBs should be individualized based on the patient's specific clinical characteristics and medical history 4, 5, 6, 7, 8
- Patients should be closely monitored for adverse effects when using any of these medications, particularly when combining ACE inhibitors and ARBs 4, 5