From the Guidelines
For a patient with high potassium who is currently on lisinopril, amlodipine, and coreg, a good replacement for lisinopril would be losartan, as it is less likely to cause hyperkalemia compared to ACE inhibitors 1. Losartan is an angiotensin II receptor blocker (ARB) that provides similar blood pressure control and cardiovascular benefits as lisinopril (an ACE inhibitor) but has a different mechanism of action that results in less potassium retention. The typical starting dose of losartan is 50 mg once daily, which can be increased to 100 mg daily if needed for blood pressure control, as indicated in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. When switching from lisinopril to losartan, it is recommended to discontinue lisinopril for 24 hours before starting losartan to avoid overlap. Key points to consider when making this switch include:
- Monitoring potassium levels within 1-2 weeks after the medication change to ensure that hyperkalemia is not worsening.
- Being aware of the potential for losartan to still cause hyperkalemia, especially in patients with chronic kidney disease (CKD) or those on potassium supplements or potassium-sparing drugs, as noted in the guideline 1.
- Considering the use of losartan as a preferred agent in patients with primary aldosteronism and resistant hypertension, as stated in the guideline 1. Overall, losartan is a suitable replacement for lisinopril in patients with high potassium levels, given its efficacy in controlling blood pressure and its relatively lower risk of causing hyperkalemia compared to ACE inhibitors 1.
From the FDA Drug Label
7.1 Agents Increasing Serum Potassium Coadministration of losartan with other drugs that raise serum potassium levels may result in hyperkalemia. 7. 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
Considering the patient is already on lisinopril (an ACE inhibitor) and has high potassium levels, replacing lisinopril with losartan (an angiotensin II receptor antagonist) may not be the best option due to the potential increased risk of hyperkalemia.
- A more suitable replacement for lisinopril would be a medication that does not increase the risk of hyperkalemia.
- However, based on the provided information, no conclusion can be drawn about a good replacement for lisinopril in this specific patient. 2
From the Research
Alternatives to Lisinopril
- Losartan is a potential replacement for lisinopril, as it has been shown to be safe and effective in patients with hypertension 3.
- The CORD trials demonstrated that switching from an ACEI to losartan is safe and effective, with no significant increase in adverse events 3.
- Losartan has been compared to other antihypertensive medications, including ramipril, and has been shown to have similar effects on blood pressure and metabolic parameters 3.
Combination Therapy
- Combination therapy with an angiotensin II receptor blocker (ARB) and a calcium channel blocker (CCB) may be an effective alternative to lisinopril, as it has been shown to reduce blood pressure more effectively than maximal doses of an ARB with hydrochlorothiazide (HCTZ) 4.
- The EXALT study compared the efficacy and safety of combination ARB/CCB with HCTZ versus maximal available combination doses of an ARB with HCTZ, and found that the combination therapy was more effective in reducing blood pressure 4.
Comparison of Lisinopril and Losartan
- A study comparing the effects of lisinopril and losartan in patients with idiopathic membranous nephropathy and nephrotic syndrome found that both medications had similar effects on renal function, hypoalbuminemia, proteinuria, and blood pressure 5.
- However, losartan was found to have a more favorable effect on serum albumin levels, with higher levels at baseline and after 12 months of treatment 5.