From the Guidelines
A patient who cannot tolerate lisinopril should be considered for alternative medications such as angiotensin receptor blockers (ARBs) like losartan or valsartan, as they have been shown to reduce morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF) 1. The specific alternative will depend on the patient's individual medical history, current health status, and reason for needing a change.
- The dosage and regimen will be determined by the prescribing physician based on these factors.
- It's crucial to continue taking lisinopril until speaking with a doctor, as suddenly stopping can cause a dangerous spike in blood pressure.
- When switching, the new medication may need to be gradually increased to the effective dose. ACE inhibitors and ARBs work similarly by affecting the renin-angiotensin-aldosterone system to lower blood pressure.
- However, ARBs may have fewer side effects for some patients, such as the dry cough sometimes associated with ACE inhibitors.
- According to the 2017 ACC/AHA/HFSA focused update, ARBs have been shown to reduce morbidity and mortality in patients with HFrEF, especially in ACE inhibitor–intolerant patients 1.
- The use of ARBs is recommended for patients with chronic HFrEF to reduce morbidity and mortality, in conjunction with evidence-based beta blockers and aldosterone antagonists in selected patients 1.
From the Research
Alternatives to Lisinopril
- Azilsartan: a newly approved angiotensin II receptor blocker, can be considered as an alternative agent for mild-to-moderate hypertension, or as an adjunctive therapy when preferred agents fail to maintain optimal blood pressure control 2.
- Losartan: an angiotensin II receptor antagonist, has been shown to have antihypertensive efficacy similar to that of angiotensin-converting enzyme (ACE) inhibitors, and may be an alternative for patients who cannot tolerate ACE inhibitors 3, 4.
- Other angiotensin II receptor blockers: such as candesartan and valsartan, have also been evaluated as alternatives to ACE inhibitors, but their effects on mortality and morbidity are still being studied 5.
Comparison with ACE Inhibitors
- Losartan has been compared to captopril, an ACE inhibitor, in patients with heart failure, and no significant difference was found between the two in terms of mortality or risk of clinical deterioration 5.
- Azilsartan has been shown to be superior to valsartan and olmesartan in lowering systolic blood pressure in short-term studies 2.
- Angiotensin II receptor blockers, including losartan, have been found to have a reduced incidence of cough compared to ACE inhibitors 3, 4.
Safety and Tolerability
- Azilsartan is well tolerated, with the most common side effects being headache and diarrhea 2.
- Losartan is generally well tolerated, with an adverse effect profile similar to that of placebo 4, 6.
- Angiotensin II receptor blockers, including losartan, have been found to have a lower incidence of certain adverse effects, such as cough and skin rash, compared to ACE inhibitors 5.