Examples of RAS Inhibitors and ACE Inhibitors Available in India
ACE inhibitors and ARBs (angiotensin receptor blockers) are the two main classes of RAS inhibitors recommended as first-line antihypertensive agents, with ACE inhibitors being more commonly prescribed than ARBs in India's diabetic hypertensive population.
ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors)
Common ACE inhibitors available in India include:
- Enalapril
- Ramipril
- Lisinopril
- Perindopril
- Captopril
- Fosinopril
- Trandolapril
These medications work by blocking the conversion of angiotensin I to angiotensin II and also potentiate bradykinin, leading to increased nitric oxide production and vasodilation 1.
ARBs (Angiotensin Receptor Blockers)
Common ARBs available in India include:
- Telmisartan
- Losartan
- Olmesartan
- Valsartan
- Irbesartan
- Candesartan
- Azilsartan
ARBs selectively block the AT1 receptor, preventing angiotensin II from exerting its effects 2.
Clinical Context in India
In India, ACE inhibitors are prescribed more frequently than ARBs - specifically, among hypertensive diabetics, ACEIs account for 60.7% of RAS blocker prescriptions versus 39.2% for ARBs 3. However, the overall use of RAS blockers remains suboptimal, with only 48.2% of hypertensive diabetics and 58.1% of those with vascular disease receiving these medications 3.
Guideline-Based Recommendations
According to the 2024 ESC Guidelines, RAS blockers (either ACE inhibitors or ARBs) combined with a dihydropyridine calcium channel blocker or diuretic are the preferred initial combination therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg) 4.
Key Points:
- Both ACE inhibitors and ARBs effectively reduce blood pressure and cardiovascular events 4
- Combining two RAS blockers (ACE inhibitor + ARB) is not recommended due to increased risk without additional benefit 4
- Fixed-dose single-pill combinations are preferred to improve adherence 4
- ACE inhibitors may provide additional cardiovascular benefits through bradykinin potentiation and nitric oxide stimulation 5, 1
Important Caveat
Monitor for hyperkalaemia, particularly in patients with chronic kidney disease, heart failure, diabetes, or when combining RAS inhibitors with other potassium-retaining medications like spironolactone 6. The incidence of hyperkalaemia increases to 5-10% with dual therapy in high-risk patients 6.