What is the recommended approach when transitioning a patient from lisinopril (Angiotensin-Converting Enzyme Inhibitor) to valsartan (Angiotensin II Receptor Blocker)?

From the Guidelines

When transitioning a patient from lisinopril to valsartan, the recommended approach is to discontinue lisinopril and begin valsartan after a 24-hour washout period, starting with a dose of 20-40 mg twice daily, as listed in Table 6 of the acc/aha 2005 guideline update 1. For patients on standard lisinopril doses (10-40 mg daily), this starting dose of valsartan can be titrated up to a maximum of 160 mg twice daily based on blood pressure response. During the transition, blood pressure should be monitored closely, especially in the first 1-2 weeks. Some key points to consider during this transition include:

• Patients should be instructed to maintain consistent sodium intake and continue other antihypertensive medications as prescribed.
• The transition is necessary because simultaneous use of ACE inhibitors and ARBs increases the risk of hyperkalemia, hypotension, and renal dysfunction without additional therapeutic benefit, as noted in the experience with these drugs in controlled clinical trials of patients with HF 1.
• Valsartan works by blocking angiotensin II receptors directly, while lisinopril prevents the conversion of angiotensin I to angiotensin II, which explains why some patients who experience ACE inhibitor-induced cough often tolerate ARBs well, as ARBs do not affect bradykinin metabolism 1. Key considerations for the transition process include:
• Monitoring for potential side effects such as hypotension, hyperkalemia, and renal dysfunction.
• Adjusting the dose of valsartan based on blood pressure response and tolerability.
• Maintaining open communication with the patient to address any concerns or questions they may have about the transition.

From the FDA Drug Label

7.3 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, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy The recommended approach when transitioning a patient from lisinopril (Angiotensin-Converting Enzyme Inhibitor) to valsartan (Angiotensin II Receptor Blocker) is to avoid dual blockade of the renin-angiotensin system (RAS), as it may increase the risk of hypotension, hyperkalemia, and changes in renal function.

• Stop lisinopril before starting valsartan to minimize the risk of adverse effects.
• Monitor blood pressure, renal function, and electrolytes closely after transitioning to valsartan.
• Consider the potential risks and benefits of transitioning the patient, and consult the patient's medical history before making any changes to their medication regimen 2, 2.

From the Research

Transitioning from Lisinopril to Valsartan

When transitioning a patient from lisinopril (Angiotensin-Converting Enzyme Inhibitor) to valsartan (Angiotensin II Receptor Blocker), several factors should be considered:

• The primary goal is to maintain or improve blood pressure control while minimizing potential side effects.
• Studies have shown that valsartan and lisinopril have similar antihypertensive efficacy, but valsartan is associated with a lower incidence of cough, a common side effect of ACE inhibitors like lisinopril 3, 4, 5.
• The recommended approach is to start with a dose of valsartan that is equivalent to the patient's current dose of lisinopril, and then adjust as needed to achieve optimal blood pressure control.

Key Considerations

• Dose equivalence: Valsartan 80 mg daily is equivalent to lisinopril 10 mg daily, and valsartan 160 mg daily is equivalent to lisinopril 20 mg daily 3, 4.
• Titration: The dose of valsartan can be titrated up or down as needed to achieve optimal blood pressure control, similar to lisinopril 3, 4.
• Side effects: Patients who experience cough or other side effects with lisinopril may benefit from switching to valsartan, which has a lower incidence of these side effects 3, 4, 5.
• Combination therapy: In some cases, combination therapy with valsartan and lisinopril may be considered, particularly in patients with microalbuminuria or other cardiovascular risk factors 6.

Clinical Evidence

• Studies have demonstrated the efficacy and safety of valsartan compared to lisinopril in various patient populations, including elderly patients and those with microalbuminuria 3, 4, 5, 6.
• A retrospective study found that valsartan was associated with a lower risk of major cardiovascular and renal events compared to extended-release metoprolol, and a nominally lower risk compared to lisinopril 7.