What is the best approach for transitioning from lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor) to an alternative antihypertensive medication?

From the Guidelines

The best approach for transitioning from lisinopril to an alternative antihypertensive medication is to use a gradual overlap strategy, starting the new medication while continuing lisinopril for 1-2 weeks, then gradually reducing the lisinopril dose. This approach is supported by the most recent guidelines, including the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. When selecting an alternative medication, consider the patient's comorbidities, such as using an angiotensin receptor blocker (ARB) like losartan (starting at 25-50 mg daily) or valsartan (80-160 mg daily) if the patient experienced ACE inhibitor cough. For patients with edema or heart failure, consider a thiazide diuretic like hydrochlorothiazide (12.5-25 mg daily) or a calcium channel blocker like amlodipine (5-10 mg daily) for those with coronary artery disease.

Key Considerations

• The major four drug classes (ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics) are recommended as first-line BP-lowering medications, either alone or in combination 1.
• Single-pill combinations are preferred when using combination therapy, and doses of BP-lowering drugs should be started at a low dose and titrated as needed 1.
• Complete blood work should be done 1-2 weeks after the transition to check electrolytes and kidney function, and patients should be advised to monitor their blood pressure at home during the transition and report significant changes (>160/100 mmHg or <90/60 mmHg) or side effects like dizziness, swelling, or worsening kidney function.

Monitoring and Follow-up

• Patients should be closely monitored during the transition period to assess the effectiveness of the new medication and to prevent rebound hypertension.
• Blood pressure should be checked regularly, and adjustments to the medication regimen should be made as needed to achieve optimal blood pressure control.
• The patient's kidney function and electrolyte levels should also be monitored, especially if they are taking medications that can affect these parameters, such as diuretics or ACE inhibitors 1.

From the FDA Drug Label

The antihypertensive effects of lisinopril are maintained during long-term therapy. Abrupt withdrawal of lisinopril has not been associated with a rapid increase in blood pressure, or a significant increase in blood pressure compared to pretreatment levels Lisinopril tablets USP may be administered alone or with other antihypertensive agents

The best approach for transitioning from lisinopril to an alternative antihypertensive medication is not directly stated in the provided drug labels. However, it can be inferred that:

• Abrupt withdrawal of lisinopril is not associated with a significant increase in blood pressure.
• Lisinopril can be administered with other antihypertensive agents. It is recommended to consult the prescribing information of the alternative antihypertensive medication and consider a gradual transition to minimize potential effects on blood pressure control 2 2.

From the Research

Transitioning from Lisinopril to Alternative Antihypertensive Medication

• The decision to transition from lisinopril, an Angiotensin-Converting Enzyme (ACE) inhibitor, to an alternative antihypertensive medication should be based on individual patient needs and medical history 3, 4.
• ACE inhibitors like lisinopril are commonly used to treat hypertension, but they can cause side effects such as coughing, which was reported in 31.7% of patients in one study 5.
• Alternative medications, such as angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide diuretics, may be considered for patients who experience adverse effects or require additional blood pressure control 3, 5.
• When transitioning from lisinopril to an alternative medication, the dosage ratio and potential interactions should be carefully considered, as demonstrated in a study where patients were converted from captopril to lisinopril at a daily oral dosage ratio of 5:1 6.
• The choice of alternative medication may depend on the patient's specific medical conditions, such as heart failure, diabetes, or chronic kidney disease, and the potential benefits and risks of each medication should be weighed 3, 4.

Considerations for Alternative Medications

• ARBs, such as losartan, have been shown to have comparable antihypertensive effects to ACE inhibitors, but with fewer adverse effects, making them a potential alternative for patients who experience side effects with ACE inhibitors 5, 4.
• Calcium channel blockers, such as amlodipine, may be considered for patients with certain medical conditions, such as diabetes or chronic kidney disease, and have been shown to have a more pronounced reduction in blood pressure compared to ACE inhibitors in some studies 5.
• Thiazide diuretics may be used in combination with other medications to achieve adequate blood pressure control, particularly in patients with heart failure or chronic kidney disease 3.

Special Considerations

• Patients with specific medical conditions, such as heart failure or diabetes, may require careful consideration when transitioning from lisinopril to an alternative medication, and the potential benefits and risks of each medication should be weighed 3, 4, 7.
• The use of ACE inhibitors, including lisinopril, has been investigated as a potential cardioprotective agent in patients receiving anthracycline-based chemotherapy, and may be considered in certain clinical scenarios 7.