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 the following day without an overlap period, starting with a dose of 80-160 mg daily, as indicated in the acc/aha 2005 guideline update 1. The transition from lisinopril to valsartan should be done with caution, considering the potential risks of hypotension, hyperkalemia, or acute kidney injury.

• Key considerations for the transition include:
  • Discontinuing lisinopril and starting valsartan the next day to avoid overlapping these medications, which both affect the renin-angiotensin-aldosterone system.
  • Selecting an appropriate starting dose of valsartan, such as 80-160 mg daily, based on the patient's previous lisinopril dose and clinical response.
  • Monitoring blood pressure and kidney function (serum creatinine and potassium) within 1-2 weeks after the switch to ensure a smooth transition and minimize potential complications.
  • Advising patients that the full therapeutic effects of valsartan may take 2-4 weeks to develop, as noted in the guideline update 1. The decision to switch from lisinopril to valsartan is often made due to ACE inhibitor-induced cough, angioedema, or other side effects specific to ACE inhibitors, and valsartan typically causes fewer cough-related side effects because it doesn't increase bradykinin levels like lisinopril does, as discussed in the guideline update 1.
• Additional recommendations for the transition include:
  • Maintaining consistent sodium intake during the transition to minimize potential fluctuations in blood pressure.
  • Continuing any other antihypertensive medications unless otherwise directed by a healthcare provider.
  • Closely monitoring patients for potential side effects or complications, such as hypotension, hyperkalemia, or acute kidney injury, and adjusting the treatment plan as needed.

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.