From the Guidelines
For patients allergic to lisinopril, Angiotensin II receptor blockers (ARBs) like losartan, valsartan, or olmesartan are the most appropriate alternative antihypertensive medications, as they work similarly to ACE inhibitors but rarely cause cross-reactivity. The choice of alternative medication should be individualized based on the patient's age, race, comorbidities, and other medications.
Alternative Treatment Options
- Calcium channel blockers such as amlodipine (5-10 mg daily) or diltiazem (120-540 mg daily) are also excellent options, working by relaxing blood vessel walls 1.
- Thiazide diuretics like hydrochlorothiazide (12.5-25 mg daily) or chlorthalidone (12.5-25 mg daily) reduce blood volume and are particularly effective in African American patients 1.
- Beta-blockers such as metoprolol (25-100 mg twice daily) may be appropriate, especially for patients with concurrent heart conditions.
- Aldosterone antagonists like spironolactone (25-50 mg daily) can be useful for resistant hypertension, as recommended in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Lifestyle Modifications
Patients should monitor their blood pressure regularly after starting any new antihypertensive medication and report any side effects promptly. Lifestyle modifications including reduced sodium intake, regular exercise, weight management, and limited alcohol consumption remain important complementary approaches to any pharmacological treatment.
Considerations for Resistant Hypertension
In patients with resistant hypertension, the addition of spironolactone to existing treatment should be considered, as recommended in the 2024 ESC guidelines 1. If spironolactone is not effective or tolerated, treatment with eplerenone instead of spironolactone, or the addition of a beta-blocker if not already indicated, and, next, a centrally acting BP-lowering medication, an alpha-blocker, or hydralazine, or a potassium-sparing diuretic should be considered.
From the Research
Alternative Treatments for Hypertension
For a patient with hypertension who is allergic to lisinopril, an Angiotensin-Converting Enzyme (ACE) Inhibitor, there are several alternative treatment options available.
- Angiotensin II Receptor Blockers (ARBs): Losartan is an example of an ARB that has been shown to be effective in reducing blood pressure in patients with hypertension 2, 3, 4.
- Calcium Channel Blockers (CCBs): Amlodipine is a CCB that has been compared to losartan and lisinopril in terms of antihypertensive effect and tolerability 3.
- Combination Therapy: The combination of an ARB and a diuretic, such as losartan-hydrochlorothiazide, has been shown to be effective in reducing blood pressure in patients with hypertension uncontrolled by monotherapy 2.
- Other ACE Inhibitors: While the patient is allergic to lisinopril, other ACE inhibitors such as enalapril, fosinopril, trandolapril, ramipril, perindopril, captopril, benazepril may be considered, but with caution and close monitoring for any signs of allergy or adverse reactions 5.
Considerations for Alternative Treatments
When selecting an alternative treatment, it is essential to consider the patient's individual characteristics, such as kidney function, blood potassium levels, and other comorbidities.
- Hyperkalemia: Patients with a history of high normal serum potassium levels should be monitored closely when treated with ACEIs or ARBs, as both can increase serum potassium levels 6.
- Coughing: Lisinopril has been associated with a high incidence of coughing, which may be a consideration when selecting an alternative treatment 3.
- Tolerability: Losartan has been shown to have superior tolerability compared to lisinopril and amlodipine in some studies 3.