From the Guidelines
Angiotensin II Receptor Blockers (ARBs) are generally not strongly associated with gastrointestinal disease, except for olmesartan which has been linked to a rare but serious condition called sprue-like enteropathy. The majority of ARBs, such as losartan, valsartan, candesartan, and irbesartan, have similar safety profiles with mild GI symptoms like nausea, abdominal discomfort, or diarrhea occurring in a small percentage of patients 1. However, olmesartan specifically has been associated with sprue-like enteropathy, which can cause chronic diarrhea, weight loss, and villous atrophy mimicking celiac disease 1. This condition typically resolves when olmesartan is discontinued. The mechanism behind this association likely involves inhibition of transforming growth factor-beta, which affects intestinal immune homeostasis. Some studies suggest that ARBs may have a better efficacy and adherence profile in women with heart failure than ACE inhibitors, but this does not necessarily imply a significant association with gastrointestinal disease 1. If a patient on olmesartan develops unexplained chronic diarrhea or significant weight loss, consider switching to a different ARB or alternative antihypertensive class. For patients with pre-existing GI conditions, most ARBs remain safe options, though monitoring for symptom changes is advisable when initiating therapy. It's worth noting that the most recent and highest quality study on this topic is from 2022, which provides the most up-to-date information on the association between ARBs and gastrointestinal disease 1. Key points to consider when prescribing ARBs include:
- Monitoring for symptom changes in patients with pre-existing GI conditions
- Considering alternative antihypertensive classes for patients who develop unexplained chronic diarrhea or significant weight loss while taking olmesartan
- Being aware of the rare but serious condition of sprue-like enteropathy associated with olmesartan.
From the FDA Drug Label
Gastrointestinal Disorders: Abdominal pain, constipation, nausea, vomiting. The Angiotensin II Receptor Blocker (ARB) losartan is associated with gastrointestinal (GI) disease, including:
- Abdominal pain
- Constipation
- Nausea
- Vomiting 2
From the Research
Association between ARBs and GI Disease
- There is limited direct evidence in the provided studies to suggest a strong association between Angiotensin II Receptor Blockers (ARBs) and gastrointestinal (GI) disease 3, 4, 5, 6, 7.
- However, some studies mention adverse effects related to the GI system, such as nausea, diarrhea, and transient elevations in liver transaminases, which are associated with the use of ARBs like candesartan cilexetil 4, 5.
- The majority of the studies focus on the antihypertensive effects, pharmacokinetics, and pharmacodynamics of ARBs, rather than their association with GI disease 3, 4, 5, 7.
- One study discusses the potential effects of ARBs on angiogenesis, which could have implications for various diseases, including those affecting the GI system, but does not provide direct evidence of an association between ARBs and GI disease 6.