What are alternative antihypertensive agents for a patient with an allergy to Angiotensin-Converting Enzyme (ACE) inhibitors?

From the Guidelines

For patients allergic to ACE inhibitors, alternative antihypertensive agents such as beta-blockers, including metoprolol (25-200 mg daily) or carvedilol (12.5-50 mg daily), should be considered as first-line therapy, especially in patients with comorbidities like coronary artery disease or heart failure 1. When selecting an alternative antihypertensive agent, it is crucial to consider the patient's comorbidities, age, and potential side effects.

• Beta-blockers like metoprolol or carvedilol are preferred in patients with heart failure or ischemic heart disease, as they have been shown to improve outcomes in these populations 1.
• Other options include alpha-1 blockers like doxazosin (1-16 mg daily) or prazosin (2-20 mg daily), which may be considered as second-line agents, especially in patients with concomitant benign prostatic hyperplasia (BPH) 1.
• Direct vasodilators such as hydralazine (100-200 mg daily) may also be used, but they are often associated with sodium and water retention and reflex tachycardia, requiring co-administration with a diuretic and beta-blocker 1. The choice of antihypertensive agent should be individualized, and regular monitoring of blood pressure and kidney function is essential after initiating therapy.
• It is also important to note that the dosages of these medications may vary depending on the patient's response and tolerability, and adjustments should be made accordingly 1.
• Additionally, the patient's kidney function and potential interactions with other medications should be carefully considered when selecting an alternative antihypertensive agent 1.

From the FDA Drug Label

Cleviprex is intended for intravenous use. Titrate drug to achieve the desired blood pressure reduction. Transition to an oral antihypertensive agent: Discontinue Cleviprex or titrate downward while appropriate oral therapy is established.

For a patient allergic to Angiotensin-Converting Enzyme (ACE) inhibitors, alternative antihypertensive agents can be considered.

• Calcium Channel Blockers like Clevidipine can be used as an alternative.
• The dosage of Clevidipine should be individualized and titrated to achieve the desired blood pressure reduction.
• It is essential to monitor blood pressure and heart rate continually during the infusion and transition to other antihypertensive therapies to avoid rebound hypertension 2.

From the Research

Alternative Antihypertensive Agents

For a patient allergic to Angiotensin-Converting Enzyme (ACE) inhibitors, several alternative antihypertensive agents can be considered. These include:

• Calcium channel blockers (CCBs) 3
• Labetalol, which is a mixed alpha/beta-adrenergic antagonist 4, 5, 6
• Hydralazine, which is a direct vasodilator 5, 6
• Clevidipine, an ultra short-acting intravenous antihypertensive agent 6, 7
• Nitroglycerin, which is a vasodilator 5, 7

Specific Considerations

When choosing an alternative antihypertensive agent, it is essential to consider the patient's specific clinical presentation and any underlying conditions. For example:

• In patients with hypertensive emergencies, intravenous agents such as labetalol, hydralazine, and clevidipine may be preferred 4, 5, 6
• In patients with heart failure, clevidipine and enalaprilat may be considered 6
• In patients with acute ischemic stroke, clevidipine may be endorsed as a first-line treatment option 6

Safety and Efficacy

The safety and efficacy of these alternative antihypertensive agents have been evaluated in various studies. For example:

• Clevidipine has been shown to be safe and effective in the acute management of moderate-to-severe elevations in blood pressure 7
• Labetalol and hydralazine have been used effectively in the treatment of hypertensive crises 4, 5