Is it better to stop Valsartan (valsartan) and start Lisinopril (lisinopril) in a diabetic patient with elevated blood pressure (hypertension)?

Switching from Valsartan to Lisinopril in Diabetic Patients with Hypertension

For diabetic patients with hypertension, switching from valsartan (an ARB) to lisinopril (an ACE inhibitor) is generally not necessary or recommended as both medication classes provide similar cardiovascular and renal protection benefits. 1

Comparing ACE Inhibitors and ARBs in Diabetic Patients

Both medication classes have strong evidence supporting their use in diabetic patients with hypertension:

• ACE inhibitors (like lisinopril) and ARBs (like valsartan) are both first-line agents for hypertension management in diabetes 1
• Both classes effectively reduce cardiovascular events in people with diabetes 1
• Both provide renoprotection, particularly important in diabetic patients 1

When to Consider Switching

There are specific circumstances where switching from valsartan to lisinopril might be considered:

1. Presence of albuminuria: ACE inhibitors have particularly strong evidence for reducing progression of diabetic nephropathy in patients with albuminuria 1

2. Cost considerations: Lisinopril is generally less expensive than valsartan

3. Side effect profile: If patient is experiencing side effects with valsartan

4. Specific contraindications: If a contraindication to ARBs develops

When to Maintain Valsartan

Reasons to continue valsartan rather than switching to lisinopril:

1. Tolerability: ARBs like valsartan have a lower incidence of cough compared to ACE inhibitors (1.1% vs 8%) 2

2. Current good control: If blood pressure is well-controlled on valsartan without side effects

3. Diabetes prevention: Valsartan has shown benefits in preventing new-onset diabetes compared to other antihypertensives 3

Important Considerations

• Never use both medications together: Combining an ACE inhibitor and ARB is contraindicated due to increased risk of hyperkalemia, syncope, and acute kidney injury without additional cardiovascular benefit 1

• Monitor renal function: For patients on either medication class, regular monitoring of serum creatinine/eGFR and potassium is recommended 1

• Multiple medications often needed: Most diabetic patients with hypertension require multiple medications to achieve blood pressure targets 1

Clinical Decision Algorithm

1. Assess current blood pressure control:

   • If well-controlled on valsartan without side effects → continue valsartan
   • If poorly controlled → consider adding a thiazide-like diuretic or calcium channel blocker before switching

2. Check for albuminuria:

   • If UACR ≥30 mg/g creatinine → either ACE inhibitor or ARB is appropriate
   • If patient has significant albuminuria and is not on maximum dose → consider maximizing current therapy before switching

3. Evaluate for side effects:

   • If patient has cough on ACE inhibitor → valsartan is preferred
   • If patient has angioedema on ACE inhibitor → valsartan is preferred

4. Consider comorbidities:

   • Heart failure with reduced ejection fraction → either medication class beneficial
   • Established coronary artery disease → either medication class beneficial

In summary, there is no clear advantage to switching from valsartan to lisinopril in most diabetic patients with hypertension if blood pressure is adequately controlled without side effects. Both medication classes provide similar cardiovascular and renal protection benefits.