What are alternative medications to switch to from lisinopril (Angiotensin-Converting Enzyme inhibitor)?

Alternatives to Lisinopril: Medication Switch Options

When switching from lisinopril, an ARB such as valsartan or candesartan is the most appropriate alternative, particularly if the reason for switching is ACE inhibitor-induced cough or angioedema. 1

First-Line Alternatives to Lisinopril

Angiotensin Receptor Blockers (ARBs)

• First choice alternative: ARBs provide similar benefits to ACE inhibitors while avoiding specific ACE inhibitor side effects
• Recommended options:
  • Valsartan: 20-40 mg twice daily initially, titrated to 160 mg twice daily 1
  • Candesartan: 4-8 mg once daily initially, titrated to 32 mg once daily 1
  • Losartan: 25-50 mg once daily initially, titrated to 50-100 mg once daily 1

Reason for ARB preference:

• ARBs are specifically recommended for patients who cannot tolerate ACE inhibitors due to cough or angioedema 1
• ARBs provide similar cardiovascular benefits to ACE inhibitors in heart failure and hypertension 1, 2
• Studies have demonstrated that ARBs like valsartan and candesartan reduce hospitalizations and mortality in patients who cannot tolerate ACE inhibitors 1

Alternative Options Based on Clinical Scenario

For Patients with Heart Failure:

1. ARB (as above)
2. ARNI (Angiotensin Receptor-Neprilysin Inhibitor):
   • Sacubitril/valsartan if patient has heart failure with reduced ejection fraction
   • Provides superior outcomes compared to ACE inhibitors alone 2

For Hypertension Without Heart Failure:

1. ARB (as above)
2. Calcium Channel Blockers:
   • Amlodipine: 2.5-5 mg once daily 1
   • Diltiazem ER: 120-360 mg once daily 1
3. Thiazide or Thiazide-like Diuretics:
   • Particularly effective in Black patients 2
   • Chlorthalidone: 12.5-25 mg once daily 1

For Resistant Hypertension:

1. Add spironolactone as fourth-line agent (if serum potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m²) 1
2. Alternative fourth-line options: amiloride, doxazosin, eplerenone, clonidine, or beta-blockers 1

Special Considerations When Switching

Angioedema History:

• Absolute contraindication to all ACE inhibitors 1
• Caution with ARBs: While ARBs are considered for patients with ACE inhibitor-induced cough, extreme caution is advised when substituting an ARB in patients with ACE inhibitor-associated angioedema 1
• Some patients have developed angioedema with ARBs after ACE inhibitor angioedema 1

Persistent Cough:

• ARBs are the preferred alternative for patients with ACE inhibitor-induced cough 1, 2
• Cough occurs in up to 20% of patients on ACE inhibitors and is a common reason for switching 2

Renal Function:

• If switching due to worsening renal function, consider that:
  • Fosinopril has dual elimination (hepatic and renal) and may be better tolerated in renal impairment 2
  • If switching away from all RAAS blockers, calcium channel blockers may be preferred 1

Black Patients:

• Consider thiazide diuretics or calcium channel blockers as first-line alternatives 2
• ARBs may be better tolerated than ACE inhibitors in this population 2

Implementation Process for Medication Switch

1. Discontinue lisinopril
2. Start new medication:
   • For ARBs: Can generally be started the next day after stopping lisinopril
   • Initial dosing should be at the lower end of the recommended range
3. Monitor:
   • Blood pressure within 1-2 weeks
   • Renal function and electrolytes within 1-2 weeks 2
4. Titrate new medication to target dose as tolerated

Remember that the choice of alternative medication should be guided by the reason for switching from lisinopril and the patient's underlying conditions, with ARBs being the most appropriate first-line alternative in most clinical scenarios.