From the Guidelines
For blood pressure control, Valsartan is generally considered the best angiotensin receptor blocker (ARB) due to its high potency, long duration of action, and favorable side effect profile, as evidenced by its use in the valsartan/sacubitril compound, which has been shown to decrease hospitalizations and mortality in patients with heart failure 1. The typical starting dose of Valsartan is 80-160 mg once daily, which can be increased to 320 mg daily if needed for optimal blood pressure control. Valsartan provides consistent 24-hour coverage with a single daily dose, improving adherence. Other excellent options include Telmisartan (starting at 40 mg daily) and Candesartan (starting at 8-16 mg daily), both of which also offer strong antihypertensive effects. ARBs work by blocking the binding of angiotensin II to its receptors, preventing vasoconstriction and sodium retention, thereby lowering blood pressure. They're particularly beneficial for patients with diabetes, chronic kidney disease, or heart failure, and have fewer side effects than many other antihypertensives. Some key points to consider when using ARBs include:
- They should be taken at the same time each day for consistent blood pressure control
- Patients should have their kidney function and potassium levels monitored periodically, especially when starting therapy
- The combination of 2 renin-angiotensin system blockers is not recommended, as it may increase the risk of adverse effects such as hypotension and renal insufficiency 1
- ARBs should not be administered concomitantly with ACE inhibitors or within 36 hours of the last dose of an ACE inhibitor, as this may increase the risk of angioedema 1
- ARBs should not be administered to patients with a history of angioedema, as they may increase the risk of recurrence 1
From the Research
Angiotensin Receptor Blockers (ARBs) for Blood Pressure Control
- ARBs are a class of effective and well-tolerated antihypertensive agents that have been shown to have added benefits in hypertensive patients, including reduction in left ventricular hypertrophy, improvement in diastolic function, and decrease in ventricular arrhythmias 2.
- The efficacy of ARBs is similar to that of thiazide diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, or calcium channel blockers in patients with similar degrees of hypertension 2, 3.
- Several ARBs are available, including losartan, valsartan, irbesartan, candesartan, telmisartan, and eprosartan, each with varying molecular structures and pharmacokinetic profiles 2.
Comparison of ARBs
- The antihypertensive potency of ARBs follows the sequence: candesartan cilexetil > telmisartan approximately = losartan > irbesartan approximately = valsartan > eprosartan 2.
- Losartan has been shown to have a lower antihypertensive efficacy compared to other ARBs, with a decrease of 10.3/6.7 mmHg in systolic/diastolic blood pressure at 25% of the maximum dose, and 13.0/8.3 mmHg at the maximum dose 4.
- Candesartan cilexetil has been shown to be effective in reducing blood pressure, with a significant reduction in mean systolic blood pressure/diastolic blood pressure from baseline 5.
Combination Therapy
- Combination therapy with an ARB and a diuretic or calcium channel blocker is commonly used to treat hypertension, but the most effective and safe combination has not been established 6, 5.
- A study comparing losartan/hydrochlorothiazide and candesartan/amlodipine found similar efficacy in reducing blood pressure, but losartan/hydrochlorothiazide was more cost-effective and had fewer adverse effects on uric acid and other metabolic parameters 5.