What is the best blood pressure medication for a patient with hypertension and type 2 diabetes who is allergic to lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor)?

Best Blood Pressure Medication for Hypertensive Type 2 Diabetic Patient with Lisinopril Allergy

For a patient with hypertension and type 2 diabetes who is allergic to lisinopril (ACE inhibitor), an angiotensin receptor blocker (ARB) is the recommended first-line treatment. 1

First-Line Treatment Options

• ARBs (such as losartan, candesartan, irbesartan, or valsartan) should be the first choice for patients with diabetes and hypertension who cannot tolerate ACE inhibitors 1
• ARBs provide similar cardiovascular and renal protection benefits as ACE inhibitors without the same allergy risk 1
• ARBs are particularly important for patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g creatinine) as they significantly reduce proteinuria and slow progression of diabetic kidney disease 1

Treatment Algorithm

Step 1: Initial Assessment

• Determine baseline blood pressure and level of albuminuria 1
• Check renal function (serum creatinine/eGFR) and potassium levels before starting therapy 1

Step 2: Medication Selection Based on BP Level

• For BP 140-159/90-99 mmHg: Start with ARB monotherapy 1
• For BP ≥160/100 mmHg: Begin with ARB plus another agent (preferably a thiazide-like diuretic or dihydropyridine calcium channel blocker) 1

Step 3: Monitoring and Titration

• Titrate ARB to maximum tolerated dose indicated for blood pressure treatment 1
• Monitor serum creatinine/eGFR and potassium levels at least annually 1
• Assess BP control and adjust therapy accordingly 1

Step 4: Add-on Therapy if Needed

• If BP target not achieved with ARB monotherapy, add a thiazide-like diuretic (chlorthalidone or indapamide preferred) 1
• If further control needed, add a dihydropyridine calcium channel blocker 1
• For resistant hypertension (not meeting targets on 3 drugs including a diuretic), consider adding a mineralocorticoid receptor antagonist 1

Specific ARB Options

• Losartan: Starting dose 25-50 mg daily, goal dose 25-100 mg daily in 1-2 divided doses 1
• Candesartan: Starting dose 16 mg as monotherapy, goal dose 2-32 mg daily in 1-2 divided doses 1
• Irbesartan: Starting dose 150 mg daily, goal dose 150-300 mg daily 1
• Valsartan: Starting dose 80 or 160 mg daily, goal dose 80-320 mg daily 1

Important Considerations

• BP target should be <130/80 mmHg for most patients with diabetes and hypertension 1
• ARBs are particularly beneficial for patients with albuminuria (≥30 mg/g creatinine) 1
• Never combine an ARB with an ACE inhibitor or direct renin inhibitor due to increased risk of adverse effects without added benefit 1
• Monitor for hyperkalemia, especially if adding a mineralocorticoid receptor antagonist to an ARB 1

Potential Pitfalls and Caveats

• ARBs may cause similar side effects as ACE inhibitors (except cough), so monitor for hypotension, hyperkalemia, and changes in renal function 1
• Some patients may have cross-reactivity between ACE inhibitors and ARBs, though this is uncommon 2
• Achievement of target BP <130/85 mmHg in hypertensive type 2 diabetes can be difficult, often requiring multiple medications 3
• If ARBs are not tolerated, calcium channel blockers (particularly dihydropyridines like amlodipine) have shown efficacy as add-on therapy in diabetic hypertensive patients 4