What alternative antihypertensive medication can be used in patients who develop a rash after taking lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor)?

Alternative Antihypertensive Medications After Lisinopril-Induced Rash

For patients who develop a rash after taking lisinopril (an ACE inhibitor), angiotensin receptor blockers (ARBs) are the recommended first-line alternative antihypertensive medication, though caution is advised due to a small risk of cross-reactivity. 1

First-Line Alternative Options

• Angiotensin Receptor Blockers (ARBs) are the preferred alternative for patients who cannot tolerate ACE inhibitors due to rash or other side effects 1
  • Options include candesartan (4-8 mg once daily), losartan (25-50 mg once daily), or valsartan (20-40 mg twice daily) 1
  • While ARBs have a different mechanism of action than ACE inhibitors, there is a small risk (2-17%) of cross-reactivity in patients who experienced angioedema with ACE inhibitors 2
  • For rash without angioedema, the risk of cross-reactivity is lower, but caution is still advised 1

Second-Line Alternative Options

• Calcium Channel Blockers (CCBs) are an excellent alternative if ARBs are contraindicated or not tolerated 1

  • Dihydropyridine CCBs (e.g., amlodipine) are preferred for hypertension without specific comorbidities 1
  • Non-dihydropyridine CCBs (verapamil, diltiazem) should be avoided in heart failure with reduced ejection fraction 1

• Thiazide or Thiazide-like Diuretics are effective alternatives, particularly in patients with volume overload 1

  • Can be used as monotherapy or in combination with other agents 1
  • Monitor for electrolyte abnormalities, particularly hypokalemia 1

• Beta-Blockers (carvedilol, metoprolol succinate, bisoprolol) should be considered primarily in patients with specific comorbidities such as coronary artery disease or heart failure 1

  • Not recommended as first-line agents for uncomplicated hypertension 1

Special Considerations

• For patients with heart failure: ARBs are recommended as first-line alternatives to ACE inhibitors 1

  • Beta-blockers and aldosterone antagonists should also be part of the regimen for heart failure with reduced ejection fraction 1

• For patients with chronic kidney disease: ARBs provide similar renoprotective effects as ACE inhibitors 1

  • Monitor renal function and potassium levels closely when initiating therapy 1

• For resistant hypertension: Consider adding a low-dose spironolactone as a fourth-line agent if serum potassium is <4.5 mmol/L and eGFR is >45 ml/min/1.73m² 1

Important Precautions

• When switching from an ACE inhibitor to an ARB due to rash, start at the lowest possible dose and titrate slowly 2
• Avoid combination therapy with ACE inhibitors and ARBs as this increases cardiovascular and renal risk without additional benefit 1
• Document the ACE inhibitor reaction in the patient's medical record to prevent future re-exposure 2
• Educate patients about potential signs of hypersensitivity reactions with the new medication 2

Monitoring Recommendations

• Assess blood pressure, renal function, and electrolytes within 1-2 weeks after initiating ARB therapy 1
• Pay particular attention to patients with diabetes, renal impairment, or low systolic blood pressure (<80 mm Hg) 1
• Monitor for signs of hypersensitivity reactions, particularly in the first few weeks of therapy 2