What is the preferred initial treatment between lisinopril (Angiotensin-Converting Enzyme Inhibitor) and losartan (Angiotensin II Receptor Blocker) for a patient with hypertension?

Lisinopril vs Losartan for Initial Hypertension Treatment

For initial treatment of hypertension, losartan is preferred over lisinopril due to its better side effect profile, particularly lower incidence of cough, while maintaining similar blood pressure lowering efficacy. 1

Efficacy Comparison

• Both lisinopril (ACE inhibitor) and losartan (ARB) effectively lower blood pressure and are recommended as first-line treatments for hypertension 2
• Lisinopril and losartan demonstrate similar effectiveness in reducing cardiovascular events in hypertensive patients 2
• In elderly patients with left ventricular hypertrophy, losartan showed superior reduction in cardiovascular events, particularly stroke, compared to beta-blockers 2
• Both medications effectively lower blood pressure regardless of race, though lisinopril is less effective in Black patients compared to losartan 3, 4

Side Effect Profile Differences

• Losartan has a significantly lower incidence of cough (29%) compared to lisinopril (72%) in patients with history of ACE inhibitor-induced cough 1
• Persistent dry cough is a common side effect with ACE inhibitors like lisinopril and can lead to treatment discontinuation 4
• Lisinopril 10mg twice daily was associated with increased odds of angioedema compared to once-daily dosing (odds ratio 2.27) 5
• Both medications require monitoring of renal function and potassium levels, especially in patients with pre-existing renal impairment 2

Special Patient Populations

Patients with Albuminuria/Kidney Disease

• For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), either an ACE inhibitor like lisinopril or an ARB like losartan is recommended as initial treatment 2
• ARBs like losartan are specifically recommended for patients with chronic kidney disease because they reduce albuminuria in addition to blood pressure control 2

Patients with Diabetes

• Both ACE inhibitors and ARBs are recommended for diabetic patients with hypertension 2
• For diabetic patients with coronary artery disease or albuminuria, either an ACE inhibitor or ARB should be part of the treatment regimen 2

Elderly Patients

• Both medications are effective in elderly patients, but dose titration should be more gradual due to greater chance of adverse effects 2
• In patients aged 55 or older, calcium channel blockers or diuretics may be more effective first-line agents than ACE inhibitors like lisinopril 2

Dosing Considerations

• Lisinopril is typically started at 10mg once daily and titrated up to 20-80mg daily as needed 6, 3
• Losartan is typically started at 50mg once daily with potential titration up to 100mg daily 4
• Once-daily dosing is sufficient for both medications; twice-daily dosing does not provide improved effectiveness 5

Algorithm for Choosing Between Lisinopril and Losartan

1. For patients with history of ACE inhibitor-induced cough or angioedema: Choose losartan 4, 1
2. For Black patients: Prefer losartan due to better efficacy 3, 4
3. For patients with left ventricular hypertrophy: Choose losartan based on superior cardiovascular outcomes 2
4. For patients with chronic kidney disease: Either medication is appropriate, but losartan may be preferred 2, 7
5. For patients with concerns about quality of life: Consider losartan, as ACE inhibitors like lisinopril may affect some aspects of emotional, cognitive, and social functioning 8

Monitoring Recommendations

• For both medications, monitor serum creatinine/eGFR and potassium levels at least annually 2
• Check blood pressure regularly to ensure target blood pressure is achieved within 3 months 6
• If blood pressure remains uncontrolled on monotherapy, consider adding a calcium channel blocker or thiazide-like diuretic 2