Is losartan (Angiotensin II Receptor Antagonist) more effective than lisinopril (Angiotensin-Converting Enzyme Inhibitor)?

From the Guidelines

Losartan and lisinopril have similar efficacy in treating hypertension and heart failure, but the choice between them depends on individual patient factors, such as the presence of a dry cough or angioedema, and should be made based on the patient's specific medical conditions and side effect profile. Both medications effectively target the renin-angiotensin-aldosterone system, but through different mechanisms, with losartan being an angiotensin II receptor blocker (ARB) and lisinopril being an angiotensin-converting enzyme (ACE) inhibitor 1. According to the 2017 ACC/AHA/HFSA focused update, ACE inhibitors and ARBs have been shown to reduce morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF) 1.

Some key points to consider when choosing between losartan and lisinopril include:

• Lisinopril is often prescribed first due to its lower cost and extensive clinical experience, typically starting at 10mg once daily 1.
• Losartan may be preferred for patients who develop a dry cough with lisinopril, which occurs in about 10-20% of patients taking ACE inhibitors 1.
• Losartan also has a slightly lower risk of angioedema compared to lisinopril 1.
• Both medications require monitoring of blood pressure, kidney function, and potassium levels, especially when starting therapy 1.
• Neither should be used during pregnancy due to potential fetal harm 1.

It's also important to note that the use of ARBs, such as losartan, has been shown to be beneficial in patients with HFrEF who are intolerant of ACE inhibitors, and that the combination of an ACE inhibitor and an ARB may provide additional benefits in reducing morbidity and mortality 1. However, the final choice between losartan and lisinopril should be made with your healthcare provider based on your specific medical conditions, side effect profile, cost considerations, and other medications you may be taking.

From the FDA Drug Label

1. 4 Dual Blockade of the Renin-Angiotensin System (RAS) Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, syncope, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy The Veterans Affairs Nephropathy in Diabetes (VA NEPHRON-D) trial enrolled 1448 patients with type 2 diabetes, elevated urinary-albumin-to-creatinine ratio, and decreased estimated glomerular filtration rate (GFR 30 to 89.9 mL/min), randomized them to lisinopril or placebo on a background of losartan therapy and followed them for a median of 2. 2 years. Patients receiving the combination of losartan and lisinopril did not obtain any additional benefit compared to monotherapy for the combined endpoint of decline in GFR, end stage renal disease, or death, but experienced an increased incidence of hyperkalemia and acute kidney injury compared with the monotherapy group

The FDA drug label does not answer the question.

From the Research

Comparison of Losartan and Lisinopril

• Losartan and lisinopril are both used to treat hypertension and heart failure, but they belong to different classes of medications: losartan is an angiotensin II receptor antagonist, while lisinopril is an angiotensin-converting enzyme (ACE) inhibitor 2, 3.
• Studies have shown that losartan is as effective as lisinopril in reducing blood pressure and improving symptoms in patients with heart failure 3, 4.
• However, losartan has been found to have a lower incidence of cough compared to lisinopril, which is a common side effect of ACE inhibitors 4, 5, 6.
• In patients with previous ACE inhibitor-induced cough, losartan has been shown to be a suitable alternative with a lower risk of cough 4, 5, 6.
• The Losartan Heart Failure Survival (ELITE II) study found no significant difference between losartan and captopril (another ACE inhibitor) in reducing overall deaths or sudden cardiac death in patients with heart failure 3.
• Overall, the choice between losartan and lisinopril depends on individual patient factors, such as the presence of cough or other side effects, and the specific clinical context 2, 3.

Side Effects and Tolerability

• Losartan has been found to be better tolerated than lisinopril in some studies, with a lower incidence of cough and other side effects 4, 5, 6.
• However, both medications can cause serious side effects, such as hyperkalemia, renal failure, and hypotension 2.
• The incidence of adverse events associated with losartan was similar to that of other antihypertensive agents, such as felodipine and nifedipine 3.

Clinical Use

• Losartan is an option for first-line therapy in patients with hypertension, particularly those who are not well managed with or who are intolerant of their current therapy 3.
• In patients with heart failure, losartan may be used as an alternative to ACE inhibitors, especially in those with previous ACE inhibitor-induced cough 3, 4, 5, 6.