ARB Medications: Comprehensive Comparison Table
Complete ARB Medication Profile
| ARB Medication | Half-Life | Blood Pressure Reduction | Compelling Indications |
|---|---|---|---|
| Losartan | 2 hours (parent drug); 6-9 hours (active metabolite EXP3174) [1] | 50-100 mg daily: Moderate BP reduction, less potent than other ARBs on mg-per-mg basis [1] | • Hypertension with left ventricular hypertrophy (stroke risk reduction - does not apply to Black patients) [2] • Type 2 diabetic nephropathy with elevated creatinine and proteinuria (UACR ≥300 mg/g) [2] • Heart failure with reduced ejection fraction (target dose 150 mg daily) [3] • Post-myocardial infarction [4] |
| Candesartan | 9 hours [5] | 8-32 mg daily: Most potent ARB on mg-per-mg basis [1] | • Heart failure with reduced ejection fraction [4] • Post-myocardial infarction [4] • Hypertension [5] • Chronic kidney disease with proteinuria [4] |
| Valsartan | 6 hours [1] | 80-320 mg daily: Moderate BP reduction, comparable to losartan [1] | • Heart failure (NYHA class II-IV) to reduce hospitalization risk [6] • Post-myocardial infarction with left ventricular failure/dysfunction (reduces cardiovascular mortality) [6] • Hypertension [6] • Available as sacubitril-valsartan (ARNI) for heart failure [4] |
| Irbesartan | 11-15 hours [1] | 150-300 mg daily: Superior BP reduction compared to losartan and valsartan; comparable to olmesartan [7,1] | • Type 2 diabetic nephropathy (both early microalbuminuria and overt nephropathy) [7] • Hypertension with left ventricular hypertrophy [8] • Proteinuria/microalbuminuria [8] • Metabolic syndrome [8] |
| Olmesartan | 13 hours [1] | 20-40 mg daily: Produces greater systolic BP reduction than losartan; comparable to irbesartan [7,1] | • Hypertension [1] • Chronic kidney disease with proteinuria [4] |
| Telmisartan | 24 hours (longest half-life among ARBs) [1,9] | 40-80 mg daily: Sustained 24-hour BP control; most potent after candesartan [1] | • Hypertension in high cardiovascular risk patients (equivalent protection to ACE inhibitors with better tolerability) [10] • Cardiovascular risk reduction in broad at-risk populations [10] • Metabolic syndrome (partial PPAR-γ agonist activity) [9] |
| Eprosartan | 5-9 hours [1] | 600-800 mg daily: Least potent ARB, requires highest mg dose [1] | • Hypertension [1] • Limited compelling indications compared to other ARBs [1] |
| Azilsartan | 11 hours [9] | 40-80 mg daily: Potent BP reduction, comparable to highest-tier ARBs [9] | • Hypertension [9] • Administered as prodrug (azilsartan medoxomil) [9] |
Key Clinical Considerations for ARB Selection
Blood Pressure Lowering Efficacy Hierarchy
On a mg-per-mg basis, ARB potency follows this sequence: candesartan > telmisartan ≈ losartan > irbesartan ≈ valsartan > eprosartan 1. However, when prescribed at standard therapeutic doses, irbesartan and olmesartan demonstrate superior absolute BP reductions compared to losartan and valsartan 7.
Compelling Indications by Clinical Scenario
Heart Failure with Reduced Ejection Fraction
- First-line ARBs: Candesartan or valsartan (equivalent efficacy to ACE inhibitors) 4
- Target doses: Candesartan 32 mg daily, valsartan 160 mg twice daily, losartan 150 mg daily 4, 3
- Critical point: Sacubitril-valsartan (ARNI) is preferred over standard ARBs or ACE inhibitors for improved outcomes 4
- Avoid: Combining ARBs with ACE inhibitors (increases hyperkalemia and renal dysfunction risk without added benefit) 4
Diabetic Nephropathy
- Early nephropathy (microalbuminuria, UACR 30-299 mg/g): Irbesartan 300 mg daily (only ARB with proven efficacy at this stage) 7, 4
- Overt nephropathy (UACR ≥300 mg/g): Irbesartan 300 mg daily or losartan 100 mg daily 2, 7
- Renoprotection is partly independent of BP lowering 7
- Monitor: Serum creatinine/eGFR and potassium within 1-2 weeks of initiation or dose changes 4
Post-Myocardial Infarction
- Preferred ARBs: Valsartan or candesartan (proven mortality reduction) 6, 4
- Use in combination with: Beta-blockers, aldosterone antagonists 4
Hypertension with Left Ventricular Hypertrophy
- Losartan specifically reduces stroke risk in this population (except Black patients where benefit does not apply) 2
- Alternative: Irbesartan (demonstrated LVH regression) 8, 7
Stroke Prevention
- Primary prevention: Any ARB with sustained 24-hour BP control 4
- Secondary prevention: ARBs combined with thiazide diuretics 4
Chronic Kidney Disease
- First-line for CKD with albuminuria: Any ARB at maximum tolerated dose 4
- Can continue ARBs as eGFR declines to <30 mL/min/1.73m² for cardiovascular benefit 4
- Contraindicated: Bilateral renal artery stenosis 4
Pharmacokinetic Distinctions Affecting Clinical Use
Duration of Action
- Longest half-life (once-daily dosing assured): Telmisartan (24 hours) 1, 9
- Shortest half-life: Losartan parent drug (2 hours), but active metabolite extends duration to 6-9 hours 1
- All ARBs provide 24-hour BP control when dosed appropriately 1
Bioavailability
- Highest: Irbesartan (60-80%) 1
- Lowest: Eprosartan (13%) 1
- Food effects: Valsartan bioavailability reduced 40-50% with food; eprosartan increased with food 1
Tissue Penetration
- Highest lipophilicity/tissue penetration: Telmisartan (volume of distribution 500 L) 1, 9
- Lowest: Candesartan (volume of distribution 9 L) 1
- Clinical relevance: Greater tissue penetration may provide additional end-organ protection beyond BP lowering 9
Critical Safety Monitoring
Absolute Contraindications for All ARBs
- Pregnancy (all trimesters) 4
- Bilateral renal artery stenosis or unilateral stenosis in solitary kidney 4
- Combination with ACE inhibitors or direct renin inhibitors (increases hyperkalemia, syncope, acute kidney injury without benefit) 4, 3
Monitoring Requirements
- Baseline: Serum creatinine, eGFR, potassium 4
- Follow-up: Recheck within 1-2 weeks after initiation or dose increase, then at least annually 4
- High-risk patients requiring more frequent monitoring: Diabetes, CKD, concomitant potassium-sparing agents, aldosterone antagonists 4
Dose Adjustments
- Renal impairment: No adjustment needed for mild-moderate impairment (CrCl 30-90 mL/min); use caution with severe impairment (CrCl <30 mL/min) 5
- Hepatic impairment: Reduce starting dose for moderate impairment; candesartan AUC increased 145% in moderate hepatic impairment 5
- Elderly patients: No routine dose adjustment needed, but higher plasma concentrations expected (candesartan Cmax 50% higher, AUC 80% higher) 5
Combination Therapy Strategies
Preferred Combinations
- ARB + thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide for cardiovascular outcomes) 4
- ARB + dihydropyridine calcium channel blocker 4
- For resistant hypertension: ARB + thiazide + calcium channel blocker + mineralocorticoid receptor antagonist 4