Commonly Prescribed Angiotensin II Receptor Blockers (ARBs)
Eight ARBs are clinically available in the United States: azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, and valsartan. 1, 2
Complete List of FDA-Approved ARBs
The following ARBs are approved for clinical use:
- Azilsartan 1, 2
- Candesartan (administered as candesartan cilexetil prodrug) 3, 1, 2
- Eprosartan 3, 1, 2
- Irbesartan 3, 1, 2
- Losartan 3, 1, 2
- Olmesartan (administered as olmesartan medoxomil) 3, 1, 2
- Telmisartan 3, 1, 4, 2
- Valsartan 3, 1, 5, 2
ARBs with Specific Evidence-Based Indications
For Hypertension
All eight ARBs are FDA-approved for treating hypertension. 1
For Heart Failure with Reduced Ejection Fraction (HFrEF)
Only three ARBs have proven mortality and hospitalization benefits in major clinical trials:
- Candesartan: Target dose 32 mg once daily 3, 6
- Losartan: Target dose 50-100 mg once daily 3, 6
- Valsartan: Target dose 160 mg twice daily 3, 6
For Diabetic Nephropathy
Losartan and irbesartan have specific renoprotective trial data and reduce microalbuminuria. 1, 7
For Post-Myocardial Infarction
Valsartan demonstrated equivalence to captopril in high-risk post-MI patients with heart failure or reduced ejection fraction. 6
For Left Ventricular Hypertrophy
Losartan reduces cardiovascular events by 13% and stroke by 25% in patients with left ventricular hypertrophy. 7
Important Clinical Distinctions
Prodrug vs. Active Drug
- Prodrugs requiring conversion: Azilsartan, candesartan cilexetil, olmesartan medoxomil 3, 2
- Active drugs: Eprosartan, irbesartan, telmisartan, valsartan 2
- Losartan is partially converted to a more active metabolite (EXP3174) 2, 8
Duration of Action
- Longer-acting (suitable for once-daily dosing): Candesartan, irbesartan, telmisartan 2, 8
- Shorter-acting: Losartan, valsartan, eprosartan 8, 9
Common Combination Products with Hydrochlorothiazide
The following ARB/HCTZ combinations are available:
- Candesartan-hydrochlorothiazide (Atacand HCT) 3
- Eprosartan-hydrochlorothiazide (Teveten-HCT) 3
- Irbesartan-hydrochlorothiazide (Avalide) 3
- Losartan-hydrochlorothiazide (Hyzaar) 3
- Olmesartan-hydrochlorothiazide (Benicar HCT) 3
- Telmisartan-hydrochlorothiazide (Micardis-HCT) 3
- Valsartan-hydrochlorothiazide (Diovan-HCT) 3
Key Safety Considerations Across All ARBs
- Contraindicated in pregnancy due to fetal toxicity 1
- Risk of hyperkalemia, especially in patients with chronic kidney disease or on potassium-sparing medications 1, 6
- Angioedema can occur, though less commonly than with ACE inhibitors 3, 1
- Caution with hypotension and renal insufficiency 3
- Avoid triple RAAS blockade (ACE inhibitor + ARB + aldosterone antagonist) due to excessive hyperkalemia risk 6