From the Guidelines
For initial hypertension treatment, lisinopril (an ACE inhibitor) at 10-20 mg once daily or losartan (an ARB) at 50 mg once daily are excellent first-line choices, as recommended by the most recent guidelines 1. Both medications effectively lower blood pressure by targeting the renin-angiotensin-aldosterone system. Lisinopril is often preferred due to its once-daily dosing, low cost, and extensive clinical experience, though it may cause a dry cough in some patients. Losartan is a good alternative, particularly for those who develop a cough with ACE inhibitors. When initiating either medication, start at a lower dose and titrate upward as needed while monitoring blood pressure and kidney function. Check potassium and creatinine levels within 2-4 weeks of starting therapy. These medications are particularly beneficial for patients with diabetes, chronic kidney disease, or heart failure, as they have been shown to reduce cardiovascular events in these populations 1. The choice between an ACE inhibitor and ARB should be individualized based on patient characteristics, comorbidities, cost considerations, and potential side effects. It is also important to note that combinations of ACE inhibitors and angiotensin receptor blockers are not recommended, as stated in the guidelines 1. In patients with albuminuria, initial treatment should include an ACE inhibitor or ARB to reduce the risk of progressive kidney disease 1. Overall, the selection of an ACE inhibitor or ARB as initial therapy for hypertension should be based on the individual patient's needs and medical history.
Some key points to consider when choosing between an ACE inhibitor and an ARB include:
- Patient characteristics, such as the presence of diabetes or chronic kidney disease
- Comorbidities, such as heart failure or coronary artery disease
- Cost considerations, as ACE inhibitors are often less expensive than ARBs
- Potential side effects, such as cough with ACE inhibitors or hyperkalemia with either class
- The need for combination therapy, as ACE inhibitors and ARBs should not be used together 1.
By considering these factors and following the most recent guidelines, healthcare providers can make informed decisions about the best initial therapy for patients with hypertension.
From the FDA Drug Label
Losartan is indicated for the treatment of hypertension in adults and pediatric patients 6 years of age and older, to lower blood pressure. Losartan Potassium Tablets is a prescription medicine called an angiotensin receptor blocker (ARB). It is used: • Alone or with other blood pressure medicines to lower high blood pressure (hypertension). Candesartan blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor in many tissues, such as vascular smooth muscle and the adrenal gland.
The FDA drug label does not answer the question of what is the best ACE inhibitor or ARB to initiate for hypertension, as it does not provide a direct comparison between different medications.
- Key points to consider when choosing an ACE inhibitor or ARB include the patient's medical history, potential side effects, and interactions with other medications.
- Losartan and candesartan are both ARBs that can be used to lower blood pressure, but the best choice for a particular patient will depend on individual factors.
- More information is needed to determine the best ACE inhibitor or ARB for a specific patient, and a healthcare professional should be consulted to make an informed decision 2, 2, 3.
From the Research
ACE Inhibitors for Hypertension
- Lisinopril is an effective ACE inhibitor for lowering blood pressure in patients with essential hypertension, with a suitable dosage of 20 to 80 mg once daily 4.
- Studies have compared the efficacy of once-daily and twice-daily dosing of lisinopril, with twice-daily administration showing greater blood pressure reductions in some cases 5, 6.
- A review of six studies found that twice-daily administration of ACE inhibitors may promote added blood pressure-lowering effects compared to once-daily administration, with no added safety concerns 6.
Comparison of ACE Inhibitors and ARBs
- There is limited direct comparison between ACE inhibitors and ARBs in the provided studies, making it difficult to determine the best option for initiating treatment for hypertension.
- However, ACE inhibitors such as lisinopril have been shown to be effective in lowering blood pressure and are well-tolerated, with few serious adverse effects reported 4.
Dosage and Administration
- Twice-daily dosing of ACE inhibitors may be associated with greater blood pressure reductions compared to once-daily dosing, but this may also lead to adherence issues 5, 6.
- The decision to use once-daily or twice-daily dosing of ACE inhibitors should be made on a case-by-case basis, taking into account patient factors and clinician judgment 6.