II. Indications
- Intolerance to ACE Inhibitor
- See ACE Inhibitor for indications
III. Contraindications
- See ACE Inhibitor for contraindications
-
Angioedema with ACE Inhibitor (relative contraindication)
- Bradykinin related reaction that recurs with ARBs in 2% of patients who had Angioedema on ACE Inhibitor
- Do not use ARB if ACE inhibitor Induced Angioedema was severe
- Precautions given to patient to stop ARB immediately and seak emergency care for signs of Angioedema recurrence
- Wait at least 4 weeks between stopping ACE Inhibitor and starting ARB
- (2013) J Allergy Clin Immunol 131:1491-3 [PubMed]
IV. Mechanism
V. Preparations: ARB alone
- Losartan (Cozaar)
- Start: 50 mg orally daily or 25 mg daily if volume depleted (MAX 100 mg/day)
- Consider twice daily divided dosing
- Irbesartan (Avapro)
- Start 150 mg orally daily (max 300 mg/day)
- Candesartan (Atacand)
- Start 8 mg orally daily (maximum 32 mg/day)
- Eprosartan (Teveten)
- Start 400 mg orally daily (maximum 800 mg/day)
- Telmisartan (Micardis)
- Start 40 mg orally daily (maximum 80 mg/day)
- Valsartan (Diovan)
- Start 80 mg orally daily (maximum 320 mg/day)
- Olmesartan (Benicar)
- Start 20 mg orally daily (maximum 40 mg/day)
- Azilsartan (Edarbi)
- Start 40 mg orally daily (maximum 80 mg/day)
VI. Preparations: Combination
-
Amlodipine (and ARB)
- Exforge (Amlodipine and Valsartan)
- Azor (Amlodipine and Olmesartan)
-
Hydrochlorothiazide (and ARB)
- Most ARB agents are available in combination with Hydrochlorothiazide (Hctz)
- Sacubitril and Valsartan (Entresto)
- Indicated in Systolic Dysfunction (consider as an alternative to ACE Inhibitor or mono Angiotensin Receptor Blocker)
- Sacubitril (neprilysin inhibitor) increases vasodilation and Sodium excretion
- Risk of Hypotension (Number needed to harm 21)
- Risk of Angioedema (Number needed to harm 200)
- See Systolic Dysfunction for dosing and references
VII. Protocol: Equivalent dosing (switching between agents)
- Losartan (Cozaar) 100 mg daily or divided twice daily
- Irbesartan (Avapro) 300 mg daily
- Candesartan (Atacand) 16 mg daily
- Eprosartan (Teveten) 800 mg daily
- Telmisartan (Micardis) 40 mg daily
- Valsartan (Diovan) 160 mg daily
- Olmesartan (Benicar) 20 mg daily
- Azilsartan (Edarbi) 40 mg daily
VIII. Efficacy
- Peak effect may require 4-6 weeks
- Proteinuria control is equivalent to ACE Inhibitors
- Evidence as of 2015 shows similar efficacy of ARBs as ACE Inhibitors in Myocardial Infarction prevention
- (2016) Presc Lett 23(3): 13
- Avoid in combination with ACE Inhibitors
- No advantage to combinations in Hypertension, vascular disease, Diabetes Mellitus, Coronary Artery Disease
- Moderate benefit of combination therapy in Congestive Heart Failure
- (2013) Prescr Lett 20(3): 13
- Reduce cardiovascular death, Cerebrovascular Accident and Myocardial Infarction risk
- Higher level cardiovascular protection than Atenolol
- However Atenolol is not the best Beta Blocker for cardiovascular disease prevention
- Dahlof (2002) Lancet 359:995-1003 [PubMed]
- ARBs do not effect Angiotensin II type 2 receptors
- Results in less effect on fibrosis and Blood Flow
- Unlike ACE Inhibitors, ARBs don't effect nitric oxide
- (2005) Prescriber's Letter 12:31-2
- Higher level cardiovascular protection than Atenolol
IX. Adverse Effects
- Valsartan (Diovan), Irbesartan (Avapro) and Losartan (Cozaar)
- N-Nitrosodimethylamine (NMDA) or N-nitrosodiethylamine (NDEA) product contamination (FDA recall 2018)
- https://www.fda.gov/Drugs/DrugSafety/ucm613916.htm
- https://www.fda.gov/Safety/Recalls/ucm624593.htm
- https://www.fda.gov/Safety/Recalls/ucm625492.htm
- Product contamination may have been for as long as 4 years
- Cancer risk 1 in 8000 patients taking Valsartan for 8 years at 320 mg/day
- (2018) Presc Lett 25(9): 49
- N-Nitrosodimethylamine (NMDA) or N-nitrosodiethylamine (NDEA) product contamination (FDA recall 2018)
- Olmesartan (Benicar)
- Sprue-like Enteropathy
- Presents with progressive, severe Chronic Diarrhea, weight loss and sprue-like intestinal changes
- May be a delayed Hypersensitivity Reaction (typically months to years after starting Olmesartan)
- Rubio-Tapia (2012) Mayo Clin Proc 87(8):732-8 [PubMed]
- Sprue-like Enteropathy
Images: Related links to external sites (from Bing)
Related Studies
losartan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
LOSARTAN POTASSIUM 100 MG TAB | Generic | $0.08 each |
LOSARTAN POTASSIUM 25 MG TAB | Generic | $0.04 each |
LOSARTAN POTASSIUM 50 MG TAB | Generic | $0.05 each |
LOSARTAN-HYDROCHLOROTHIAZIDE 100-12.5 MG TAB | Generic | $0.13 each |
LOSARTAN-HYDROCHLOROTHIAZIDE 100-25 MG TAB | Generic | $0.14 each |
LOSARTAN-HYDROCHLOROTHIAZIDE 50-12.5 MG TAB | Generic | $0.12 each |
cozaar (on 1/14/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
COZAAR 100 MG TABLET | Generic | $0.08 each |
COZAAR 50 MG TABLET | Generic | $0.05 each |
irbesartan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
IRBESARTAN 150 MG TABLET | Generic | $0.18 each |
IRBESARTAN 300 MG TABLET | Generic | $0.24 each |
IRBESARTAN 75 MG TABLET | Generic | $0.17 each |
IRBESARTAN-HYDROCHLOROTHIAZIDE 150-12.5 MG TB | Generic | $0.19 each |
IRBESARTAN-HYDROCHLOROTHIAZIDE 300-12.5 MG TB | Generic | $0.24 each |
avapro (on 1/3/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
AVAPRO 150 MG TABLET | Generic | $0.18 each |
AVAPRO 300 MG TABLET | Generic | $0.24 each |
candesartan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
CANDESARTAN CILEXETIL 16 MG TB | Generic | $0.79 each |
CANDESARTAN CILEXETIL 32 MG TB | Generic | $0.96 each |
CANDESARTAN CILEXETIL 4 MG TAB | Generic | $0.80 each |
CANDESARTAN CILEXETIL 8 MG TAB | Generic | $0.77 each |
CANDESARTAN-HYDROCHLOROTHIAZIDE 16-12.5 MG TB | Generic | $1.12 each |
CANDESARTAN-HYDROCHLOROTHIAZIDE 32-12.5 MG TB | Generic | $1.76 each |
CANDESARTAN-HYDROCHLOROTHIAZIDE 32-25 MG TAB | Generic | $1.47 each |
telmisartan (on 1/18/2023 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
TELMISARTAN 20 MG TABLET | Generic | $0.19 each |
TELMISARTAN 40 MG TABLET | Generic | $0.26 each |
TELMISARTAN 80 MG TABLET | Generic | $0.28 each |
TELMISARTAN-AMLODIPINE 80-5 MG | Generic | $3.05 each |
TELMISARTAN-HYDROCHLOROTHIAZIDE 40-12.5 MG TB | Generic | $0.66 each |
TELMISARTAN-HYDROCHLOROTHIAZIDE 80-12.5 MG TB | Generic | $0.86 each |
TELMISARTAN-HYDROCHLOROTHIAZIDE 80-25 MG TAB | Generic | $0.79 each |
micardis (on 1/10/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
MICARDIS 80 MG TABLET | Generic | $0.28 each |
valsartan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
VALSARTAN 160 MG TABLET | Generic | $0.23 each |
VALSARTAN 320 MG TABLET | Generic | $0.27 each |
VALSARTAN 40 MG TABLET | Generic | $0.16 each |
VALSARTAN 80 MG TABLET | Generic | $0.19 each |
VALSARTAN-HYDROCHLOROTHIAZIDE 160-12.5 MG TAB | Generic | $0.26 each |
VALSARTAN-HYDROCHLOROTHIAZIDE 160-25 MG TAB | Generic | $0.30 each |
VALSARTAN-HYDROCHLOROTHIAZIDE 320-12.5 MG TAB | Generic | $0.34 each |
VALSARTAN-HYDROCHLOROTHIAZIDE 320-25 MG TAB | Generic | $0.34 each |
VALSARTAN-HYDROCHLOROTHIAZIDE 80-12.5 MG TAB | Generic | $0.22 each |
diovan (on 7/27/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
DIOVAN 160 MG TABLET | Generic | $0.23 each |
DIOVAN 320 MG TABLET | Generic | $0.27 each |
DIOVAN 80 MG TABLET | Generic | $0.19 each |
olmesartan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
OLMESARTAN MEDOXOMIL 20 MG TAB | Generic | $0.08 each |
OLMESARTAN MEDOXOMIL 40 MG TAB | Generic | $0.13 each |
OLMESARTAN MEDOXOMIL 5 MG TAB | Generic | $0.06 each |
OLMESARTAN-HYDROCHLOROTHIAZIDE 20-12.5 MG TAB | Generic | $0.20 each |
OLMESARTAN-HYDROCHLOROTHIAZIDE 40-12.5 MG TAB | Generic | $0.26 each |
OLMESARTAN-HYDROCHLOROTHIAZIDE 40-25 MG TAB | Generic | $0.26 each |
benicar (on 1/18/2023 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
BENICAR HCT 40-25 MG TABLET | Generic | $0.27 each |
entresto (on 7/27/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
ENTRESTO 24 MG-26 MG TABLET | $10.18 each | |
ENTRESTO 49 MG-51 MG TABLET | $10.18 each | |
ENTRESTO 97 MG-103 MG TABLET | $10.18 each | |
exforge (on 7/27/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
EXFORGE HCT 10-320-25 MG TAB | $12.94 each |