ACE inhibitors or an ARB for hypertension or diabetic kidney disease
A shift in thinking about the cardiovascular (CV) benefits of angiotensin receptor blockers (ARBs) will lead to more use of angiotensin receptor blockers (ARBs) instead of angiotensin converting enzymes inhibitors (ACEIs). ACEIs are mostly recommended to be used, since they have more CV outcomes data and seemed to have a bigger impact on CV events than ARBs. And low-cost generic ACEIs have been available for years. But patients in older ACEI studies were at higher CV risk due to (more smoking, less use of statins, etc) than patients in newer ARB studies. So, CV benefit appeared greater with ACEIs compared to ARBs.
Now a new analysis adjusting for these differences suggests that ACEIs and ARBs have similar CV efficacy in many patients. Plus, ARBs may be more user-friendly. About one in 30 patients will stop an ACEI due to cough, and one in 300 will develop angioedema. But ARBs rarely cause cough or angioedema. Consider the indication to decide if an ARB is a good option.
- For hypertension or diabetic kidney disease, suggest either an ACEI or an ARB, since efficacy seems similar.
- For systolic heart failure, continue to advise starting with an ACEI. ACEIs seem to show more benefit than ARBs in heart failure.
- Point out that not all generic ARBs are low in cost.
- Continue to recommend switching to an ARB if patients develop a cough or mild angioedema with an ACEI.
- But suggest being more cautious with ARBs if angioedema is severe, such as with airway obstruction.
- Get our notes "Angiotensin-Converting Enzyme (ACE) Inhibitors" and "Angiotensin II Receptor Blockers (ARBs)".
References
- Omboni, S. and Volpe, M. (2018). Angiotensin Receptor Blockers Versus Angiotensin Converting Enzyme Inhibitors for the Treatment of Arterial Hypertension and the Role of Olmesartan. Advances in Therapy. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824372.
- Consult QD. (2019). ACE Inhibitor and ARB Therapy: Practical Recommendations. [online] Available at: https://consultqd.clevelandclinic.org/ace-inhibitor-and-arb-therapy-practical-recommendations.
