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ACE-Inhibitor or ARB?

Mar 09, 2015

First, I know I have written several blogs about current or recently approved medications. I have always been fascinated with the chemistry of medications, but more importantly how and why do we use certain medications for a specific disease state? On a regular basis, I am having a discussion with my providers at a rural health family medicine clinic – “Which one is better an ACE-inhibitor or ARB?” “Which one should I use among patients with diabetes who need additional blood pressure control?” As a pharmacist, I have looked for key factors for why a patient may be prescribed an ARB, such as documented allergy (i.e. cough), documented angioedema, or insurance. Either option – ACE-inhibitor or ARB – has become the standard of care for patients with diabetes. 

When talking about the latest blood pressure guidelines – JNC VIII – calcium channel blockers (i.e. amlodipine), thiazide-type diuretic (i.e. hydrochlorothiazide) are recommended at the same level of ACE-inhibitors and ARBs as there is no superior evidence among these classes. However, patients with diabetes may benefit from either an ACE-inhibitor or ARB due to risk of cardiovascular events. A patient with diabetes is at a higher risk of heart failure, myocardial infarction, and stroke. Therefore, the benefit would definitely be gained with an ACE-inhibitor or ARB for these conditions. It is okay for patients with diabetes to be prescribed amlodipine or hydrochlorothiazide, but it would be better for a patient with diabetes who also has chronic kidney disease, albuminuria, heart failure, myocardial infarction and/or stroke. No matter what, it will take several agents to lower the patient’s blood pressure. I think about all the available combination products – small doses of several agents can lower a patient’s blood pressure. It is important to strive for a desired blood pressure goal (i.e. for diabetes, less than 140/90 mm Hg per the JNC VIII and ADA guidelines) rather than maximize doses, which could increase the risk of adverse events. 

While writing about blood pressure management, it is important to counsel patients about: 
• Decreased sodium intake (recently encouraged amount = <2300 mg/day) 
• Weight loss (5-10 kg loss) 
• Physical activity (150 minutes per week of aerobic activity) 
• DASH diet (fruits, vegetables, whole grains) 
• Reduced alcohol intake 

For everyone’s review, here is a list of current ACE-inhibitors and ARB with brand names (combination products are not provided): 

• ACE-inhibitors 
o Benazepril – LOTENSIN 
o Captopril – CAPTOTEN 
o Enalapril – VASOTEC 
o Fosinopril – MONOPRIL 
o Moexipril – UNIVASC 
o Perindopril – ACEON 
o Quinapril – ACCUPRIL 
o Ramipril – ALTACE 
o Trandolapril – MAVIK 

• ARBs 
o Azilsartan – EDARBI 
o Candesartan – ATACAND 
o Eprosartan – TEVETEN 
o Irbesartan – AVAPRO 
o Losartan – COZAAR 
o Olmesartan – BENICAR 
o Telmisartan – MICARDIS
o Valsartan – DIOVAN

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