Tobi H, van den Berg PB, de Jong-van den Berg LT. ACE inhibitors and ARBs equally effective in diabetics. Baseline characteristics of these patients are shown in Table 1. The median prescribed dosage corresponded to the DDD (Table 1, ). 42. Users of ACE inhibitors switched drugs more than ARB users. 9. Journal of Molecular Medicine 84 (2006): 814-820. The 2 exceptions were captopril, which was prescribed below the DDD of 50 mg in 65% of patients, and ramipril, which was prescribed above the DDD of 2.5 mg in 70% of patients. Gogovor A, Dragomir A, Savoie M, Perreault S. Comparison of persistence rates with angiotensin-converting enzyme inhibitors used in secondary and primary prevention of cardiovascular disease. For the same reason, frequency of medication administration (eg, once daily, twice daily) could not be analyzed because of indication bias. 2006;41:274-284. These results are in accordance with a previously published study analyzing compliance and persistence in more than 6000 ACE inhibitor users, which also found the highest compliance and persistence for ramipril and the lowest for enalapril.45 In contrast to ACE inhibitors, the specific ARBs had very similar patterns of drug utilization. Monitoring requirements when switching ACE-inhibitors • Serum Potassium levels • Renal function (Creatinine clearance) • Blood pressure • Care should be taken in patients on diuretic therapy (monitor for hypotension). Comparative clinical- and cost-effectiveness of candesartan and losartan in the management of hypertension and heart failure: a systematic review, meta- and cost-utility analysis. In monotherapy, it has shown greater efficacy in lowering BP than ACE-inhibitors and calcium-channel blockers.12,13 However, it was associated with an unacceptable risk of angioedema due to excessive inhibition of bradykinin degradation (presumably via neprilysin, ACE, and aminopeptidase P).3–5 In contrast to omapatrilat, in LCZ696, the ACE inhibition has been replaced with an angiotensin … tool for switching between agents in canada ©2018 Canadian Pharmacists Association The information provided is intended to help prescribers select an alternative agent from the angiotensin II receptor antagonist (ARB) class. On the contrary switching to other antihypertensive drugs at the moment of upregulation of AT1 receptors and ACE2 or even starting the treatment with ARB in ARB-naïve patients is controversial. Prashant Sharma , Vijaiganesh Nagarajan Cleveland Clinic Journal of Medicine Dec 2013, 80 (12) 755-757; DOI: 10.3949/ccjm.80a.13041 2005;19(10):793-799. Incident users of RAS inhibitors (ATC C09) older than 18 years were included. Bohm M, Baumhäkel M, Mahfoud F, Werner C. From evidence to rationale: cardiovascular protection by angiotensin II receptor blockers compared with angiotensin-converting enzyme inhibitors. There was variation in drug-utilization patterns between the specific ACE inhibitors. Users of ramipril and fosinopril showed the highest persistence: 85.8% and 83.4%, respectively (P <.001 and P = .047 vs enalapril, respectively). BMJ. A novel finding of our study is that, apart from factors leading to therapy switches, compliance and persistence were similar between ACE inhibitors and ARBs. Segura J, Christiansen H, Campo C, Ruilope LM. Researchers have previously received independent research grants from sanofi-aventis (manufacturer of ramipril, irbesartan, and losartan) and Daiichi-Sankyo (manufacturer of captopril and olmesartan). Objectives: The CORD trials tested ramipril and losartan in patients with hypertension. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Angiotensin II receptor blockers (ARB) are currently debated as an option for treatment of coronavirus disease 2019 (COVID-19). Sharma PP. Our results support a recent cost-effectiveness analysis that recommended generic cheaper ARBs over more expensive branded ARBs, as the differences in efficacy are small.46 Our study showed that differences in compliance, persistence, and switching behavior between ARBs are also small, thereby providing even less reason to prescribe expensive ARBs. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) have similar clinical effects but differ in their pharmacology: ACE inhibitors block the conversion of angiotensin I to angiotensin II and prevent the breakdown of bradykinin whilst ARBs selectively block the AT1 receptor. ARNI should not be administered concomitantly with ACE-I or ARB, nor within 36 hours of switching from or to an ACE-I. Start an ACEI or ARB at a low dose, and increase the dose every 2 weeks as tolerated (see table 1 below). Penning-van Beest F, van Herk-Sukel M, Gale R, Lammers JW, Herings R. Three-year dispensing patterns with long-acting inhaled drugs in COPD: a database analysis. N Engl J Med. New study presents "strong evidence" that continuing ACE inhibitor/ARB therapy in typical patients with chronic renal disease and declining kidney function "does not lead to harm" and ups survival. 23. Drug-utilization patterns were investigated: incidence, dosage, 1-year compliance, long-term persistence, and switching behavior. If a patient begins to cough and I switch from an ACE inhibitor to an angiotensin receptor blocker (ARB), will the positive bradykinin endothelial and/or the nephroprotective effects be lost? Bergman U. Question: switching from beta blocker to ace inhibitor cmvm - Tue May 05, 2009 1:01 pm: Share | My 42 yo husband has been on atenolol 100mg daily for over a year. 11. 15. Frishman WH. ACE inhibitors versus ARBs: comparison of practice guidelines and treatment selection considerations. The following drugs were investigated: captopril, enalapril, lisinopril, perindopril, ramipril, and fosinopril (ACE inhibitors), and losartan, valsartan, irbesartan, candesartan, and olmesartan (ARBs). outcomes compared to the ACE inhibitor alone. If a patient develops an ACEI-induced cough, … Bloodpressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. J Hum Hypertens. At least one of these exceptions must be documented in the patient record lieu of prescription, if they apply: Medical reason(s) for not prescribing ACE/ARB therapy Higher patient age and comedication for dyslipidemia increased the chance of being compliant (9.4% and 25.6% over 10 years, respectively, P <.001), while comedication for COPD and later year of initiating therapy decreased the chance of being compliant (-24.3% per year [P = .005] and -1.5% per year [P = .035], respectively). As an exception, ramipril was often prescribed at a higher dose, 5 mg/day, than the DDD of 2.5 mg. Clinical trial data in cardiovascular disease5 and renal disease6 also showed that ramipril is often prescribed at doses above 2.5 mg/day. 2003;326(7404):1427. Replacing hormone therapy—is the decline in prescribing sustained, and are nonhormonal drugs substituted? Do not administer within 36 hours of switching from or to an ACE inhibitor. The history of the Drug Utilization Research Group in Europe. Differences in compliance were tested using logistic regression. Br J Clin Pharmacol.2008;66(2):313-315. Differences in persistence and switching patterns were plotted using Kaplan-Meier plots and tested using the log-rank test and Cox proportional hazard analysis. 18. 3. Mancia G, Laurent S, Agabiti-Rosei E, et al. Majority of doctors adopt another approach of switching to another type of treatment like ARBs. 12 NOV 2013. JAMA. 2010;69(2):200-203. Chen K, Chiou CF, Plauschinat CA, Frech F, Harper A, Dubois R. Patient satisfaction with antihypertensive therapy. Cough — if the cough is intolerable (for example it prevents the person from sleeping) and other causes have been ruled out, consider switching to … Address correspondence to: Stefan Vegter, PharmD, Unit of Pharmaco-Epidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands. Formulary. Prescription data between 1999 and 2010 were retrieved from the database, which holds a representative sample of the Dutch population of more than 500,000 individuals. 2000;342(10):748]. Author Affiliations: From Department of Pharmacy (SV, NHN, STV, LJ, MJP, CB), University of Groningen, Groningen, the Netherlands. Morimoto T, Gandhi TK, Fiskio JM, et al. After 3 years of therapy, 24.2% of ACE inhibitor users had switched therapy, compared with 13.1% of ARB users (P <.001). This drug-utilization study in a prescription database of more than 50,000 patients analyzed compliance, persistence, and switching behavior with angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Drug comparisons based on potency Drugs Aging. Patient characteristics varied among users of different ACE inhibitors (Table 1), while users of different ARBs were largely similar. ENTRESTO is contraindicated with concomitant use of ACE inhibitors. Corrao G, Zambon A, Parodi A, et al. 16. Monitoring requirements when switching ACE-inhibitors • Serum Potassium levels • Renal function (Creatinine clearance) • Blood pressure • Care should be taken in patients on diuretic therapy (monitor for hypotension). Toward a standard definition and measurement of persistence with drug therapy: examples from research on statin and antihypertensive utilization.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology. Comparing methods to identify general internal medicine clinic patients with chronic heart failure. World Health Organ Tech Rep Ser. Therefore switching from ACE inhibitors to ARB might be beneficial in patients at risk or with COVID-19 in prevention of such sequelae when they are already on therapy affecting the Renin-Angiotensin System. 3, Zheng, Y., Ma, Y., Zhang, J. et al. 19. ACE to ARB Conversion Table Angiotensin Receptor Blocker (ARB) Dose Conversion Drugs Low Dose Medium Dose High Dose losartan (Cozaar) 125. 36. No such censoring was used in other studies, and as a consequence, these studies failed to detect the similarity in compliance and persistence between drug classes. J Hypertens. N Engl J Med. 45. 2010;27(5):257-284. Drug costs associated with non-adherence to cholesterol management guidelines for primary prevention of cardiovascular disease in an elderly population: the Rotterdam study. The selection and use of essential medicines. These patients cumulated close to 200,000 patient-years of medication use. Risks for the public are minimized by the obliged purchase of coverage and by government-mandated acceptance for basic insurance plans. 2011;65(3):253-263. In terms of drug-utilization characteristics, there appears to be no reason for prescribing more expensive branded ARBs rather than cheaper generic ARBs. The findings also showed no clinical reason to switch from an ARB to an ACE inhibitor to minimize COVID-19 risk. Variations in compliance, persistence, and switching behavior were detected between specific ACE inhibitors, but not between specific ARBs. Switching. Pharmacoepidemiology. Hernandez AF, Harrington RA. Although we adjusted the results for several comorbidities by proxy of comedication, the possibility of residual confounding, influence of treatment history (such as chronic kidney disease), or indication bias remains. ENTRESTO is contraindicated in patients with a history of angioedema related to previous angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy. 2004;13(3):173-179. An extensive meta-analysis calls into question the standard practice of switching from an ACEI to an ARB in patients with type 2 diabetes. If a patient begins to cough and I switch from an ACE inhibitor to an angiotensin receptor blocker (ARB), will the positive bradykinin endothelial and/or the nephroprotective effects be lost? Four-year persistence patterns among patients initiating therapy with the angiotensin II receptor antagonist losartan versus other antihypertensive drug classes. Good and poor adherence: optimal cut-point for adherence measures using administrative claims data. Drugs were systematically classified using the Anatomical Therapeutic Chemical ATC) Classification System of the World Health Organization. In the land of high blood pressure medications, ACE inhibitors and ARBs are pretty standard.That means that if you are being treated for high blood pressure, you’re likely to be on one of these medications.ACE inhibitors and ARBs represent two groups of drugs that treat hypertension, but they differ slightly in how they work and their side effects. Switching from lisinopril to losartan may help reduce the likelihood of developing a dry cough. Validation studies, however, showed good correlation between prescription claims and actual drug use.47 Second, the indication for prescribing was not registered in our database. For years, interruption of the renin-angiotensin-aldosterone system (RAAS) pathway through administration of angiotensin-converting enzyme inhibitors (ACEIs) or, if ACEIs can’t be tolerated, by angiotensin receptor blockers (ARBs), has been standard practice. Like ACE inhibitors, ARBs are associated with changes in renal function and the same monitoring advice for measuring serum creatinine and electrolytes in patients taking ACE inhibitors applies for patients being treated with ARBs. At the same time unoppossed effect of angiotensin II leads to mycardial injury and elevation of blood pressure which are observed in the most severe cases. Based on this he continued to argue that the question is not “should” patients taking medium doses of ACEI or ARB be switched, but rather “how.” He explained that “forcing” patients to up titrate to highest dose of ACEI first (enalapril 10mg twice daily) before switching to the ARNI, may have risks, and is not preferable. Grosso AM, Bodalia PN, Macallister RJ, Hingorani AD, Moon JC, Scott MA. Misdiagnosis and mistreatment of a common side-effect—angiotensin-converting enzyme inhibitorinduced cough. Furthermore, the findings showed no clinical reason to switch from an ARB to an ACE inhibitor to minimize COVID-19 risk. The average prescribed dosage of captopril was below the DDD and did not increase over time. Discontinuation of and changes in drug therapy for hypertension among newly-treated patients: a population-based study in Italy. An evaluation of risk factors for adverse drug events associated with angiotensin-converting enzyme inhibitors. Medication compliance and persistence: terminology and definitions. Value Health. Dusing R. Adverse events, compliance, and changes in therapy. 20. After 3 years of treatment, persistence with ACE inhibitors and ARBs was not significantly different both without and with adjustment for possible confounders (81.9% vs 82.4%, P = .197). Drug compliance (ie, adherence) is defined as “the extent to which a patient acts in accordance with the prescribed interval and dose of a dosing regimen.”33 A common method is the proportion of days covered, calculated as the number of days the patient had access to the drug divided by the number of days in a specified time period.34 This time period was 1 year, starting at therapy initiation. The difference in compliance was small, however (86.1% vs 88.8%), and previous studies found no differences in adverse event rates between ARBs across the approved dosage ranges.16 Therefore, a confounding effect of indication bias or residual confounding cannot be ruled out. Comorbidities were recorded by proxy of comedication, prescribed before or at maximum half a year after initiating RAS inhibiting therapy. Vink NM, Klungel OH, Stolk RP, Denig P. Comparison of various measures for assessing medication refill adherence using prescription data. Enlund H. Measuring patient compliance in antihypertensive therapy—some methodological aspects. Cicardi M, Zingale LC, Bergamaschini L, Agostoni A. Angioedema associated with angiotensin-converting enzyme inhibitor use: outcome after switching to a different treatment. Fixed-dose combinations with diuretics were also included. Lancet. On a group level, ARBs are sometimes proposed to be superior to ACE inhibitors.9 However, comparative studies often fail to demonstrate clinically relevant differences between ACE inhibitors and ARBs, and guidelines commonly suggest they are equivalent for nearly all indications.10, Complicating these matters is the debate surrounding the comparative effectiveness of specific ACE inhibitors and ARBs.11,12 For the specific drugs there is no conclusive evidence on differences in drug efficacy and tolerability. 16 MAR 2016. This section features links to a wide range of clinical resources on equivalent doses and conversions for opioids, benzodiazepines, antidepressants, antipsychotics, corticosteroids and more. Lancet. Compliance, persistence, and switching behavior varied between specific ACE inhibitors but not between specific ARBs. The Md did not say anything about tapering off the beta blocker. The Md did not say anything about tapering off the beta blocker. All statistical analyses were performed using R, version 2.5.1 (the GNU Project, On the drug level, several differences between the ACE inhibitors were detected. Therefore switching from ACE inhibitors to ARB might be beneficial in patients at risk or with COVID-19 in prevention of such sequelae when they are already on therapy affecting the Renin-Angiotensin System. The most frequent prescribed ACE inhibitor was enalapril (37.2%) and the most frequent prescribed ARB was losartan (34.5%); these drugs were used as reference drugs. Prescribe* and document ACE inhibitor or ARB therapy for patients ≥18 years with HF who have a current or prior LVEF < 40%. Document contraindication(s) to ACE/ARB. 29. 23 Most patients will not have increases in serum creatinine that necessitate withdrawal of treatment. Author Disclosures: The authors (SV, NHN, STV, LJ, MJP, CB) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. After excluding 24,805 patients who discontinued or switched treatment, 20,236 ACE inhibitor users and 6140 ARB users were analyzed for 1-year compliance. Different angiotensin-converting enzyme inhibitors have similar clinical efficacy after myocardial infarction. Losartan) appears to be equal to that of atenolol or ACE inhibitors; ARBs and thiazide diuretics may be combined, resulting in additive hypotensive effects. The most frequently prescribed RAS inhibitors were enalapril and losartan. 2009;958:1-242. His Md has switched him to lisinopril 10mg daily. Switching from ACE inhibitors to ARB in preventing severe course of COVID-19 Dear Editor, Angiotensin II receptor blockers (ARB) are currently debated as an option for treatment of coronavirus disease 2019 (COVID-19). 2008;65(2):217-223. Can an ARB be given to patients who have had angioedema on an ACE inhibitor? ACE INHIBITORS AND ARBS CLINICAL GUIDELINE NOVEMBER 2020 CONVERSION TABLES TABLE 2. If used for heart failure with reduced ejection fraction or kidney disease with albuminuria, re-start at a lower dose once serum K < 5.5 mmol/L and then continue to monitor: if the patient was on a combination of ACE or ARB … 2009;27(11):2121-2158. 2002;359(9311):995-1003. In: Strom BL, ed. 2002;16(8):569-575. Authorship Information: Concept and design (SV, NHN, STV, LJ, MJP, CB); acquisition of data (SV, NHN, STV); analysis and interpretation of data (SV, NHN, STV, CB); drafting of the manuscript (SV, MJP, CB); critical revision of the manuscript for important intellectual content (SV, STV, LJ, MJP, CB); statistical analysis (SV, NHN, STV); administrative, technical, or logistic support (STV); and supervision (LJ, MJP, CB). Am Heart J. By design, none of these patients had switched or permanently discontinued RAS therapy. These results support prescribing of cheap generic ARBs as opposed to expensive ARBs. E-mail: [email protected] My blood pressure has been very well controlled (averaging 115/65) for some weeks now but 1) I have that very difficult, dry tickle cough that sometimes comes with ACE inhibitors and 2) my potassium levels have been on the rise. Antihypertensives are a cornerstone in the prevention and treatment of cardiovascular and renal diseases.1 Agents that inhibit the renin-angiotensin system (RAS), which include angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), are especially important. Medical Author: Dwight Makoff, M.D. 38. Candesartan users were less compliant and switched less often compared with users of other ARBs. Several cases described a washout period of less than 36 hours when switching from an ACE inhibitor to Entresto. 2008;68(9): 1207-1225. Furthermore, doctors may switch from an ARB drug to an ACE inhibitor or visa versa. Compliance among users of ramipril (90.4%, P = .05) and fosinopril (91.6%, P = .017) was higher compared with compliance among users of enalapril (87.9%). Vitry A, Lai YH. N Engl J Med. 2001;142(6):1003-1009. Drugs. First, our analysis used prescription data, which did not necessarily reflect actual drug use. The time between the first prescription and the point at which an unacceptable prescription gap occurs was measured.36 The length of this unacceptable gap or “grace period” was 90 days.36,37 In case of overlapping prescriptions, the second prescription was shifted forward to account for drug stockpiling.38 Patients were censored when lost to follow-up or when switching therapy, as switching was analyzed separately. 22. How to titrate ACE inhibitors and angiotensin receptor blockers in renal patients: according to blood pressure or proteinuria? Further evidence emerges supporting ACE inhibitor use in dementia. 1995;273(18): 1450-1456. Angiotensin-Converting Enzyme Inhibitor-Induced Cough ACCP Evidence-Based Clinical Practice Guidelines Peter V. Dicpinigaitis, MD, FCCP Background: A dry, persistent cough is a well-described class effect of the angiotensin-converting enzyme (ACE) inhibitor medications. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. Ace-inhibitor conversions for all of the common ace-inhibitors based on the estimated potency.

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