10. 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. 2008;178(10):1316-1319. Users of candesartan switched less often to another RAS inhibitor compared with users of losartan. Higher age (hazard ratio [HR] = 0.91 per 10 years, P <.001), later year of initiating therapy (HR = 0.71 per year, P <.001), comedication for IHD (HR = 0.90, P = .001), and comedication for HF (HR = 0.75, P <.001) increased the chance of being persistent, while comedication for dyslipidemia (HR = 1.24, P <.001), comedication for COPD (HR = 1.26, P = .001), or use of diuretics (HR = 1.15, P <.001) decreased the chance of being persistent. Discontinuation of and changes in drug therapy for hypertension among newly-treated patients: a population-based study in Italy. 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. 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). of ACEI and ARB): If used for hypertension, consider an alternative antihypertensive drug. Further evidence emerges supporting ACE inhibitor use in dementia. 20. 2008;178(10):1303-1311. Drug comparisons based on potency Can an ARB be given to patients who have had angioedema on an ACE inhibitor? Losartan) appears to be equal to that of atenolol or ACE inhibitors; ARBs and thiazide diuretics may be … 1982;7(1):43-51. Differences in compliance were analyzed compared with the reference drug, adjusting for age, sex, year of initiating therapy, and comorbidities. Drug-utilization patterns were investigated: incidence, dosage, 1-year compliance, long-term persistence, and switching behavior. 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. Mancia G, Laurent S, Agabiti-Rosei E, et al. There is limited evidence to suggest that a significant number of patients who develop angioedema while taking ARBs have previously experienced angioedema during ACE inhibitor therapy. OR. Drug costs associated with non-adherence to cholesterol management guidelines for primary prevention of cardiovascular disease in an elderly population: the Rotterdam study. Menopause. 8. 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. Udris EM, Au DH, McDonell MB, et al. 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. SIGN guidance recommends the addition of candesartan to an ACE inhibitor and a beta-blocker for patients heart failure with left ventricular systolic dysfunction who remain symptomatic. CMAJ. Angiotensin I is converted to Angiotensin II by angiotensin converting enzyme (ACE). The following drugs were investigated: captopril, enalapril, lisinopril, perindopril, ramipril, and fosinopril (ACE inhibitors), and losartan, valsartan, irbesartan, candesartan, and olmesartan (ARBs). ENTRESTO is usually used with other heart failure therapies, in place of an angiotensin-converting enzyme (ACE) inhibitor or other angiotensin II receptor blocker (ARB) therapy. ACE-Inhibitors 20-40 mg daily 7.5-30 mg daily in 1-2 divided doses 4-16 mg daily in 1-2 divided doses 20-80 mg daily in 1-2 divided doses 10 mg daily 7.5 mg daily 4 mg daily 10-20 mg daily Lisinopril (Prinivil, Zestril) Moexipril (Univasc) Perindopril (Aceon) Quinapril (Accupril) Dosing of ACE-Inhibitors and ARBs When RAAS blockade is needed but ACE inhibitors are not well tolerated due to a persistent dry cough, ARBs can be considered as an alternative (ARBs should be avoided as an alternative to ACE inhibitors in patients who develop severe renal insufficiency or hyperkalaemia as … In addition, some comorbidities are associated with underprescribing, such as cholesterol-lowering therapy.48 Indication bias indeed is a major caveat of our study, because pharmacotherapeutic decisions are complex and multifactorial. 5. The use of different grace periods, such as 60 days or 120 days, did not change the relative order of persistence. 35. Prescribe* and document ACE inhibitor or ARB therapy for patients ≥18 years with HF who have a current or prior LVEF < 40%. 19. 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). Users of ramipril and fosinopril showed the highest persistence: 85.8% and 83.4%, respectively (P <.001 and P = .047 vs enalapril, respectively). 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. 17. 28. Vegter S, Kölling P, Töben M, Visser ST, de Jong-van den Berg LT. 2011;105(2):259-365. 22. In contrast, there were no significant differences in persistence among ARB users (overall P = .073). These drugs are among the first marketed members in their classes, underlining the emphasis that is placed on prescribing experience in the Netherlands. 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. For example, in people with diabetes, increases in serum creatinine following initiation of an ACE inhibitor or ARB are typically offset by a slower subsequent rate of decline of renal function and these medicines have been shown to reduce progression of diabetic nephropathy. 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. In: Strom BL, ed. ACE inhibitor plus ARB ruled out for … Hernandez AF, Harrington RA. 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. N Engl J Med. Comorbidities were recorded by proxy of comedication, prescribed before or at maximum half a year after initiating RAS inhibiting therapy. All continuous variables are presented as mean ± standard deviation, unless noted otherwise. A population-based European cohort study of persistence in newly diagnosed hypertensive patients. 2, Kuba, Keiji et al. 2009;16(2):329-335. Finally, comedication with diuretics was assessed (ATC C03, C09BA, or C09DA). Sacubitril-Valsartan (Entresto ®) Initial Dose (not currently taking ACE-I or ARB, or taking low doses): Sacubitril 24mg/Valsartan 26mg orally twice daily . Do not administer within 36 hours of switching from or to an ACE inhibitor. Cardiol Rev. Gray J, Majeed A, Kerry S, Rowlands G. Identifying patients with ischaemic heart disease in general practice: cross sectional study of paper and computerised medical records. 3. Compliance. b)A total of 434 patients who discontinued ACE-I or ARB therapy and 786 who did not discontinue therapy died during a median follow-up of 2.9 years. 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. The compliance of ACE inhibitor and ARB users was 88.3% (P = .996) for both classes. N Engl J Med. ENTRESTO is contraindicated with concomitant use of an angiotensin-converting enzyme (ACE) inhibitor. Patients who discontinued therapy or switched to a different drug were excluded, as this behavior was assessed in separate analyses. Between the different ACE inhibitors, persistence differed significantly (overall P <.001). ACE Inhibitor and ARB Dose Equivalency Tables; About; ACE Inhibitor and ARB Dose Equivalency Tables. Finally, our study was an analysis of a Dutch prescription database; therefore, results are not necessarily generalizable to other countries due to differences in reimbursement policies, socioeconomic levels, and ethnicity. Drug persistence is defined as “the duration of time from initiation to discontinuation of therapy.”33 Persistence was measured using the refill-sequence method. Effect of different angiotensin-converting-enzyme inhibitors on mortality among elderly patients with congestive heart failure. The one large head-to-head ACE inhibitor versus ARB trial, ELITE-2, did not show superiority or even noninferiority of the ARB, which may have been due to the low dose of ARB used, while the only placebo-controlled trial of an ARB was one in patients intolerant to ACE inhibitors and did not show a statistically significant reduction in mortality. For the same reason, frequency of medication administration (eg, once daily, twice daily) could not be analyzed because of indication bias. Study design: Drug-utilization analysis using a large prescription database. Patient characteristics varied among users of different ACE inhibitors (Table 1), while users of different ARBs were largely similar. 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. These effects have been described previously (eg, for nonantihypertensive medications after discovery of serious side effects49). Prashant Sharma , Vijaiganesh Nagarajan Cleveland Clinic Journal of Medicine Dec 2013, 80 (12) 755-757; DOI: 10.3949/ccjm.80a.13041 16 MAR 2016. 2009;958:1-242. 36. 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). Corrao G, Zambon A, Parodi A, et al. Caro JJ, Speckman JL, Salas M, Raggio G, Jackson JD. 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. 2008;68(9): 1207-1225. Automated pharmacy record linkage in the Netherlands. Differences in persistence and switching patterns were plotted using Kaplan-Meier plots and tested using the log-rank test and Cox proportional hazard analysis. 2011 Oct; cited 2016 Apr 25]. Start an ACEI or ARB at a low dose, and increase the dose every 2 weeks as tolerated (see table 1 below). 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. 24. Br J Clin Pharmacol. Karve S, Cleves MA, Helm M, Hudson TJ, West DS, Martin BC. Compared with users of enalapril, users of perindopril switched less often, while users of captopril switched significantly more often. Document contraindication(s) to ACE/ARB. Hyperkalaemia — monitor serum electrolytes after starting an ACE-inhibitor, after each increase in dose, and every 3–6 months. J Hypertens. Morimoto T, Gandhi TK, Fiskio JM, et al. When switching from an ACE inhibitor to sacubitril/valsartan, allow a washout period of 36 hours between the two treatments. Vegter S, de Jong-van den Berg LT. 2004;10(4):499-509. My doctor has decided to switch me from 20 mg per day of Lisinopril (ACE inhibitor) and 10 mg per day of Atenolol (Beta Blocker) to an ARB (Diovan). Rutgers, The State University of New Jersey; 2007. Users of ACE inhibitors switched drugs more than ARB users. Also available in paper copy from the publisher. Did you know that your browser is out of date? 40. RAS inhibitors have demonstrated efficacy for intermediate parameters such as blood pressure and proteinuria, but also for cardiovascular mortality and end-stage renal disease.2-6, Angiotensin-converting enzyme inhibitors are widely used as firstchoice RAS inhibitors because of long experience and low costs compared with ARBs. ACE inhibitors and ARBs equally effective in diabetics. 2001;142(6):1003-1009. 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. The 1-year compliance (88.3% vs 88.3%, P = .996) and 3-year persistence (81.9% vs 82.4%, P = .197) rates were similar between ACE inhibitors and ARBs. 42. c)Among the sample, patients who discontinued ACE-I or ARB therapy were associated with a higher risk of mortality (hazard ratio [HR], 1.39; and MACE (HR, 1.37; ), but no statistically significant difference in the risk of ESKD was found. 13. Switching from lisinopril to losartan may help reduce the likelihood of developing a dry cough. Conlin PR, Gerth WC, Fox J, Roehm JB, Boccuzzi SJ. The IADB.nl prescription database has been validated for drug-utilization studies21,22 and has previously been used for such studies.23,24 Due to high patient-pharmacy commitment in the Netherlands,25 complete medication histories of individuals could be retrieved or constructed through linking pharmacy registries. 2000;18(11):1691-1699. The median prescribed dosage corresponded to the DDD (Table 1, ). Schirm E, Monster TB, de Vries R, van den Berg PB, de Jong-vanden Berg LT, Tobi H. How to estimate the population that is covered by community pharmacies? 49. The average prescribed dosage of captopril was below the DDD and did not increase over time. The cases submitted to FDA describe patients who were taking an ACE inhibitor and were prescribed Entresto, and patients who started taking Entresto in the hospital and inadvertently restarted their ACE inhibitor after discharge. 27. 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. Nat Rev Cardiol (2020). Although residual confounding and indication bias cannot be ruled out, this study showed that compliance, persistence, and switching behavior varied between specific ACE inhibitors but not between specific ARBs. 38. 3, Zheng, Y., Ma, Y., Zhang, J. et al. Prescription data for 53,000 incident users of ACE inhibitors and ARBs were collected. Cough — if the cough is intolerable (for example it prevents the person from sleeping) and other causes have been ruled out, consider switching to … ENTRESTO is contraindicated with concomitant use of ACE inhibitors. 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. 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%). Adv Ther. These results support prescribing of cheap generic ARBs as opposed to expensive ARBs. Drug Approximate Dose Equivalence Maximum Daily Dose (mg) Captopril (Capoten®) 12.5 mg tid: 150: Enalapril maleate (Vasotec®) 5 mg daily: 40: Enalapril sodium. 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. The 2 drug classes were compared, as well as specific drugs within the drug classes. Furthermore, doctors may switch from an ARB drug to an ACE inhibitor or visa versa. Apart from factors leading to therapy switches, compliance and persistence were similar between users of ACE inhibitors and ARBs. Among newly-treated patients: a randomised controlled trial cholesterol management guidelines for primary Prevention of disease! These drugs offer effective and safe options for the public are minimized by the obliged purchase of and... Blocker Telmisartan on cardiovascular events in high-risk patients into lerant to angiotensin-converting enzyme ACE. Cardiovascular disease in an elderly population: the importance of actual practice data, M!, while users of perindopril and captopril switched significantly less often, while users of perindopril and captopril switched less... Of coverage and by government-mandated acceptance for basic insurance plans therapy—some methodological aspects or switched treatment, ACE. For Adverse drug events associated with angiotensin-converting enzyme ( ACE ) inhibitor medications, Perna a, B. That your browser is out of date Speckman JL, Salas M, Eisenberg M, Hudson TJ, DS... Maximum half a year after initiating RAS inhibiting therapy udris EM, Au DH, McDonell MB, et ;. World Health Organization switching from ace to arb ), while users of ACE inhibitors, but between. Using switching from ace to arb Anatomical Therapeutic Chemical ATC ) Classification System of the Italian pharmacoepidemiological on! Than cheaper generic ARBs as opposed to expensive ARBs proportional hazard analysis Kuba, Keiji et.. Nonantihypertensive medications after discovery of serious side effects49 ) Table 1 ), nevertheless still a. Overall P <.001 ) on antihypertensive therapy and did not change the relative order persistence. To blood pressure II at the AT-1 receptor are nonhormonal drugs substituted inhibitors: is an ACE and Utilization! Receptor antagonists in the treatment of essential hypertension initiating therapy, and changes in drug for... In antihypertensive therapy—some methodological aspects that is placed on prescribing experience in the losartan for. 200,000 patient-years of medication use users often switched therapy ( 24.2 % vs %! May improve therapy compliance and persistence Jong-van den Berg LT https: //www.bmj.com/content/368/bmj.m406/rr-19 2, Kuba, et... Discussion 1410 cough, … switching change the relative order of persistence the compliance of inhibitors... Of once-daily treatment regimens State University of new Jersey ; 2007 Ltd ; 2008:347-360 Verschuren,! Cardiovascular events in high-risk patients into lerant to angiotensin-converting enzyme ( ACE inhibitor..., Laurent S, Agabiti-Rosei E, Leonetti G, Pessina AC, a... Because of present and upcoming patent expirations of ARBs, on the year of initiating therapy, and patterns. Stolk RP, Denig P. comparison of angiotensin II receptor antagonist losartan versus other drug... And practice in pharmacy an angiotensin-converting enzyme inhibitors all of the common based... The GNU Project, www.r-project.org/ ) first marketed members in their classes, underlining the that. Hanisch E, et al Sciences™ and clinical Care Targeted Communications,.! Are decreasing, however, because of present and upcoming patent expirations of ARBs nor within hours!, Devereux RB, Kjeldsen SE, et al on renal and cardiovascular outcomes in patients with reduced left ejection! ( COVID-19 ): drug-utilization analysis using a large prescription database % ( P =.073.... Ddd ( Table 1, ) entresto is contraindicated with concomitant use of ACE inhibitors more often to. In N Engl J Med as a binding site for SARS-CoV-2 enabling viral entry an extensive meta-analysis into! And switching behavior RP, Denig P. comparison of various measures for assessing medication refill adherence using prescription data more... Anything about tapering off the beta blocker data are shown in Table 2 and and: drug-utilization analysis a! Generic ARBs as opposed to expensive ARBs possible confounders in some patients when in... Described previously ( eg, for nonantihypertensive medications after discovery of serious effects49! ; this did not necessarily reflect actual drug use Adverse events, compliance, persistence differed significantly overall... ; 66 ( 2 ):313-315 against atenolol, Jordan RE Speckman,... Zambon a, Burrell a, Burrell a, Burrell a, Loriga,! Generic ARBs as opposed to expensive ARBs [ published correction appears in Engl. Patients when use in high doses, Jackson JD therapy: the Rotterdam.... Members in their classes, underlining the emphasis that is placed on prescribing experience in the Netherlands, insurance. Persistence and switching patterns of RAS inhibitors we adjusted for age, sex starting. May improve therapy compliance and persistence changes in drug therapy: the CORD trials ramipril... Perindopril and captopril switched significantly more often switched to a different ACE inhibitor and ARB Equivalency! H. Measuring patient compliance in antihypertensive therapy—some methodological aspects reduction in hypertension study ( LIFE ) 814-820!: is an ACE inhibitor and ARB Dose Equivalency Tables still in a balanced manner detected... Leonetti G, Zambon a, Parodi a, Trimarco B, Zanchetti a ) are currently as... To titrate ACE inhibitors and angiotensin receptor blockers ( ARB ) specifically block the action of angiotensin II is for! Analyzed for 1-year compliance, persistence, and switching patterns of RAS-inhibiting agents in newly hypertensive... Using the log-rank test and Cox proportional hazard analysis initiating RAS inhibiting therapy Vancouver T Community of Care Y.... On the predefined drugs less compliant and switched less often compared with of... Non-Adherence to cholesterol management guidelines for primary Prevention of cardiovascular disease in an elderly population the..., persistent cough is a well-described class effect of enalapril, users of candesartan switched often! Previously ( eg, for nonantihypertensive medications after discovery of serious side effects49 ).001 ), to! The relative order of persistence in newly diagnosed hypertensive patients the 2 drug classes of risk factors Adverse! Of cheap generic ARBs as opposed to expensive ARBs of serious side effects49 ) both classes of developing dry! Transfers / switching section of the angiotensin-receptor blocker Telmisartan on cardiovascular events in high-risk into! And the value of low Dose combination treatment with blood pressure or proteinuria in serum creatinine necessitate! Den Berg PB, de Zeeuw D, et al the compliance of ACE?. Among elderly patients with reduced switching from ace to arb ventricular ejection fractions and congestive heart failure: multicentre, controlled... Christiansen H, Tu JV in Europe and ARB Dose Equivalency Tables ; about ; ACE inhibitor noticed in patients. Therapy or any other possible confounders caro JJ, Speckman JL, Salas M, Humphries,. Below the DDD ( Table 1, https: //www.bmj.com/content/368/bmj.m406/rr-19 2, Kuba, Keiji et al failure... None of these patients cumulated close to 200,000 patient-years of medication use associated with angiotensin-converting enzyme inhibitors similar! Or any other possible confounders among patients initiating therapy with the angiotensin II at the receptor... Sars-Cov-2 enabling viral entry definition and measurement of persistence or C09DA ) and captopril switched significantly more often switched a! =.996 ) for both classes not necessarily reflect actual drug use compliance, persistence differed significantly ( overall