Indications

• Congestive Heart Failure (CHF) (see Congestive Heart Failure)
• Diabetic Nephropathy (see Diabetes Mellitus)
• Hypertension (see Hypertension)

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Pharmacology

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Administration

Oral (PO)

• Dose: XXXX

Dose Adjustment

• Hepatic:
• Renal:

Concomitant Administration of ACE Inhibitors and ARB’s (see Angiotensin Converting Enzyme Inhibitors and see Angiotensin II Receptor Blockers)

• Combination ACE Inhibitor and ARB Therapy Increases the Risk of Adverse Effects (Arch Int Med, 2007) [MEDLINE]: including hyperkalemia, medication discontinuation due to adverse effects, worsened renal function, and symptomatic hypotension
  • Combination ACE Inhibitor and ARB Therapy Does Not Increase the Rate of Malignancy (J Hypertens, 2011) [MEDLINE]
  • Recommendation: it is recommended to not use combination ACE inhibitor and ARB therapy

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Adverse Effects

Allergic/Immunologic Adverse Effects

Angioedema (see Angioedema)

• Epidemiology
  • Less common with ARB’s than with ACE Inhbitors
  • Telmisartan (0.1%) Has a Lower Incidence of Angioedema than Ramipril (0.3%) (NEJM, 2008) [MEDLINE]
  • Cross-Reactivity
    • In Patients with ACE-inhibitor-Associated Angioedema, the Risk of Development of Any Subsequent ARB-Associated Angioedema is 2-17%
    • In Patients with ACE-inhibitor-Associated Angioedema, the Risk of Development of Subsequent Confirmed ARB-Associated Angioedema is 0-9.2%
• Physiology
  • Class Effect, Which is Common to All ARB’s (see Angiotensin II Receptor Blockers)

Cardiovascular Adverse Effects

Hypotension (see Hypotension)

• Epidemiology
  • More Common with ARB’s than with ACE Inhibitors
  • Telmisartan Has a Significantly Higher Rate of Symptomatic Hypotension (2.6%) vs Ramipril (1.7%) (NEJM, 2008) [MEDLINE]
• Physiology
  • Class Effect, Which is Common to All ARB’s (see Angiotensin II Receptor Blockers)
  • Due to Basic Pharmacology of ARB’s (see Angiotensin II Receptor Blockers)

Syncope (see Syncope)

• Epidemiology
  • Ramipril (0.2%) and Telmisartan (0.2%) Have Similar Rates of Syncope Requiring Discontinuation of the Drug (NEJM, 2008) [MEDLINE]

Endocrinologic Adverse Effects

Drug-Induced Hypoaldosteronism (see Hypoaldosteronism)

• Clinical
  • Hyperkalemia (see Hyperkalemia)
  • Non-Anion Gap Metabolic Acidosis (see Metabolic Acidosis-Normal Anion Gap)

Pulmonary Adverse Effects

Cough (see Cough)

• Epidemiology
  • Less common with ARB’s than with ACE-Inhibitors
  • Ramipril has higher incidence of cough (4.2%) than telmisartan (1.1%) (NEJM, 2008) [MEDLINE]
• Physiology
  • Class Effect, Which is Common to All ARB’s (see Angiotensin II Receptor Blockers)

Renal Adverse Effects

Acute Kidney Injury (AKI) (see Acute Kidney Injury)

• Epidemiology
  • Ramipril (1.9%) and telmisartan (2.0%) demonstrate similar rates of AKI, as defined by doubling of serum creatinine (NEJM, 2008) [MEDLINE]

Hyperkalemia (see Hyperkalemia)

• Epidemiology
  • Similar Rates of Hyperkalemia are Observed with Ramipril (3.3%) and Telmisartan (3.4%) (NEJM, 2008) [MEDLINE]
• Physiology
  • Due to Drug-Induced Hypoaldosteronism (See Above)

Non-Anion Gap Metabolic Acidosis (see Metabolic Acidosis-Normal Anion Gap)

• Physiology
  • Due to Drug-Induced Hypoaldosteronism (See Above)

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References

• xxxx