ACE Inhibitors vs. ARBs

  • Medical Editor: John P. Cunha, DO, FACOEP
    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

View the High Blood Pressure (Hypertension) Slideshow Pictures

ACE Inhibitors vs. ARBs

What are ACE Inhibitors and ARBs?

ACE inhibitors (angiotensin converting enzyme inhibitors) work by preventing a natural body substance called angiotensin I from converting into angiotensin II, which cases blood vessels to narrow and constrict. By preventing this change, the blood vessels remain relaxed and blood pressure decreases.

ARBs (angiotensin-receptor blockers) also affect angiotensin, but they prevent angiotensin II from binding to an area on blood vessels called receptors. They have the same result as ACE inhibitors in that blood vessels remain relaxed and blood pressure decreases.

What are the side effects of ACE inhibitors and ARBs?

ACE Inhibitors

ACE inhibitors are well-tolerated by most individuals. Nevertheless, they are not free of side effects, and some patients should not use ACE inhibitors.

ACE inhibitors usually are not prescribed for pregnant women because they may cause birth defects.

Individuals with bilateral renal artery stenosis (narrowing of the arteries that supply the kidneys) may experience worsening of kidney function, and people who have had a severe reaction to ACE inhibitors probably should avoid them.

The most common side effects are:

It may take up to a month for coughing to subside, and if one ACE inhibitor causes cough it is likely that the others will too. The most serious, but rare, side effects of ACE inhibitors are:

ARBs

ARBs are well tolerated by most individuals. The most common side effects are

Compared to ACE inhibitors, cough occurs less often with ARBs.

Serious side effects of ARBs:

  • The most serious, but rare, side effects are
    • kidney failure,
    • liver failure (hepatitis),
    • serious allergic reactions,
    • a decrease in white blood cells,
    • a decrease in blood platelets, and
    • swelling of tissues (angioedema).
  • There have been reports of rhabdomyolysis (destruction of skeletal muscle) in patients receiving ARBs.
  • Individuals who have narrowing of both arteries that supply the kidneys or have had a severe reaction to ARBs should avoid them.
  • Like other antihypertensives, ARBs have been associated with sexual dysfunction.

What drugs interact with ACE inhibitors and ARBs?

ACE inhibitors

ACE inhibitors have few interactions with other drugs.

  • Since ACE inhibitors may increase blood levels of potassium, the use of potassium supplements, salt substitutes (which often contain potassium), or other drugs that increase the body's potassium may result in excessive blood potassium levels.
  • ACE inhibitors also may increase the blood concentration of lithium (Eskalith, Lithobid) and lead to an increase in side effects from lithium.
  • There have been reports that aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Advil, Children's Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever etc.), indomethacin (Indocin, Indocin-SR), and naproxen (Anaprox, Naprelan, Naprosyn, Aleve) may reduce the blood pressure lowering effects of ACE inhibitors.
  • Patients receiving diuretics may experience excessive reduction in blood pressure when ACE inhibitors are started. Stopping the diuretic or increasing salt intake prior to taking the ACE inhibitor may prevent excessive blood pressure reduction. Close supervision for at least two hours after the start of ACE inhibitors and until blood pressure is stable is recommended if the diuretic cannot be stopped.
  • ACE inhibitors should not be combined with ARBs because such combinations increase the risk of hypotension, hyperkalemia, and renal impairment.
  • Ace inhibitors should not be combined with aliskiren (Tekturna), another class of drugs that is used to treat high blood pressure because such combinations increase the risk of kidney failure, excessive low blood pressure, and hyperkalemia.
  • Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and low blood pressure) may occur when injectable (gold sodium aurothiomalate [Myochrysine]), used in the treatment of rheumatoid arthritis, is combined with ACE inhibitors.

ARBs

ARBs have few interactions with other drugs.

  • Since ARBs may increase blood levels of potassium, the use of potassium supplements, salt substitutes (which often contain potassium), or other drugs that increase potassium may result in excessive blood potassium levels and cardiac arrhythmias.
  • ARBs may also increase the blood concentration of lithium (Eskalith, Lithobid) and lead to an increase in side effects from lithium.
  • Rifampin (Rifadin) reduces the blood levels of losartan, and fluconazole (Diflucan) reduces the conversion of losartan to its active form. These effects could decrease the effects of losartan.
  • ARBs should not be combined with ACE inhibitors because such combinations increase the risk of hypotension, hyperkalemia, and renal impairment.
  • ARBs should not be combined with aliskiren (Tekturna) because such combinations increase the risk of kidney failure, excessive low blood pressure, and hyperkalemia.

What are the different types of ACE inhibitors and ARBs?

ACE Inhibitors

The following is a list of the ACE inhibitors that are available in the United States:

  • benazepril (Lotensin)
  • captopril (Capoten- discontinued brand)
  • enalapril (Vasotec, Epaned, [Lexxel- discontinued brand])
  • fosinopril (Monopril- Discontinued brand)
  • lisinopril (Prinivil, Zestril, Qbrelis)
  • moexipril (Univasc- Discontinued brand)
  • perindopril (Aceon)
  • quinapril (Accupril)
  • ramipril (Altace)
  • trandolapril (Mavik)

ARBs

The following is a list of currently available ARBs:

  • azilsartan (Edarbi)
  • candesartan (Atacand),
  • eprosartan (Teveten),
  • irbesartan (Avapro),
  • telmisartan (Micardis),
  • valsartan (Diovan),
  • losartan (Cozaar), and
  • olmesartan (Benicar).

FDA Prescribing Information

Quick GuideHow to Lower Blood Pressure: Exercise Tips

How to Lower Blood Pressure: Exercise Tips

Subscribe to MedicineNet's Heart Health Newsletter

By clicking Submit, I agree to the MedicineNet's Terms & Conditions & Privacy Policy and understand that I may opt out of MedicineNet's subscriptions at any time.

FDA Logo

Report Problems to the Food and Drug Administration

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.

Reviewed on 10/5/2017
References
FDA Prescribing Information

Health Solutions From Our Sponsors