Alternatives To Lisinopril & Losartan
In our latest question and answer, our pharmacist discusses possible alternatives to lisinopril (ACE-Inhibitor) & Losartan (ARB - Angiotensin Receptor Blocker).
I have been on Losartan/Hcz 100mg/12.5mg for approximately 3 years. My BP has been running around 104/60. Within the last year I have developed most of the rare conditions. In the last 3 months I have seen a Gastroenterologist and been diagnosed with Autoimmune Atrophic Gastritis. I have also seen a Rheumatologist and been diagnosed with Fibromyalgia . My alternative medicine doctor has been testing me and keeps telling me my body doesn't like the Losartan. Just in the last week or so I have been cutting my meds in half and I have been feeling better, BP running round 135/70 something and I don't have the extreme body aches, my stomach has been better and my urine isn't a dark yellow and I'm not as fatigued. I have been trying to research a blood pressure medication that I could switch to without the same side affects but have not been having very good luck. Can you help me find an alternative to Losartan? I was on Lisinopril but gave me a chronic cough that's when I switched to Losartan.
There are many alternative blood pressure medications to the drugs you have tried already. The choice of your next medication should be a decision between your doctor and yourself, but we can certainly give you some guidance based on the latest blood pressure guidelines from the Eighth Joint National Committee (JNC VIII).
To start off, you have tried drugs from two different classes of medications, ACE-Is (Angiotensin Converting Enzyme Inhibitors) and ARBs (Angiotension II Receptor Blockers). Both of these drugs modulate the 'renin-angiotension-aldosterone' system, also known as RAAS.
The graphic above looks somewhat complicated but it gives you a visual to better understand how these drugs work and how they all affect the same system in our bodies.
Lisinopril inhibits the ACE enzyme, which stops the conversion of angiotensin I to angiotensin II. Angiotensin II has a wide range of effects on the body including vasoconstriction, which raises blood pressure. As such, reducing angiotensin II produces vasodilation (among other effects), which reduces blood pressure. In addition, ACE-Inhibitors such as lisinopril inhibit the release of aldosterone, a hormone that regulates sodium/potassium in the blood.
ACE-Inhibitor medications work well and are often considered first line therapy for the treatment of blood pressure. Unfortunately, they are very much associated with a dry, irritating cough. The cough isn't thought to cause harm aside from being irritating. Many patients find the cough too troublesome and choose to find a different, more tolerable medication.
Losartan works one step further in the RAAS system. It is an angiotension II blocker and interferes with the binding of angiotensin II to its receptors. This leads to lower blood pressure and overall vasodilation. ARB drugs tend to be just as effective as ACE-Inhibitors and aren't associated with causing a cough. However, if you are having problems with losartan as well, we need to look at other classes.
There is one more drug that directly affects the RAAS system and that is Tekturna (aliskiren). Tekturna is a direct renin inhibitor, which is one of the first pathway steps in the RAAS system (see image above). Renin converts angiotensinogen to angiotension I. Inhibiting renin stops this conversion, which leads to an overall decrease in angiotensin II and aldosterone.
The problem with Tekturna is that it doesn't have a real advantage over ACE-Is and ARBs. It is more expensive and there is limited data on how Tekturna affects overall outcomes in terms of heart attack and stroke rates. There have been a few studies that show that Tekturna is no more effective than the other drugs and may cause the same side effects. It certainly could be an option for you but if you want to avoid drugs that directly affect the RAAS system, there are other alternatives.
Past ACE-I and ARB medications, the JNC VIII guidelines recommend the following as possible options:
- Thiazide Diuretics
- Calcium Channel Blockers
- Beta Blockers
The most commonly used class of blood pressure medications (outside ACE-Is & ARBs) are the thiazide diuretics. These include hydrochlorothiazide and chlorthalidone. Often times, these are added on to other blood pressure medications and work synergistically.
There are many different factors that can influence the appropriate choice for you. Your race needs to be taken into consideration (African Americans tend not to respond well ACE-Is for example) as well as your compelling indications (e.g. Diabetes, Chronic Kidney Disease). The JNC VIII guidelines, as well as other guidelines, recommend different drugs for different situations.
It is best to have a conversation with your doctor to go over your options to pick the best alternative therapy for you. As we have shown, there are many possibilities.