2.5.5.2 Angiotensin-II receptor antagonists (AIIRAs/ARBs)

Hypertension
ChoiceDrugDosage
1st choicesLosartan tablets 12.5mg, 25mg, 50mg, 100mgDose: usually 50mg once daily (intravascular volume depletion, initially 25mg once daily); if necessary increased after several weeks to 100mg once daily; Elderly over 75 years initially 25mg daily
Or
Candesartan tablets 2mg, 4mg, 8mg, 16mg, 32mgDose: initially 8mg (intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max 32mg once daily; usual maintenance dose 8mg once daily

Heart Failure
ChoiceDrugDosage
1st choiceCandesartan tablets 2mg, 4mg, 8mg, 16mg, 32mgDose: initially 4mg once daily, increased at intervals of at least 2 weeks to ‘target dose’ of 32mg once daily or to max tolerated dose
2nd choice
Valsartan capsules 40mg, 80mg, 160mg, Dose: initially 40mg twice daily increased at intervals of at least 2 weeks up to max 160mg twice daily

Diabetic nephropathy in type II diabetes mellitus
ChoiceDrugDosage
1st choiceLosartan tablets 12.5mg, 25mg, 50mg, 100mgDose: usually 50mg once daily (intravascular volume depletion, initially 25mg once daily); if necessary increased after several weeks to 100mg once daily; Elderly over 75 years initially 25mg daily
2nd choiceIrbesartan tablets 75mg, 150mg, 300mgDose:
initially 150mg once daily, increased to 300mg once daily if tolerated (in haemodialysis or in elderly over 75 years, consider initial dose of 75mg once daily)

Prescribing Notes

  • Refer to NICE NG136 – Hypertension in adults: diagnosis and management – August 2019.
  • ARBs should be reserved for patients who develop a persistent cough or intolerance with/to ACE inhibitors.
  • Monitoring requirements are the same for ACE inhibitors and ARBs.
  • ACE inhibitors and ARBs are contra-indicated in pregnancy and should be avoided in patients who become pregnant.
  • The combination of an ACE inhibitor and ARB may cause increased adverse events and is not usually recommended. Refer to MHRA advice. Occasionally in heart failure and under secondary care supervision only, candesartan may intentionally be combined with an ACE inhibitor (in patients meeting CHARM-added inclusion criteria).
  • For the prescribing of sacubitril/valsartan (Entresto) refer to NICE TA388. Treatment with sacubitril valsartan should be started by a heart failure specialist with access to a multidisciplinary heart failure team. Dose titration and monitoring should be performed by the most appropriate team member as defined in NICE NG106 Chronic heart failure in adults.

Cautions

  • Patients taking ACE inhibitors or ARBs should be informed that they are at an increased risk of acute kidney injury if they develop an illness associated with hypovolaemia and hypotension. ACE inhibitors and ARBs should be stopped temporarily.
  • As elderly patients are at particular risk of renal impairment, renal function should be monitored pre-treatment in patients taking ARBs. Regular U&E checks may be needed after initiation.
  • ARBs should be used with care or avoided in aortic stenosis or outflow tract obstruction.
  • Caution is required in patients who may have renovascular disease. ARBs should be used with caution in patients with renal artery stenosis.