Dual Therapy with ACE Inhibitors and ARBs

Introduction to Recommended Therapies

The American College of Cardiology recommends against combining lisinopril (an ACE inhibitor) and losartan (an ARB) due to increased risk of adverse effects without additional cardiovascular benefit 1
The European Society of Cardiology states that combining two RAS blockers (ACE inhibitor and an ARB) is not recommended 3
The American Diabetes Association notes that the use of both ACE inhibitors and ARBs in combination is contraindicated given the lack of added ASCVD benefit and increased rate of adverse events 5

First-line antihypertensive medications include ACE inhibitors, ARBs, thiazide-like diuretics, and dihydropyridine calcium channel blockers, as recommended by the European Society of Cardiology and the American Diabetes Association 3, 5
When a single agent is insufficient for blood pressure control, the preferred approach is to combine medications with complementary mechanisms of action, such as ACE inhibitor + calcium channel blocker, ACE inhibitor + thiazide diuretic, ARB + calcium channel blocker, or ARB + thiazide diuretic, as suggested by the American College of Cardiology and the European Society of Cardiology 1, 6, 7

In patients with albuminuria or diabetic nephropathy, either an ACE inhibitor OR an ARB (not both) is recommended as first-line therapy due to their renoprotective effects, according to the American Journal of Kidney Diseases and the American Diabetes Association 2, 5
For patients who cannot tolerate ACE inhibitors, ARBs are an appropriate alternative with similar efficacy, as reported by Circulation and the European Heart Journal 8, 9
Beta-blockers can be added to either an ACE inhibitor or ARB when there are specific indications such as coronary artery disease, post-myocardial infarction, heart failure with reduced ejection fraction, or for heart rate control, as recommended by the European Society of Cardiology 3, 4

When using either an ACE inhibitor OR an ARB, monitor renal function and serum electrolytes within 1-2 weeks after initiation, after dose changes, and during maintenance therapy, as suggested by the European Heart Journal and Circulation 8, 9
Be particularly vigilant in patients with reduced renal function, diabetes, or those taking potassium supplements or potassium-sparing diuretics, as recommended by the American College of Cardiology and the American Diabetes Association 1, 6