Alternative to Lisinopril in ACE Inhibitor Allergy

Primary Recommendation: ARBs as First-Line Alternative

The American College of Cardiology recommends switching to an angiotensin receptor blocker (ARB) such as losartan 50mg daily or valsartan 160mg daily as the preferred alternative to lisinopril when a patient has an ACE inhibitor allergy 1
ARBs are the recommended alternative for patients who cannot tolerate ACE inhibitors due to allergy or adverse effects, according to the American College of Cardiology and American Heart Association 1, 2
The 2018 ACC/AHA hypertension guidelines explicitly list multiple ARB options as alternatives to ACE inhibitors for blood pressure management, including losartan 50-100mg once daily, valsartan 80-320mg once daily, irbesartan 150-300mg once daily, candesartan 8-32mg once daily, and telmisartan 20-80mg once daily 1

If the patient's "allergy" to lisinopril was angioedema, exercise extreme caution when prescribing an ARB, as cross-reactivity can occur, according to the American College of Cardiology and American Heart Association 2
Wait at least 6 weeks after discontinuing the ACE inhibitor before initiating an ARB in patients with prior angioedema, as recommended by the American College of Cardiology 1

The combination of amlodipine plus an ARB, such as valsartan, is explicitly recommended in guidelines as effective dual therapy for stage 2 hypertension, according to the American College of Cardiology 1

Initiate losartan 50mg daily or valsartan 160mg daily, and titrate to maximum dose if blood pressure remains uncontrolled, as recommended by the American College of Cardiology 1
Monitor blood pressure at monthly intervals until control is achieved, and check renal function and potassium within 2-4 weeks of initiation, similar to monitoring with ACE inhibitors 1, 4

Beta-blockers are not recommended as first-line alternatives unless the patient has specific indications like heart failure with reduced ejection fraction, post-MI status, or coronary artery disease, according to the American College of Cardiology and American Heart Association 1, 5

Do not combine ACE inhibitors with ARBs, as this increases risk of hyperkalemia, hypotension, and renal dysfunction without improving outcomes, according to the American College of Cardiology and American Heart Association 1, 2
Avoid ARBs in pregnancy, as they carry the same fetal risk as ACE inhibitors, according to the American College of Cardiology 1, 3
Monitor for hyperkalemia, especially if the patient has chronic kidney disease or is on potassium supplements, as recommended by the American College of Cardiology 1