Switching from ACE Inhibitors to ARBs

Rationale for Switching

ACE inhibitors and ARBs are both effective antihypertensive medications that work on the renin-angiotensin-aldosterone system (RAAS), but through different mechanisms, as stated by the American Journal of Kidney Diseases 1
Common reasons for switching from an ACE inhibitor to an ARB include ACE inhibitor-induced cough, which does not occur with ARBs, according to the European Journal of Heart Failure 2
Angioedema with ACE inhibitors is another reason for switching, as ARBs have a lower risk, as noted by the European Journal of Heart Failure 2

For patients switching to sacubitril/valsartan (ARNI), a 36-hour washout period is required between stopping an ACE inhibitor and starting an ARNI due to increased risk of angioedema when these mechanisms overlap, as recommended by Circulation 4, 5
For patients with a history of angioedema with ACE inhibitors, consider a longer washout period, although the specific guideline society was not mentioned 3

Monitor blood pressure within 1-2 weeks after switching to ensure adequate control, as suggested by the American Journal of Kidney Diseases 6
Check serum creatinine and potassium within 1-2 weeks, especially in patients with pre-existing kidney dysfunction, according to the European Journal of Heart Failure 2

Never use ACE inhibitors and ARBs concurrently, as this combination increases the risk of adverse effects without additional benefit, as stated by Circulation and the Journal of the American College of Cardiology 4, 7
Temporary discontinuation during acute illness is recommended, as both ACE inhibitors and ARBs should be temporarily stopped during episodes of volume depletion to prevent acute kidney injury, as noted by the American Journal of Kidney Diseases 6
Medication adherence challenges should be addressed, ensuring the patient understands the new dosing schedule to maintain adherence, as recommended by the Journal of the American College of Cardiology 7