Switching from Lisinopril to Losartan in Patients with History of Angioedema

Risk Assessment and Considerations

ACE inhibitors like lisinopril have a higher incidence of angioedema compared to ARBs, with black patients and smokers being at particularly higher risk 2
While ARBs are generally safer alternatives for patients who experienced angioedema with ACE inhibitors, there remains a modest risk of recurrent angioedema (2-17%) when switching to an ARB 2
The mechanism of ACE inhibitor-induced angioedema involves bradykinin accumulation, while the mechanism for ARB-associated angioedema is less clear but may also influence bradykinin levels 2

Discontinue lisinopril immediately if the patient experienced angioedema while taking it, then implement a 6-week washout period before starting losartan at a low dose (25-50 mg once daily) 1, 4
Monitor closely for signs of angioedema during the first weeks of therapy, and gradually titrate the losartan dose if needed and tolerated, up to 50-100 mg once daily 2, 4

Risk factors for recurrent angioedema when switching to an ARB include severity of the initial angioedema episode, black race, and smoking history 2
Alternative antihypertensive options if ARBs are contraindicated or not tolerated include calcium channel blockers, thiazide diuretics, and beta-blockers (with caution) 1, 2

Provide clear instructions on when to discontinue the medication and seek emergency care, and schedule follow-up within 1-2 weeks after initiating losartan to assess for adverse effects 2, 4
Monitor blood pressure, renal function, and potassium during the transition period 4

ARBs should be used with extreme caution in patients with a history of angioedema associated with ACE inhibitors, and the decision to use an ARB should involve careful risk-benefit assessment considering the therapeutic need for angiotensin/renin inhibition versus the risk of recurrent angioedema 2, 4
Avoid ARNIs (angiotensin receptor-neprilysin inhibitors) in patients with a history of angioedema as they carry an increased risk 5, 6, 7