Angiotensin Receptor Blocker Selection for Hypertension Management

Patient Selection and Treatment Outcomes

The American Diabetes Association recommends that for patients with diabetic nephropathy and macroalbuminuria, losartan or irbesartan are the preferred ARBs, with losartan being the only ARB with FDA-approved indication specifically for reducing hard renal endpoints in type 2 diabetic nephropathy 1
Losartan is the first-choice ARB based on the landmark RENAAL trial, which demonstrated a 16% reduction in the composite endpoint of doubling serum creatinine, ESRD, or death, with 25% reduction in sustained doubling of serum creatinine and 29% reduction in ESRD 1
Irbesartan is equally effective based on the IDNT trial, showing similar renoprotective efficacy in type 2 diabetic nephropathy with macroalbuminuria 1

The American Heart Association suggests that multiple-drug therapy is generally required to achieve BP targets, particularly in diabetic kidney disease, and that enhancing efficacy with thiazide or loop diuretics is recommended as 60-90% of patients in major ARB trials used concomitant diuretics 1, 2, 3
The American Diabetes Association recommends that patients on ARB therapy should be monitored for serum creatinine/eGFR and potassium within 7-14 days after initiation or dose change, and at least annually 2, 3

The American College of Cardiology advises against using ARBs in pregnancy, symptomatic hypotension, uncontrolled hyperkalemia, and bilateral renal artery stenosis 1
The European Society of Cardiology recommends avoiding the combination of ARB + ACE inhibitor, as this increases adverse events without mortality benefit, and never combining ARB + direct renin inhibitor due to lack of added benefit and increased adverse events 1, 2, 3, 6