Category: Fellows Posters
Guidelines pertaining to the management of chronic kidney disease, hypertension, heart failure, acute coronary syndromes and diabetic nephropathy noted above recommend either ACEI or ARB. Prescribing considerations in initiating ARBs over ACEIs is generally reserved for patients with a contraindication or unfavorable side effect profile. While clinical efficacy and safety is loosely comparable between the two drug classes, risk is arguably higher with ACEIs for dry cough and angioedema whereby ARBs generally exhibit placebo rates of both. In this report, we will examine the literature and propose clinical prescribing/use considerations in support of ARBs over ACEIs.
After a review of the literature, an ambulatory care pharmacist provided academic detailing and provider education around using ARBs over ACEIs for naïve patients, existing ACEI users, and patients with a history of angioedema to ACEIs. Communications were also sent through an electronic and printed monthly provider newsletter with a “clinical pharmacy spotlight” section. The majority of patients at the health center are on Medicaid and many are African-American. As such, risk-based, formulary-specific, and cost-conscious approaches were taken in the development of the aforementioned content.
Most clinical practice guidelines have evolved from suggesting ACEI before ARB in favor of suggesting either ACEI or ARB. Cost is no longer a barrier to access for ARBs and both classes have comparable benefits. Angioedema remains a life-threatening medical situation and risk can be notably reduced by avoiding ACEIs, especially in African-Americans. Despite the relatively low incidence rate of angioedema with ACEIs, millions of patients use them which means hundreds may die from angioedema. The future of ACEI use may be changing and clinical practice guidelines look to be re-evaluating their historical suggestions around ACEI and ARB use.