Should an ACE Inhibitor (ACEI) ever be combined with an Angiotensin II Receptor Blocker (ARB) or a R

As seen in the Consultant Connection April 2013 Issue
Todd Harris RPh. CGP; Pharmacist’s Letter: March 2013; Vol: 29, No. 3

The answer to that question is, very rarely.   Many years ago, physicians combined these medications hoping that by combining them, it would lead to better outcomes.   As it turns out the combination of an ACEI and ARB aren’t beneficial and may actually cause harm.  Despite this we occasionally see patients admitted to a long-term care facility still taking these combos…often because they seem to be doing okay.  It goes back to the “If it isn’t broken…don’t fix it theory.”  What we need to do is consider the evidence and whether it would be appropriate to change the therapy.
ACEI plus ARB combinations don’t improve cardiovascular outcomes in patients with hypertension, vascular disease, diabetes or after a heart attack.  Using the combination can lead to syncope or renal impairment.   There’s also no proof they reduce progression of kidney disease.  The only time that it may make sense to use the combination, is in patients with systolic heart failure.  Adding an ARB to an ACEI may modestly reduce mortality or hospitalizations however, a better choice may be to combine an ACEI with an aldosterone antagonist (spironolactone) instead of an ARB.  Studies have shown that adding an aldosterone antagonist to an ACEI prevents 7 more deaths per 1000 patients per year than using the combination of an ARB plus ACEI.  Much of the same can be said about the combination of a Renin Inhibitor (aliskiren - Tekturna).  This combination doesn’t improve cardiovascular outcomes in patients with diabetes or after a heart attack and puts the patient at risk for hypotension or hyperkalemia. 
When a resident is receiving one of the above combinations, it is recommended that it be brought to the attending physician’s attention for him to evaluate.  Many times medications get changed or added to a patient’s drug regimen when they are admitted/discharged from the hospital.  Then when the resident is admitted to a long-term care facility these medications are combined with medications they were taking at home which may lead to unnecessary duplication of therapy.  If it is decided that the resident is to remain on any of the above combinations, make sure the blood pressure and kidney function are monitored closely.

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