ACE inhibitor + ARB

[JayEm]

Would you dispense a script that had both lisinopril and irbesartan for example? I came across a prescription the other day for a patient on moxonidine, furosemide, lacidipine, bisoprolol, irbesartan and lisinopril (sildenafil too!). How common is it to see someone on all these BP drugs?

During my hospital cross sector placement, I remember one of the pharmacists telling a junior doctor off for prescribing both an ACE inhibitor and ARB but it isn't really a serious interaction according to the BNF as long as the patient is monitored. What would you do if you saw it in community?

[Nik]

There could have been a number of reasons the hospital pharmacist advised against using both drugs together, eg reducing renal function (as well as the fact that there's little if any evidence for using two together). The increased hyperkalaemic risk is somewhat negated by the furosemide, but they should be having regular renal function tests if they are on both together. Do you remember the dose of lisinopril ? Could it have been uptitrated instead of adding the irbesartan ?

[hibernia]

Do you remember the dose of lisinopril ? Could it have been uptitrated instead of adding the irbesartan ?

Perhaps the first issue isn't the dose of lisinopril but if the patient is taking it at all.

Would you dispense a script that had both lisinopril and irbesartan for example? I came across a prescription the other day for a patient on moxonidine, furosemide, lacidipine, bisoprolol, irbesartan and lisinopril (sildenafil too!). How common is it to see someone on all these BP drugs?

In my experience it is fairly common. If a drug isn't working the usual approach is to add another, without any thought to compliance or trying basic lifestyle measures such as losing weight, taking more exercise or reducing salt intake.
Often when a new drug is added patients simply drop the old one, either because no-one has told them to continue it or they have side-effects or just don't want to take more tablets. They feel fine so they either don't take their medication or take in a haphazard way, often restarting it a few days before their appointment.

[shan]

They can be used in patients with recent history of heart failure, but under a consultant's supervision. Rare but possible. But in general I have seen many GPs blindly prescribing both and we as community pharmacists do an MUR and refer back with a note to titrate the "prils" unless it is a must to prescribe together as I said before.

Shan

[shupagirl]

Sorry if this is not the right place to post this but could someone tell me what the difference is between the 2 Perindoprils (Arginine and Erbumine)? I've read somewhere that if a patient is on one they can change over to the other as there's not much difference between the two. The only difference is the molecular weights. Is this true?

[johnep]

One is patented, the other isn't.
johnep

[shan]

one comes in funny strengths and the comes in 2, 4, and 8mgs. One is cheaper and the other is expensive. One is freely available as generic other one is always out of stock. so NHS wants the one that can save money and time.

Shan

[Nik]

They can be used in patients with recent history of heart failure, but under a consultant's supervision.

Can you give me some evidence for this please.

[shan]

Combination therapy with an A2RA plus an ACE inhibitor would appear to have a very limited role. SIGN guidance on the management of chronic heart failure (SIGN 95) suggests this may be a specialist option in patients with heart failure who are still symptomatic despite optimised ACE inhibitor and beta-blocker therapy. This is based on results from the CHARM-Added trial were the addition of candesartan to ACE inhibitor treatment reduced hospitalisations for heart failure but not all-cause mortality. However, combination therapy in patients with heart failure increases adverse effects, including hypotension, worsening renal function and hyperkalaemia, and requires very careful monitoring.

Got from National Prescribing Centre NPC Rapid Review » ACE inhibitors, not A2RAs or combination therapy, in ischaemic heart disease

Shan

[Nik]

So by recent history of heart failure do you mean acute heart failure ? Or is it used in chronic heart failure ?