Lisinopril to losartan
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Comparative Analysis of Lisinopril and Losartan
Introduction to Lisinopril and Losartan
Lisinopril and losartan are commonly prescribed medications for managing hypertension and related cardiovascular conditions. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor, while losartan is an angiotensin II receptor blocker (ARB). Both medications work by affecting the renin-angiotensin system but through different mechanisms.
Blood Pressure Reduction
Both lisinopril and losartan are effective in reducing systolic and diastolic blood pressure. Studies have shown that both medications significantly lower blood pressure in patients with mild to moderate hypertension, with no significant difference between the two treatments in terms of blood pressure reduction.
Insulin Sensitivity
Lisinopril has been found to improve insulin sensitivity in non-diabetic hypertensive patients, as indicated by an increase in glucose infusion rate (GIR) and total glucose requirement (TGR) during euglycemic hyperinsulinemic clamp tests. In contrast, losartan did not significantly affect insulin sensitivity.
ACE2 Expression and COVID-19 Implications
Lisinopril increases tissue levels of ACE2, the receptor for SARS-CoV-2, across various tissues, including the small intestine, lung, kidney, and brain. This increase in ACE2 levels was not observed when losartan was added to lisinopril treatment, suggesting that losartan may counteract the ACE2 elevation induced by lisinopril.
Diabetic Nephropathy and Proteinuria
Combination therapy with lisinopril and losartan has been explored for treating diabetic nephropathy. While dual therapy reduced proteinuria more effectively than monotherapy, it also increased the risk of adverse events such as hyperkalemia and acute kidney injury. Consequently, the combination therapy was associated with higher safety concerns and was not found to be more beneficial in terms of mortality or progression to end-stage renal disease (ESRD) .
Cough Incidence
Lisinopril is associated with a higher incidence of cough compared to losartan. In patients with a history of ACE inhibitor-induced cough, losartan was found to cause significantly fewer instances of cough than lisinopril, making it a preferable option for patients who experience this side effect .
Myocardial Perfusion Reserve
Lisinopril has been shown to improve myocardial perfusion reserve (MPR) in patients with hypertension and left ventricular hypertrophy (LVH), likely due to its effect on bradykinins. Losartan, which does not affect bradykinins, did not show a similar improvement in MPR.
Twice-Daily vs. Once-Daily Dosing
A real-world study comparing twice-daily (BID) and once-daily (QDay) dosing of lisinopril and losartan found no significant differences in blood pressure control between the two dosing regimens. However, BID dosing of lisinopril was associated with an increased risk of angioedema compared to QDay dosing.
Conclusion
Both lisinopril and losartan are effective antihypertensive agents with distinct profiles. Lisinopril may offer additional benefits in terms of insulin sensitivity and myocardial perfusion but comes with a higher risk of cough and potential increases in ACE2 levels. Losartan, on the other hand, is less likely to cause cough and may mitigate some of the adverse effects associated with lisinopril. The choice between these medications should be tailored to the individual patient's needs and medical history.
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