- ACRONYMS AND DEFINITIONS
- ARB - Angiotensin II receptor blocker
- CrCl - Creatinine clearance
- GFR - Glomerular filtration rate
- HCTZ - Hydrochlorothiazide
- P = drugs with pediatric dosing
- ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)
Azilsartan (Edarbi®)
Dosage forms
Tablet
- 40 mg
- 80 mg
Dosing
Hypertension (adults)
- Starting: 80 mg once daily
- Maintenance: 40 - 80 mg once daily
- Max: 80 mg once daily
- Consider starting dose of 40 mg a day if on high doses of diuretics
- May take without regard to food
Kidney disease
- No dose adjustment necessary
- See ARBs in kidney disease for more
Liver disease
- Child-Pugh A or B: no dose adjustment necessary
- Child-Pugh C: has not been studied
Generic / Price
- NO/$$$$Candesartan (Atacand®)
Dosage forms
Tablet
- 4 mg
- 8 mg
- 16 mg
- 32 mg
Dosing
Hypertension (adults)
- Starting: 16 mg once daily
- Maintenance: 8 - 32 mg/day
- Max: 32 mg/day
- May be given in one or two divided doses
- Lower starting dose may be appropriate in patients taking diuretics
- Most of the antihypertensive effect occurs within the first 2 weeks, and maximum reduction is seen in 4 - 6 weeks
- May take without regard to food
Heart failure (adults)
- Starting: 4 mg once daily
- Target dose: 32 mg once daily
- Max: 32 once daily
- Dose may be doubled every 2 weeks as tolerated
- May take without regard to food
Hypertension (1 to 5 years old)
- Starting: 0.20 mg/kg/day
- Maintenance: 0.05 to 0.4 mg/kg/day
- May be given in one or two divided doses
- See Atacand PI [sec 2.2] for instructions on compounding a 1 mg/ml suspension
- May take without regard to food
Hypertension (6 to <17 years old)
- Starting (< 50 kg): 4 - 8 mg/day
- Starting (≥ 50 kg): 8 - 16 mg/day
- Maintenance (< 50 kg): 2 - 16 mg/day
- Maintenance (≥ 50 kg): 4 - 32 mg/day
- May be given in one or two divided doses
- See Atacand PI [sec 2.2] for instructions on compounding a 1 mg/ml suspension
- May take without regard to food
Kidney disease
- Use caution
- See ARBs in kidney disease for more
Liver disease
- Child-Pugh B: starting dose should be 8 mg/day when treating hypertension
- Child-Pugh C: has not been studied
Generic / Price
- YES/$Irbesartan (Avapro®)
Dosage forms
Tablet
- 75 mg
- 150 mg
- 300 mg
Dosing
Hypertension (adults)
- Starting: 150 mg once daily
- Maintenance: 150 - 300 mg once daily
- Max: 300 mg once daily
- A starting dose of 75 mg once daily is recommended in patients who are volume and salt depleted (e.g. aggressive diuretic therapy or hemodialysis)
- May take without regard to food
Diabetic nephropathy (adults)
- Target dose: 300 mg once daily
- A starting dose of 75 mg once daily is recommended in patients who are volume and salt depleted (e.g. aggressive diuretic therapy or hemodialysis)
- May take without regard to food
Hypertension (6 - 12 years old)
- Starting: 75 mg once daily
- Max: 150 mg once daily
- May take without regard to food
- AAP recommended dosing [2]
Hypertension (≥ 13 years old)
- Starting: 150 mg once daily
- Max: 300 mg once daily
- May take without regard to food
- AAP recommended dosing [2]
Kidney disease
- No dose adjustment necessary unless patient is volume depleted
- See ARBs in kidney disease for more
Liver disease
- No dose adjustment necessary
Generic / Price
- YES/$Losartan (Cozaar®)
Dosage forms
Tablet
- 25 mg
- 50 mg
- 100 mg
Dosing
Hypertension (adults)
- Starting: 50 mg once daily
- Maintenance: 25 - 100 mg once daily
- Max: 100 mg once daily
- A starting dose of 25 mg is recommended in patients with volume depletion (e.g. diuretic therapy)
- Blood pressure effect occurs within one week, but maximum effect may take 3 - 6 weeks
- May take without regard to food
Diabetic nephropathy (adults)
- Starting: 50 mg once daily
- Maintenance: 50 - 100 mg once daily
- Max: 100 mg once daily
- May take without regard to food
Hypertension with left ventricular hypertrophy (adults)
- Starting: 50 mg once daily
- Maintenance: 50 - 100 mg once daily
- Max: 100 mg once daily
- Concomitant HCTZ is recommended at a dose of 12.5 mg (50 mg dose) or 25 mg (100 mg dose)
- May take without regard to food
Hypertension (≥ 6 years old)
- Starting: 0.7 mg/kg (max 50 mg) once daily
- Max: 1.4 mg/kg (max 100 mg) once daily
- Not recommended in pediatric patients with GFR < 30 ml/min
- See Cozaar PI [sec 2.5] for instructions on compounding a 2.5 mg/ml suspension
- May take without regard to food
Kidney disease
- No dose adjustment necessary unless patient is volume depleted
- See ARBs in kidney disease for more
Liver disease
- Child-Pugh A or B: use a starting dose of 25 mg once daily
- Child-Pugh C: has not been studied
Generic / Price
- YES/$Olmesartan (Benicar®)
Dosage forms
Tablet
- 5 mg
- 20 mg
- 40 mg
Dosing
Hypertension (adults)
- Starting: 20 mg once daily
- Maintenance: 20 - 40 mg once daily
- Max: 40 mg once daily
- A lower starting dose may be appropriate in patients with volume depletion (e.g. diuretic therapy)
- May take without regard to food
Hypertension (≥ 6 years old)
- 44 lbs (20 kg) to less than 77 lbs (35 kg)
- Starting: 10 mg once daily
- Max: 20 mg once daily
- Greater than or equal to 77 lbs (35 kg)
- Starting: 20 mg once daily
- Max: 40 mg once daily
- Increase dose at intervals of 2 weeks
- See Benicar PI [sec 2.2] for instructions on compounding a 2 mg/ml suspension
- May take without regard to food
Kidney disease
- No initial dose adjustment is recommended
- See ARBs in kidney disease for more
Liver disease
- No initial dose adjustment is recommended
Generic / Price
- YES/$Telmisartan (Micardis®)
Dosage forms
Tablet
- 20 mg
- 40 mg
- 80 mg
Dosing
Hypertension (adults)
- Starting: 40 mg once daily
- Maintenance: 20 - 80 mg once daily
- Max: 80 mg once daily
- Most of the blood pressure effect is seen within 2 weeks, and maximum effect occurs within 4 weeks
- May take without regard to food
Cardiovascular risk reduction (adults)
- Dosing: 80 mg once daily
- May take without regard to food
Kidney disease
- No initial dose adjustment is necessary
- See ARBs in kidney disease for more
Liver disease
- Monitor carefully and uptitrate slowly in patients with biliary obstructive disorders or hepatic insufficiency
Generic / Price
- YES/$Valsartan (Diovan®)
Dosage forms
Tablet
- 40 mg
- 80 mg
- 160 mg
- 320 mg
Dosing
Hypertension (adults)
- Starting: 80 - 160 mg once daily
- Maintenance: 80 - 320 mg once daily
- Max: 320 mg once daily
- Blood pressure effect is seen within 2 weeks, and maximum effect occurs within 4 weeks
- May take without regard to food
Heart failure (adults)
- Starting: 40 mg twice daily
- Maintenance: 80 - 160 mg twice daily
- Max: 160 mg twice daily
- May take without regard to food
Post-Myocardial infarction (adults)
- Starting: 20 mg twice daily
- Maintenance: 40 - 160 mg twice daily
- Max: 160 mg twice daily
- May be initiated as early as 12 hours after a myocardial infarction
- May take without regard to food
Hypertension (1 - 16 years old)
- Starting: 1 mg/kg (max 40 mg) once daily
- Max: 4 mg/kg (max 160 mg) once daily
- A starting dose of 2 mg/kg may be considered in cases when a greater reduction of blood pressure is needed
- Has not been studied in pediatric patients with GFR < 30 ml/min
- See Diovan PI [sec 2.1] for instructions on compounding a 4 mg/ml suspension
- When the suspension is replaced by a tablet, the dose of valsartan may need to be increased. The bioavailability of valsartan in the suspension is 1.6 times that of the tablet.
- May take without regard to food
Kidney disease
- CrCl ≥ 30 ml/min: no dose adjustment necessary
- CrCl < 30 ml/min: has not been studied
- See ARBs in kidney disease for more
Liver disease
- Child-Pugh A or B: no dose adjustment necessary
- Child-Pugh C: has not been studied
Generic / Price
- YES/$Atacand HCT® (candesartan + HCTZ)
Dosage forms
Tablet
- Candesartan - HCTZ
- 16 mg - 12.5 mg
- 32 mg - 12.5 mg
- 32 mg - 25 mg
Dosing
Hypertension
- Dosing: HCTZ 12.5 - 50 mg/day | Candesartan 8 - 32 mg/day
- May be given once daily or in two divided doses
- Maximal effect seen within 4 weeks
- May take without regard to food
Generic / Price
- YES/$$-$$$Avalide® (irbesartan + HCTZ)
Dosage forms
Tablet
- Irbesartan - HCTZ
- 150 mg - 12.5 mg
- 300 mg - 12.5 mg
Dosing
Hypertension
- Starting: 150/12.5 mg once daily
- Max: 300/25 mg once daily
- Titrate dose at intervals of 1 - 2 weeks
- May take without regard to food
Generic / Price
- YES/$Benicar HCT® (olmesartan + HCTZ)
Dosage forms
Tablet
- Olmesartan - HCTZ
- 20 mg - 12.5 mg
- 40 mg - 12.5 mg
- 40 mg - 25 mg
Dosing
Hypertension
- Starting: 20/12.5 - 40/12.5 mg once daily
- Max: 40/25 mg once daily
- May take without regard to food
Generic / Price
- YES/$Diovan HCT® (valsartan + HCTZ)
Dosage forms
Tablet
- Valsartan - HCTZ
- 80 mg - 12.5 mg
- 160 mg - 12.5 mg
- 160 mg - 25 mg
- 320 mg - 12.5 mg
- 320 mg - 25 mg
Dosing
Hypertension
- Starting: 160/12.5 mg once daily
- Max: 320/25 mg once daily
- Titrate dose at intervals of 1 - 2 weeks
- Maximum effect seen within 2 - 4 weeks
- May take without regard to food
Generic / Price
- YES/$Edarbyclor® (azilsartan + chlorthalidone)
Dosage forms
Tablet
- Azilsartan - Chlorthalidone
- 40 mg - 12.5 mg
- 40 mg - 25 mg
Dosing
Hypertension
- Starting: 40/12.5 mg once daily
- Max: 40/25 mg once daily
- Increase dose if needed after 2 - 4 weeks
- Most of the antihypertensive effect is seen within 1 - 2 weeks
- May take without regard to food
Generic / Price
- NO/$$$$Hyzaar® (losartan + HCTZ)
Dosage forms
Tablet
- Losartan - HCTZ
- 50 mg - 12.5 mg
- 100 mg - 12.5 mg
- 100 mg - 25 mg
Dosing
Hypertension
- Starting: 50/12.5 mg once daily
- Max: 100/25 mg once daily
- Increase dose at intervals of 3 weeks
- May take without regard to food
Hypertension with left ventricular hypertrophy
- Starting: 50/12.5 mg once daily
- Max: 100/25 mg once daily
- May take without regard to food
Generic / Price
- YES/$Micardis HCT® (telmisartan + HCTZ)
Dosage forms
Tablet
- Telmisartan - HCTZ
- 40 mg - 12.5 mg
- 80 mg - 12.5 mg
- 80 mg - 25 mg
- Comes in sealed blister pack of 30 tablets
Dosing
Hypertension
- Starting: 80/12.5 mg once daily
- Max: 160/25 mg once daily
- Titrate dose at intervals of 2 - 4 weeks
- Do not remove tablet from blister pack until ready to take
- May take without regard to food
Generic / Price
- YES/$Azor® (amlodipine + olmesartan)
Dosage forms
Tablet
- Amlodipine - Olmesartan
- 5 mg - 20 mg
- 5 mg - 40 mg
- 10 mg - 20 mg
- 10 mg - 40 mg
Dosing
Hypertension
- Starting: 5 mg/20 mg once daily
- Maintenance: 5 mg/20 mg - 10 mg/40 mg once daily
- Max: 10 mg/40 mg once daily
- Titrate dose at intervals of 1 - 2 weeks
- May take without regard to food
Generic / Price
- YES/$Exforge® (amlodipine + valsartan)
Dosage forms
Tablet
- Amlodipine - Valsartan
- 5 mg - 160 mg
- 5 mg - 320 mg
- 10 mg - 160 mg
- 10 mg - 320 mg
Dosing
Hypertension
- Starting: 5 mg/160 mg once daily
- Maintenance: 5 mg/160 mg - 10 mg/320 mg once daily
- Max: 10 mg/320 mg once daily
- Full antihypertensive effect typically seen within 2 weeks
- May take without regard to food
Generic / Price
- YES/$-$$Twynsta® (amlodipine + telmisartan)
Dosage forms
Tablet
- Telmisartan - Amlodipine
- 40 mg - 5 mg
- 40 mg - 10 mg
- 80 mg - 5 mg
- 80 mg - 10 mg
Dosing
Hypertension
- Starting: 40 mg/5 mg once daily
- Maintenance: 40 mg/5 mg - 80 mg/10 mg once daily
- Max: 80 mg/10 mg once daily
- Most of the antihypertensive effect is seen within 2 weeks
- May take without regard to food
Generic / Price
- YES/$$Exforge HCT® (amlodipine + valsartan + HCTZ)
Dosage forms
Tablet
- Amlodipine - Valsartan - HCTZ
- 5 mg - 160 mg - 12.5 mg
- 5 mg - 160 mg - 25 mg
- 10 mg - 160 mg - 12.5 mg
- 10 mg - 160 mg - 25 mg
- 10 mg - 320 mg - 25 mg
Dosing
Hypertension
- Starting: 5/160/12.5 once daily
- Maintenance: 5/160/12.5 mg - 10/320/25 mg once daily
- Max: 10/320/25 mg once daily
- Titrate dose at intervals of 2 weeks
- Full antihypertensive effect is seen after 2 weeks
- May take without regard to food
Generic / Price
- YES/$-$$Tribenzor® (amlodipine + olmesartan + HCTZ)
Dosage forms
Tablet
- Amlodipine - Olmesartan - HCTZ
- 5 mg - 20 mg - 12.5 mg
- 5 mg - 40 mg - 12.5 mg
- 5 mg - 40 mg - 25 mg
- 10 mg - 40 mg - 12.5 mg
- 10 mg - 40 mg - 25 mg
Dosing
Hypertension
- Starting: 5/20/12.5 mg once daily
- Maintenance: 5/20/12.5 mg - 10/40/25 mg once daily
- Max: 10/40/25 mg once daily
- Titrate dose at intervals of 2 weeks
- May take without regard to food
Generic / Price
- YES/$- Kidney disease
- While ARBs are beneficial in treating and preventing kidney disease, their inhibitory effects on the RAAS system can be detrimental when kidneys are severely compensated, leading to elevations in potassium, serum creatinine, and BUN. The risk of adverse effects depends on the degree of kidney disease and concurrent medical problems (e.g. heart failure, diabetes). To help avoid these issues, ARBs should be started at the lowest dose possible and titrated slowly in patients with significant kidney disease.
- The STOP ACEi study (N=411) published in 2022 randomized patients with GFR < 30 ml/min to discontinue or continue their ACE inhibitor or ARB. The primary outcome was GFR at 3 years. At the end of the study, there was no significant difference in GFR between the groups (discontinue - 12.6 ml/min, continue - 13.3 ml/min, p=0.42). End-stage kidney disease or the initiation of renal replacement therapy occurred in 62% of discontinue patients and 56% of continue patients (HR 1.28, 95%CI [0.99 - 1.65]) [PMID 36326117].
- Azilsartan (Edarbi®)
- No dose adjustment necessary
- Candesartan (Atacand®)
- Use caution
- Irbesartan (Avapro®)
- No dose adjustment necessary unless patient is volume depleted
- Losartan (Cozaar®)
- No dose adjustment necessary unless patient is volume depleted
- Olmesartan (Benicar®)
- No initial dose adjustment is recommended
- Telmisartan (Micardis®)
- No initial dose adjustment is necessary
- Valsartan (Diovan®)
- CrCl ≥ 30 ml/min: no dose adjustment necessary
- CrCl < 30 ml/min: has not been studied
- Liver disease dosing
- Azilsartan (Edarbi®)
- Child-Pugh A or B: no dose adjustment necessary
- Child-Pugh C: has not been studied
- Candesartan (Atacand®)
- Child-Pugh B: starting dose should be 8 mg/day when treating hypertension
- Child-Pugh C: has not been studied
- Irbesartan (Avapro®)
- No dose adjustment necessary
- Losartan (Cozaar®)
- Child-Pugh A or B: use starting dose of 25 mg once daily
- Child-Pugh C: has not been studied
- Olmesartan (Benicar®)
- No initial dose adjustment is recommended
- Telmisartan (Micardis®)
- Monitor carefully and uptitrate slowly in patients with biliary obstructive disorders or hepatic insufficiency
- Valsartan (Diovan®)
- Child-Pugh A or B: no dose adjustment necessary
- Child-Pugh C: has not been studied
- DRUG INTERACTIONS
- NOTE: The drug interactions presented here are NOT all-inclusive. Other interactions may exist. Drug interaction checkers provide the most efficient and practical way to check for interactions among multiple medications. A free interaction checker is available from Drugs.com (see Drugs.com interactions checker).
- All ARBs
- ACE inhibitors - see combining ARBs and ACE inhibitors
- Aliskiren (Tekturna®) - Aliskiren should not be prescribed with ARBs in patients with diabetes or decreased kidney function (GFR<60ml/min)
- Lithium - ARBs can increase lithium levels. This combination should be avoided, or lithium levels should be checked frequently if they are taken together.
- Medications that can raise potassium levels - ARBs may raise potassium levels and cause hyperkalemia. When taken with other potassium-raising medications, the risk is increased. While it is often appropriate to combine ARBs with other potassium-raising drugs, patients and providers should be aware of the potential risks. See RAAS inhibitor-induced hyperkalemia for recommendations on addressing hyperkalemia in ARB-treated patients.
- Examples of medications that may raise potassium levels include:
- Aldosterone antagonists (spironolactone and eplerenone)
- ACE inhibitors
- Aliskiren (Tekturna®)
- Cyclosporine (Neoral®)
- ENaC inhibitors (triamterene, amiloride)
- Finerenone (Kerendia®)
- Heparin - heparin raises potassium secondarily by inhibiting aldosterone synthesis. LMWH does not appear to have the same effect. [3]
- Penicillin G potassium injection (1 million units contains 1.68mEq of potassium)
- Potassium supplements (K-Dur®, etc)
- Tacrolimus (Prograf®)
- Trimethoprim (part of Bactrim® and Septra®)
- Voclosporin (Lupkynis®)
- NSAIDS (Advil®, Aleve®, etc.) - NSAIDS can attenuate the effect of ARBs. This is more of a concern when NSAIDS are taken on a chronic basis. Cases of decreased kidney function have been reported when NSAIDS were taken with ARBs. The risk appears to be greater with advanced age, dehydration, and underlying kidney disease.
- Salt substitutes (No-Salt®, etc.) - Salt substitutes typically contain a high amount of potassium (16.4 mEq per 1/4 teaspoon). Since ARBs can raise potassium levels, caution should be used when consuming salt substitutes.
- Telmisartan (Micardis®)
- Digoxin - telmisartan has been shown to increase digoxin levels. When taken together, digoxin levels should be monitored.
- Ramipril (Altace®) - Ramipril, an ACE inhibitor, should not be taken with telmisartan. Telmisartan has been shown to significantly increase ramipril levels.
- Metabolism and clearance
- Azilsartan (Edarbi®)
- CYP2C9 - substrate
- Candesartan (Atacand®)
- No significant liver metabolism
- Irbesartan (Avapro®)
- CYP2C9 - substrate
- Losartan (Cozaar®)
- CYP2C9 - substrate
- CYP3A4 - substrate
- P-glycoprotein - substrate
- Olmesartan (Benicar®)
- OATP - substrate
- Telmisartan (Micardis®)
- Valsartan (Diovan®)
- OATP - substrate
- PRICE ($) INFO
Pricing legend
- $ = 0 - $50
- $$ = $51 - $100
- $$$ = $101 - $150
- $$$$ = > $150
- Pricing based on one month of therapy at standard dosing in an adult
- Pricing based on information from GoodRX.com®
- Pricing may vary by region and availability
- BIBLIOGRAPHY
- 1 - Manufacturer's Package Insert for each drug listed
- 2 - PMID 28827377 - Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, Pediatrics (2017)
- 3 - PMID 22560830 - Use and safety of unfractionated heparin for anticoagulation during maintenance hemodialysis, Am J Kidney Dis (2021)