3. Duplicative Therapy

Administration of two or more ARBs concurrently is not justified. Additional therapeutic benefit is not appreciated when multiple ARBs are utilized concomitantly. Patient profiles containing regimens comprised of two or more ARBs administered concurrently will be reviewed.

Recent studies have documented concurrent administration of ARBs and ACE inhibitors may result in an increased incidence of adverse effects (e.g., hypotension, hyperkalemia, syncope, renal failure) in patients with heart failure due to myocardial infarction or left ventricular dysfunction, as well as other patients at high risk for vascular events (e.g., diabetic patients) without added benefit. Additional studies have not documented significant benefit with ACE inhibitor-ARB combination therapy in managing hypertension or diabetic nephropathy. The American College of Cardiology/American Heart Association guidelines state that ARB-ACE inhibitor combination therapy may be considered in heart failure patients, not recently post myocardial infarction, who have not responded to target doses of an ACE inhibitor and beta blocker. The guidelines warn that routine combined use of an ACE inhibitor, an ARB, and an aldosterone antagonist is potentially harmful to patients with heart failure with a reduced ejection fraction. The 2017 focused update recommends an ACE inhibitor OR an ARB, but they do not explicitly address the use of both agents at the same time. Adjunctive administration of ARBs and ACE inhibitors should be considered cautiously, if at all, in these patient populations.