Home > For Consumers > Comparing ACE Inhibitors and related drugs
  • We are sorry, but NCBI web applications do not support your browser and may not function properly. More information

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.

Dean L. PubMed Clinical Q&A [Internet]. Bethesda (MD): National Center for Biotechnology Information (US); 2008-2013.

PubMed Clinical Q&A.

Comparing ACE Inhibitors and related drugs

Laura Dean, MD.

National Center of Biotechnology Information (NCBI)

Created: October 1, 2010.

Angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (AIIRA) and direct renin inhibitors (DRI) are used to treat high blood pressure, coronary artery disease, heart failure, diabetic nephropathy, and kidney disease. Although the exact mechanisms of these three types of drugs are different, they are all thought to work by interrupting the cycle within the renin-angiotensin system.

Among these drugs, ACE inhibitors were the first to be developed and are thought to work by blocking the conversion of angiotensin I to angiotensin II. However, ACE inhibitors also lead to an increase in bradykinin, which is thought be the main cause behind the persistent dry cough that some patients develop. As an alternative to ACE inhibitors, AIIRAs were then developed to produce a similar interruption of the renin-angiotensin system, but without also increasing bradykinin levels. Most recently, a third type of drug, DRI (direct renin inhibitor) was developed that reduces the amount of angiotensin I, the precursor to angiotensin II.

Currently 11 ACE inhibitors, 7 AIIRAs, and 1 DRI are available in the United States.

The "Drug Class Review on Direct Renin Inhibitors, Angiotensin Converting Enzyme Inhibitors, and Angiotensin II Receptor Blockers" compares the safety and effectiveness of 19 drugs. A summary of the findings is below.

How do ACE inhibitors, AIIRAs, and DRIs compare in effectiveness?

ACE inhibitors and AIIRAs have similar effects on important outcomes, including reducing risk of cardiovascular events and death and improving renal function and quality of life symptoms. This is found when ACE inhibitors and AIIRAs are given in combination, and when one or the other drug is used alone. The benefits are found in patients with heart disease, high blood pressure, diabetic and nondiabetic proteinuria, and chronic kidney disease. No studies were found that directly compared the effectiveness of aliskiren (DRI) to either an ACE inhibitor or an AIIRA. [details]

For detailed comparisons between DRIs, AIIRAs, and ACE inhibitors, please see the Drug Class Review.

How do ACE inhibitors, AIIRAs, and DRIs compare in harms?

Overall, fewer patients experienced cough and withdrawal with AIIRAs than with ACE inhibitors. Low blood pressure is more common when AIIRAs and ACE inhibitors are used in combination . No studies were found that directly compared the harms between aliskiren (DRI) and either an ACI inhibitor or an AIIRA. [details]

How does the direct renin inhibitor, aliskiren, compare in effectiveness and harms?

There are two studies available at this time:

  • In patients with heart failure and hypertension taking either an ACE inhibitor or AIIRA, there is no significant difference between the addition of either aliskiren or placebo in serum creatine levels, adverse events, or withdrawal rates. [details]
  • When added to losartan (AIIRA) in patients with diabetic nephropathy, aliskiren was superior to placebo in decreasing the urinary albumin:creatinine ratio and increasing the number of patients who achieved a 50% or greater reduction in albuminuria, but did not improve risk of death. There were no significant differences between aliskiren and placebo in risk of withdrawal or any harms outcomes. [details]

Does age or other patient factors influence effectiveness or harms?

For heart failure, there is no significant difference between ACE inhibitors and AIIRAs based on age, ejection fraction, and extent of heart failure. Among patients on prior beta-blocker therapy, however, there was a significantly higher risk of all-cause mortality or heart failure-related mortality and hospital admissions with losartan (AIIRA) than with captopril (ACE inhibitor).

For high blood pressure, the rate of cough is significantly lower for eprosartan than enalapril, regardless of age (above or below 65 years) and race (black or non-black).

When added to losartan (AIIRA) in patients with diabetic nephropathy, greater improvements in kidney function (lowered the albumin:creatinine ratio) were found for aliskiren over placebo, regardless of gender, age, or race.

Data are limited for chronic kidney disease and proteinuria not caused by diabetes. [details]

Direct renin inhibitors included in this review

Generic NameTrade Names
AliskirenTekturna
Rasilez

Angiotensin II receptor blockers included in this review

Generic NameTrade Names
CandesartanAtacand
EprosartanTeveten
IrbesartanAvapro
LosartanCozaar
OlmesartanBenicar
Olmetec
TelmisartanMicardis
ValsartanDiovan

Angiotensin converting enzyme inhibitors included in this review

Generic NameTrade Names
BenazeprilLotensin
CaptoprilCapoten
CilazaprilInhibace
EnalaprilVasotec
FosinoprilMonopril
LisinoprilPrinivil
Zestril
MoexiprilUnivasc
PerindoprilAceon
Coversyl
QuinaprilAccupril
RamiprilAltace
TrandolaprilMavik

Further information

Image th-acei10.jpgThis PubMed Clinical Q&A was reviewed by Kimberly Peterson, MS.

For the full report and evidence tables, please see:
Norris S, Weinstein J, Peterson K, et al. Drug Class Review: Direct Renin Inhibitors, Angiotensin Converting Enzyme Inhibitors, and Angiotensin II Receptor Blockers: Final Report [Internet]. Portland (OR): Oregon Health & Science University; 2010 Jan. Available at: http://www.ncbi.nlm.nih.gov/books/NBK47119/.