Olmesartan (Benicar, Olmecip)

Indications


Pharmacology

Metabolism

  • xxx

Administration

  • PO: xxx

Dose Adjustment

  • Hepatic
  • Renal

Concomitant Administration of ACE Inhibitors and ARBS

  • Combination ACE Inhibitor and ARB Therapy Increases the Risk of Adverse Effects [MEDLINE]: including hyperkalemia, medication discontinuation due to adverse effects, worsened renal function, and symptomatic hypotension
    • Combination ACE Inhibitor and ARB Therapy Does Not Increase the Rate of Malignancy [MEDLINE]
    • Recommendation: it is recommended to not use combination ACE inhibitor and ARB therapy

Adverse Effects

Allergic/Immunologic Adverse Effects

Angioedema (see Urticaria-Angioedema, [[Urticaria-Angioedema]])

  • Epidemiology: less common with ARB’s than with ACE inhbitors
    • Telmisartan (0.1%) has a lower incidence of angioedema than ramipril (0.3%) [MEDLINE]
    • Cross-Reactivity
      • In patients with ACE-inhibitor-associated angioedema, the risk of development of any subsequent ARB-associated angioedema is 2-17%
      • In patients with ACE-inhibitor-associated angioedema, the risk of development of subsequent confirmed ARB-associated angioedema is 0-9.2%
  • Physiology: class effect (common to all ARB’s)

Cardiovascular Adverse Effects

Hypotension (see Hypotension, [[Hypotension]])

  • Epidemiology: more common with ARB’s than with ACE inhibitors
    • Telmisartan has significantly higher rate of symptomatic hypotension (2.6%) vs ramipril (1.7%) [MEDLINE]
  • Physiology: class effect (common to all ARB’s)
    • Due to basic pharmacology of ARB’s

Syncope (see Syncope, [[Syncope]])

  • Epidemiology: ramipril (0.2%) and telmisartan (0.2%) have similar rates of syncope requiring discontinuation of the drug [MEDLINE]

Endocrinologic Adverse Effects

Gastrointestinal Manifestations

Sprue-Like Enteropathy

  • Epidemiology: occurs months-years after initiation of drug
  • Clinical
    • Diarrhea
    • Weight Loss
  • Treatment: resolves after discontinuation of olmesartan
  • Rechallenge with Olmesartan: sometimes results in recurrence of the symptoms

Pulmonary Adverse Effects

Cough (see Cough, [[Cough]])

  • Epidemiology: less common with ARB’s than with ACE-Inhibitors
    • Ramipril has higher incidence of cough (4.2%) than telmisartan (1.1%) [MEDLINE]
  • Physiology: class effect (common to all ARB’s)

Renal Adverse Effects

Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]])

  • Epidemiology
    • Ramipril (1.9%) and telmisartan (2.0%) demonstrate similar rates of AKI, as defined by doubling of serum creatinine [MEDLINE]

Hyperkalemia (see Hyperkalemia, [[Hyperkalemia]])

  • Epidemiology: similar rates of hyperkalemia are observed with ramipril (3.3%) and telmisartan (3.4%) [MEDLINE]
  • Physiology: due to drug-induced hypoaldosteronism (see above)

Non-Anion Gap Metabolic Acidosis (see Metabolic Acidosis-Normal Anion Gap, [[Metabolic Acidosis-Normal Anion Gap]])

  • Physiology: due to drug-induced hypoaldosteronism (see above)

Other Effects

  • ARBS’s Do Not Increase the Risk of Malignancy [http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm257670.htm]
  • ARBS’s Do Not Increase the Risk of Myocardial Infarction [MEDLINE]

References

  • Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a quantitative review of data from randomized clinical trials. Arch Intern Med. 2007;167(18):1930 [MEDLINE]
  • Risk of angioedema with angiotensin receptor blockers in patients with prior angioedema associated with angiotensin-converting enzyme inhibitors: a meta-analysis. Ann Allergy Asthma Immunol. 2008 Nov;101(5):495-9. doi: 10.1016/S1081-1206(10)60288-8 [MEDLINE]
  • Potential of antihypertensive drugs for the prevention and treatment of Alzheimer’s disease. Expert Review of Neurotherapeutics 8 (9): 1286. September 2008. doi:10.1586/14737175.8.9.1285
  • ONTARGET Investigators: Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358(15):1547 [MEDLINE]
  • Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet. 2008;372(9638):547 [MEDLINE]
  • Use of angiotensin receptor blockers and risk of dementia in a predominantly male population: prospective cohort analysis. BMJ 2010; 340 (9): b5465. doi:10.1136/bmj.b5465 [MEDLINE]
  • http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm257670.htm
  • Angiotensin receptor blockers and risk of myocardial infarction: meta-analyses and trial sequential analyses of 147 020 patients from randomised trials. BMJ. 2011;342:d2234 [MEDLINE]
  • Effects of telmisartan, irbesartan, valsartan, candesartan, and losartan on cancers in 15 trials enrolling 138,769 individuals. J Hypertens. 2011;29(4):623 [MEDLINE]