ACE inhibitors and sartans – why should they not be prescribed together?

Combination treatment of hypertension has been prescribed more and more frequently in recent years. The blood pressure lowering effect is greater and side effects are less pronounced when agents acting on various systems are combined. Unfortunately, this condition is not fulfilled when an ACE inhibitor is combined with a sartan. Both drugs suppress the renin-angiotensin system therefore their combination is not very effective (in respect of blood pressure reduction) and leads to higher risk of side effects because most side effects are not counteracted, but rather augmented by the other agent (for instance both agents increase the potassium level). Indeed, the ONTARGET trial proved that in patients with symptomatic atherosclerosis or diabetes, but without heart failure combination treatment with an ACE inhibitor and a sartan is not related to any benefit when compared with monotherapy, but leads to more side effects. However, it should be underlined that these findings do not preclude the combination of an ACE inhibitor and a sartan in heart failure patients or those with resistant hypertension.