Lisinopril to Entresto Conversion: Optimize Heart Failure Treatment

Heart failure is a major global health issue affecting millions of individuals. It’s a chronic condition where the heart fails to pump blood efficiently, leading to symptoms like shortness of breath, fatigue, and fluid retention. Managing heart failure with the right medication is crucial for improving the quality of life, reducing hospitalizations, and prolonging survival.

Among the most commonly prescribed drugs for heart failure are Lisinopril, an ACE inhibitor, and Entresto, a combination of sacubitril and valsartan, which belong to a new class of heart failure medications. Understanding the nuances of transitioning between these two treatments can significantly impact outcomes, especially as heart failure management evolves with advancements in pharmaceutical science.

Let’s explore the Lisinopril to Entresto conversion, highlighting dosage adjustments, clinical considerations, potential side effects, and why this switch might be necessary in heart failure management.

What is Lisinopril?

Lisinopril is part of a class of drugs called angiotensin-converting enzyme (ACE) inhibitors, which have long been a cornerstone in the treatment of heart failure and high blood pressure. By blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, Lisinopril helps to relax blood vessels, reduce blood pressure, and ease the workload on the heart.

Benefits of Lisinopril for Heart Failure

• Reduced Blood Pressure: Lisinopril lowers blood pressure, making it easier for the heart to pump blood.
• Prevention of Fluid Retention: By lowering the levels of aldosterone (a hormone that retains salt and water), Lisinopril helps prevent fluid buildup, which is common in heart failure.
• Reduced Symptoms of Heart Failure: Lisinopril improves heart function, helping to alleviate symptoms such as fatigue and breathlessness.
• Long-Term Outcomes: ACE inhibitors like Lisinopril have been shown to reduce hospitalizations and increase survival rates in patients with heart failure.

What is Entresto?

Entresto (sacubitril/valsartan) is a newer medication specifically designed for the treatment of heart failure. It’s a combination of two active ingredients:

1. Sacubitril: A neprilysin inhibitor that helps to enhance the body’s natural mechanisms for relaxing blood vessels and reducing fluid buildup.
2. Valsartan: An angiotensin II receptor blocker (ARB) that also relaxes blood vessels by blocking the effects of angiotensin II, similar to how Lisinopril works but without increasing bradykinin, a compound responsible for the characteristic cough side effect of ACE inhibitors.

The Case for Switching from Lisinopril to Entresto

Why convert from Lisinopril to Entresto? While Lisinopril has been a reliable treatment for heart failure for decades, recent clinical trials have shown that Entresto provides superior outcomes in reducing cardiovascular death and heart failure hospitalization compared to ACE inhibitors alone.

The PARADIGM-HF trial, one of the largest heart failure studies, demonstrated that Entresto reduced the risk of cardiovascular death by 20% and the risk of first heart failure hospitalization by 21% compared to enalapril, another ACE inhibitor. This has led to the recommendation that Entresto be considered in place of an ACE inhibitor for many patients with heart failure.

Key Considerations for Lisinopril to Entresto Conversion

When converting from Lisinopril to Entresto, it’s important to understand that this is not a simple drug substitution. Because these medications work differently, the transition must be done carefully, with attention to dosage, timing, and potential risks.

1. The 36-Hour Washout Period

One of the most important things to note during the conversion is the requirement for a 36-hour washout period between stopping Lisinopril and starting Entresto. This is necessary because taking an ACE inhibitor (like Lisinopril) and Entresto together can increase the risk of angioedema, a potentially life-threatening swelling of the face, lips, throat, or other areas of the body.

To minimize this risk, the ACE inhibitor must be discontinued, and the patient should wait 36 hours before starting Entresto.

2. Dosage Conversion

Switching from Lisinopril to Entresto isn’t a one-to-one dosage conversion. Instead, Entresto is typically started at a lower dose and then gradually titrated upward based on the patient’s tolerance and kidney function. For example:

• Lisinopril: Patients may be taking a common dose of 10-40 mg per day.
• Entresto: The initial dose is generally 24/26 mg or 49/51 mg twice daily, depending on the patient’s blood pressure, kidney function, and previous heart failure treatment.

The exact dose of Entresto will depend on several factors, including how well the patient tolerated Lisinopril and their overall health status.

3. Monitoring and Follow-Up

Once the switch is made, it’s essential to closely monitor the patient’s response to Entresto. This includes:

• Blood Pressure: Both Lisinopril and Entresto can lower blood pressure, so it’s important to monitor for hypotension (low blood pressure).
• Renal Function: Kidney function should be checked regularly, as both medications are processed by the kidneys and can affect their function.
• Potassium Levels: Both Lisinopril and Entresto can cause hyperkalemia (high potassium levels), so potassium levels should be monitored to avoid complications.

Regular follow-up visits are important to assess the effectiveness of the medication and to adjust the dose as needed.

Potential Side Effects of Lisinopril vs. Entresto

Both medications have potential side effects that need to be considered when converting from one to the other.

Common Side Effects of Lisinopril:

• Cough: One of the most common reasons patients switch from Lisinopril to Entresto is due to the persistent dry cough caused by the accumulation of bradykinin, which occurs with ACE inhibitors.
• Hyperkalemia: Elevated potassium levels can occur with Lisinopril and may require dietary adjustments or medication changes.
• Renal Dysfunction: ACE inhibitors can affect kidney function, so monitoring renal performance is critical.

Common Side Effects of Entresto:

• Hypotension: Because Entresto is a powerful vasodilator, it can cause significant drops in blood pressure, especially in patients who are already taking other blood pressure-lowering medications.
• Hyperkalemia: Like Lisinopril, Entresto can also lead to high potassium levels, necessitating regular blood tests.
• Angioedema: Although less common with Entresto than with ACE inhibitors, angioedema can still occur and is a serious side effect that requires immediate medical attention.

Special Considerations for Specific Patient Populations

Certain patients may require special attention when converting from Lisinopril to Entresto, particularly those with renal impairment, elderly patients, and those with low blood pressure.

• Renal Impairment: Patients with kidney problems may need lower doses of Entresto, and renal function should be monitored closely during the transition.
• Pregnancy and Breastfeeding: Neither Lisinopril nor Entresto is recommended for use during pregnancy due to the risk of fetal harm. Women of childbearing age should be advised to use contraception while on either medication.
• Elderly Patients: Older patients are more likely to experience side effects such as low blood pressure and kidney dysfunction, so extra caution is needed when adjusting doses.

Benefits of Switching from Lisinopril to Entresto

The key reasons for converting from Lisinopril to Entresto revolve around improved patient outcomes, particularly in terms of reducing hospitalizations and cardiovascular mortality. Entresto’s dual mechanism of action — inhibiting neprilysin to enhance beneficial peptides and blocking the harmful effects of angiotensin II — provides a broader spectrum of benefits for heart failure patients.

Improved Heart Failure Management

The combination of sacubitril and valsartan has been shown to:

• Reduce the risk of death from cardiovascular causes.
• Lower the rate of first and subsequent heart failure hospitalizations.
• Improve patients’ overall quality of life by better managing heart failure symptoms.

Making the Switch

Converting from Lisinopril to Entresto is a decision that should be made based on a comprehensive assessment of the patient’s health, tolerability to medications, and the potential benefits of Entresto. With the demonstrated advantages of Entresto in reducing heart failure-related deaths and hospitalizations, many healthcare providers are recommending this switch for appropriate patients. However, it’s essential to follow the correct procedure, including the 36-hour washout period, dosage adjustments, and close monitoring of side effects such as hypotension and hyperkalemia.

Patients who are switched from Lisinopril to Entresto often experience significant improvements in their heart failure management, with fewer hospitalizations and better overall quality of life. Always consult your healthcare provider before making any changes to your medication regimen.