Major
Enalapril × telmisartan
Angiotensin-converting enzyme inhibitors (ACEi)×Angiotensin II receptor blocker (ARB)
Mechanism
Dual RAAS blockade – increased hyperkalaemia, hypotension, and acute kidney injury without outcome improvement (ONTARGET).
Symptoms
Muscle weakness, paraesthesia, slowed pulse, arrhythmias. ECG: peaked T waves, widened QRS. Severe cases progress to cardiac arrest.
Management
The combination is not prescribed. Choose one: ACE-I (enalapril) if tolerated, ARB (telmisartan) if there is a dry cough.
Sources
- ONTARGET Investigators: Telmisartan, Ramipril, or Both in Patients at High Risk for Vascular Events (2008)– N Engl J Med 2008;358(15):1547–1559