Angiotensin II receptor blocker

Group of pharmaceuticals that modulate the renin–angiotensin system

"Sartan" redirects here. For the village in Iran, see Sartan, Iran.

Losartan, the first ARB

Angiotensin II receptor blockers (ARBs), formally angiotensin II receptor type 1 (AT1) antagonists,[1] also known as angiotensin receptor blockers,[2][3] angiotensin II receptor antagonists, or AT1 receptor antagonists, are a group of pharmaceuticals that bind to and inhibit the angiotensin II receptor type 1 (AT1) and thereby block the arteriolar contraction and sodium retention effects of renin–angiotensin system.[4]

Their main uses are in the treatment of hypertension (high blood pressure), diabetic nephropathy (kidney damage due to diabetes) and congestive heart failure. They selectively block the activation of the AT1 receptor, preventing the binding of angiotensin II compared to ACE inhibitors.[4]

ARBs and the similar-attributed ACE inhibitors are both indicated as the first-line antihypertensives in patients developing hypertension along with left-sided heart failure.[5] However, ARBs appear to produce less adverse effects compared to ACE inhibitors.[5]

## Medical uses

[edit]

Angiotensin II receptor blockers are used primarily for the treatment of hypertension where the patient is intolerant of ACE inhibitor therapy primarily because of persistent and/or dry cough.[6] They do not inhibit the breakdown of bradykinin or other kinins, and are thus only rarely associated with the persistent dry cough and/or angioedema that limit ACE inhibitor therapy.[citation needed] More recently, they have been used for the treatment of heart failure in patients intolerant of ACE inhibitor therapy, in particular candesartan. Irbesartan and losartan have trial data showing benefit in hypertensive patients with type 2 diabetes,[citation needed] and may delay the progression of diabetic nephropathy.[citation needed] A 1998 double-blind study found "that lisinopril improved insulin sensitivity whereas losartan did not affect it."[7] Candesartan is used experimentally in preventive treatment of migraine.[8][9] Lisinopril has been found less often effective than candesartan at preventing migraine.[10]

The angiotensin II receptor blockers have differing potencies in relation to blood pressure control, with statistically differing effects at the maximal doses.[11] When used in clinical practice, the particular agent used may vary based on the degree of response required.

Some of these drugs have a uricosuric effect.[12][13]

Angiotensin II, through AT1 receptor stimulation, is a major stress hormone and, because (ARBs) block these receptors, in addition to their eliciting anti-hypertensive effects, may be considered for the treatment of stress-related disorders.[14]

In 2008, they were reported to have a remarkable negative association with Alzheimer's disease (AD). A retrospective analysis of five million patient records with the US Department of Veterans Affairs system found different types of commonly used antihypertensive medications had very different AD outcomes. Those patients taking angiotensin receptor blockers (ARBs) were 35 to 40% less likely to develop AD than those using other antihypertensives.[15][16]

A retrospective study of 1968 stroke patients revealed that prestroke treatment with ARB may be associated with both reduced stroke severity and better outcome. This finding agrees with experimental data that suggest that ARB's exert a cerebral protective effect.[17]

## Adverse effects

[edit]

This class of drugs is usually well tolerated. Common adverse drug reactions (ADRs) include: dizziness, headache, and/or hyperkalemia. Infrequent ADRs associated with therapy include: first dose orthostatic hypotension, rash, diarrhea, dyspepsia, abnormal liver function, muscle cramp, myalgia, back pain, insomnia, decreased hemoglobin levels, renal impairment, pharyngitis, and/or nasal congestion.[18] A 2014 Cochrane systematic review based on randomized controlled trials reported that when comparing patients taking ACE inhibitors to patients taking ARBs, fewer ARB patients withdrew from the study due to adverse events compared to ACE inhibitor patients.[19]

While one of the main rationales for the use of this class is the avoidance of a persistent dry cough and/or angioedema associated with ACE inhibitor therapy, rarely they may still occur. In addition, there is also a small risk of cross-reactivity in patients having experienced angioedema with ACE inhibitor therapy.[18]

### Myocardial infarction

[edit]

The issue of whether angiotensin II receptor antagonists slightly increase the risk of myocardial infarction (MI or heart attack) is currently being investigated. Some studies suggest ARBs can increase the risk of MI.[20] However, other studies have found ARBs do not increase the risk of MI.[21] To date, with no consensus on whether ARBs have a tendency to increase the risk of myocardial infarction, further investigations are underway.[needs update]

Indeed, as a consequence of AT1 blockade, ARBs increase angiotensin II levels several-fold above baseline by uncoupling a negative-feedback loop. Increased levels of circulating angiotensin II result in unopposed stimulation of the AT2 receptors, which are, in addition, upregulated. However, recent data suggest AT2 receptor stimulation may be less beneficial than previously proposed, and may even be harmful under certain circumstances through mediation of growth promotion, fibrosis, and hypertrophy, as well as eliciting proatherogenic and proinflammatory effects.[22][23][24]

### Cancer

[edit]

A study published in 2010 determined that "...meta-analysis of randomised controlled trials suggests that ARBs are associated with a modestly increased risk of new cancer diagnosis. Given the limited data, it is not possible to draw conclusions about the exact risk of cancer associated with each particular drug. These findings warrant further investigation."[25] A later meta-analysis by the U.S. Food and Drug Administration (FDA) of 31 randomized controlled trials comparing ARBs to other treatment found no evidence of an increased risk of incident (new) cancer, cancer-related death, breast cancer, lung cancer, or prostate cancer in patients receiving ARBs.[26] In 2013, comparative effectiveness research from the United States Department of Veterans Affairs on the experience of more than a million veterans found no increased risks for either lung cancer[27] or prostate cancer.[28] The researchers concluded: "In this large nationwide cohort of United States Veterans, we found no evidence to support any concern of increased risk of lung cancer among new users of ARBs compared with nonusers. Our findings were consistent with a protective effect of ARBs."[27]

In May 2013, a senior regulator at the Food & Drug Administration, Medical Team Leader Thomas A. Marciniak, revealed publicly that contrary to the FDA's official conclusion that there was no increased cancer risk, after a patient-by-patient examination of the available FDA data he had concluded that there was a lung-cancer risk increase of about 24% in ARB patients, compared with patients taking a placebo or other drugs. One of the criticisms Marciniak made was that the earlier FDA meta-analysis did not count lung carcinomas as cancers. In ten of the eleven studies he examined, Marciniak said that there were more lung cancer cases in the ARB group than the control group. Ellis Unger, chief of the drug-evaluation division that includes Marciniak, was quoted as calling the complaints a "diversion," and saying in an interview, "We have no reason to tell the public anything new." In an article about the dispute, the Wall Street Journal interviewed three other doctors to get their views; one had "no doubt" ARBs increased cancer risk, one was concerned and wanted to see more data, and the third thought there was either no relationship or a hard to detect, low-frequency relationship.[29]

A 2016 meta-analysis including 148,334 patients found no significant differences in cancer incidence associated with ARB use.[30]

### Kidney failure

[edit]

Although ARBs have protective effects against developing kidney diseases for patients with diabetes and previous hypertension without administration of ARBs,[31] ARBs may worsen kidney functions such as reducing glomerular filtration rate associated with a rise of serum creatinine in patients with pre-existing proteinuria, renal artery stenosis, hypertensive nephrosclerosis, heart failure, polycystic kidney disease, chronic kidney disease, interstitial fibrosis, focal segmental glomerulosclerosis, or any conditions such as ARBs-treated but still clinically present hypertension that lead to abnormal narrowing of blood vessels to the kidney that interrupts oxygen and nutrient supply to the organ.[32][33][34][35][36][37][31][excessive citations]

## History

[edit]

Further information: Discovery and development of angiotensin receptor blockers

## Structure

[edit]

Losartan, irbesartan, olmesartan, candesartan, valsartan, fimasartan include the tetrazole group (a ring with four nitrogen and one carbon). Losartan, irbesartan, olmesartan, candesartan, and telmisartan include one or two imidazole groups.

## Mechanism of action

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These substances are AT1-receptor antagonists; that is, they block the activation of angiotensin II AT1 receptors. AT1 receptors are found in smooth muscle cells of vessels, cortical cells of the adrenal gland, and adrenergic nerve synapses. Blockage of AT1 receptors directly causes vasodilation, reduces secretion of vasopressin, and reduces production and secretion of aldosterone, among other actions. The combined effect reduces blood pressure.[citation needed]

The specific efficacy of each ARB within this class depends upon a combination of three pharmacodynamic (PD) and pharmacokinetic (PK) parameters. Efficacy requires three key PD/PK areas at an effective level; the parameters of the three characteristics will need to be compiled into a table similar to one below, eliminating duplications and arriving at consensus values; the latter are at variance now.[citation needed]

### Pressor inhibition

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Pressor inhibition at trough level — this relates to the degree of blockade or inhibition of the blood pressure-raising ("pressor") effect of angiotensin II. However, pressor inhibition is not a measure of blood pressure-lowering (BP) efficacy per se. The rates as listed in the U.S. Food and Drug Administration (FDA) Package Inserts (PIs) for inhibition of this effect at the 24th hour for the ARBs are as follows:

* Valsartan - 30% at 80 mg
* Telmisartan - 40% at 80 mg
* Losartan - 25–40% at 100 mg
* Irbesartan - 40% at 150 mg; 60% 300 mg
* Azilsartan - 60% at 32 mg
* Olmesartan - 61% at 20 mg; 74% at 40 mg

### AT1 affinity vs AT2

[edit]

This section needs additional citations for verification. Please help improve this article by adding citations to reliable sources in this section. Unsourced material may be challenged and removed. (January 2022) (Learn how and when to remove this message)

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The ratios of AT1 to AT2 in binding affinities of the specific ARBs are shown as follows. However, AT1 affinity vs AT2 is not a meaningful indicator of blood pressure response.[38]

* Losartan - 1000-fold[citation needed]
* Telmisartan - 3000-fold[citation needed]
* Irbesartan - 8500-fold[citation needed]
* Candesartan - greater than 10000-fold[citation needed]
* Olmesartan - 12500-fold[citation needed]
* Valsartan - 30000-fold[39][40]
* Saprisartan – ???[41]

### Binding affinities Ki

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This section needs expansion. You can help by adding to it. (May 2019)

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### Component

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Nearly all ARBs contain biphenyltetrazole moiety except telmisartan and eprosartan.[40]

### Active agent

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Losartan carries a heterocycle imidazole while valsartan carries a nonplanar acylated amino acid.[40]

## Pharmacokinetics comparison

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Table 1: Comparison of ARB pharmacokinetics Drug  | Trade name  | Biological half-life [hrs]  | Peak plasma concentration [Tmax]  | Protein binding [%]  | Bioavailability [%]  | Renal/hepatic clearance [%]  | Food effect  | Daily dosage [mg]  | Metabolism/transporter

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Losartan | Cozaar  | 2 h  | 1 hr [42] | 98.7%  | 33%  | 10/90%  | Minimal  | 50–100  | Sensitive substrates: CYP2C9 and CYP3A4[42]
EXP 3174 active metabolite of losartan  | \-  | 6–9 hrs  | 3–4 hrs after oral losartan administration[42] | 99.8%  | –  | 50/50%  | –  | –  | AUC reduced by phenytoin and rifampin by 63%[43] and 40%[42] respectively; specific CYP450 isozymes are unknown
Candesartan | Atacand  | 9  | 3–4 hrs[44] | >99%  | 15%  | 60/40%  | No  | 4–32  | Moderate sensitive substrate: CYP2C9[44]
Valsartan | Diovan  | 6  | 2–4 hrs[45] | 95%  | 25%  | 30/70%  | Yes  | 80–320  | Substrates: MRP2 and OATP1B1/SLCO1B1[45]
Irbesartan | Avapro  | 11–15  | 1.5–2 hrs[46] | 90–95%  | 70%  | 20/80%  | No  | 150–300  | Minor substrates of CYP2C9[46]
Telmisartan | Micardis  | 24  | 0.5–1 hr [47] | >99%  | 42–58%  | 1/99%  | No  | 40–80  | None known; >97% via biliary excretion[47]
Eprosartan | Teveten  | 5  | 1–2 hrs [48] | 98%  | 13%  | 30/70%  | No  | 400–800  | None known; >90% via renal and biliary excretion[48]
Olmesartan | Benicar/Olmetec  | 14–16  | 1–2 hrs [49] | >99%  | 29%  | 40/60%  | No  | 10–40  | Substrates of OATP1B1/SLCO1B1[49]
Azilsartan | Edarbi  | 11  | 1.5–3 hrs [50] | >99%  | 60%  | 55/42%  | No  | 40–80  | Minor substrates of CYP2C9 [50]
Fimasartan | Kanarb  | 7–11  | 0.5–3 hrs after dosing.[51] | >97%  | 30–40%  | –  | –  | 30–120  | None known; primarily biliary excretion [52]
Drug  | Trade name  | Biological half-life [hrs]  | Peak plasma concentration [Tmax]  | Protein binding [%]  | Bioavailability [%]  | Renal/hepatic clearance [%]  | Food effect  | Daily dosage [mg]  | Metabolism/transporter

[53][54][55][56][57]

Further information: Discovery and development of angiotensin receptor blockers

## Research

[edit]

### Longevity

[edit]

Knockout of the Agtr1a gene that encodes AT1 results in marked prolongation of the life-span of mice, by 26% compared to controls. The likely mechanism is reduction of oxidative damage (especially to mitochondria) and overexpression of renal prosurvival genes. The ARBs seem to have the same effect.[58][59]

### Fibrosis regression

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ARBs, such as losartan, have been shown to curb or reduce muscular,[60] liver,[61] cardiac,[62] and kidney[63] fibrosis.

### Dilated aortic root regression

[edit]

A 2003 study using candesartan and valsartan demonstrated an ability to regress dilated aortic root size.[64]

## Impurities

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See also: Ranitidine § impurities

### Nitrosamines

[edit]

In 2018 and in 2019, the U.S Food and Drug Administration (FDA) found traces of NDMA and NDEA impurities in the angiotensin II receptor blocker (ARB) drug products valsartan, losartan, and irbesartan.[65][66][67][68][69] The FDA stated "In June 2018, FDA was informed of the presence of an impurity, identified as N-Nitrosodimethylamine (NDMA), from one[70] API producer. Since then, FDA has determined that other types of nitrosamine compounds, e.g., N-Nitrosodiethylamine (NDEA), are present at unacceptable levels in APIs from multiple API producers of valsartan and other drugs in the ARB class."[71] In 2018, the FDA issued guidance to the industry on how to assess and control the impurities.[72]

In August 2020, the European Medicines Agency (EMA) provided guidance to marketing authorization holders on how to avoid the presence of nitrosamine impurities in human medicines and asked them to review all chemical and biological human medicines for the possible presence of nitrosamines and to test the products at risk.[73]

In November 2020, the Committee for Medicinal Products for Human Use (CHMP) of the EMA aligned recommendations for limiting nitrosamine impurities in sartan medicines with recommendations it issued for other classes of medicines.[74] The main change concerns the limits for nitrosamines, which previously applied to the active ingredients but now apply instead to the finished products (e.g. tablets).[74] These limits, based on internationally agreed standards (ICH M7(R1)), should ensure that the excess risk of cancer from nitrosamines in any sartan medicines is below 1 in 100,000 for a person taking the medicine for lifelong treatment.[74]

These sartan medicines have a specific ring structure (tetrazole) whose synthesis could potentially lead to the formation of nitrosamine impurities.[74][75] Other sartan medicines which do not have this ring, such as azilsartan, eprosartan and telmisartan, were not included in this review but are covered by the subsequent review of other medicines.[74]

### Azides

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Losartan azide (left) and AZBT (right), two azido process impurities detected in sartans. Losartan azide occurs exclusively during manufacture of losartan, while AZBT can be found in several drugs in the class.

In April 2021, the European Directorate for the Quality of Medicines (EDQM) warned of the risk of contamination with non-nitrosamine impurities (specifically, azido compounds) in tetrazole-containing sartans.[76] In September 2021, the EDQM announced that investigations had revealed a novel azido contaminant which occurs only in losartan (losartan azide or losartan azido impurity) and which was found to be mutagenic on Ames testing.[77]

Later in 2021 and 2022, several cases of contamination with azido impurities were detected in losartan, irbesartan, and valsartan, prompting regulatory responses ranging from investigation to market withdrawals and precautionary recalls in Australia,[78] Brazil,[79] and Europe (including Switzerland).[80][81]

Teva Pharmaceuticals announced that it would change its losartan manufacturing process to prevent future contamination with these impurities,[80] and the Indian API manufacturer IOL Chemicals and Pharmaceuticals applied for a patent on a new synthesis of losartan designed to be free of azido contaminants.[82]

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45. ^ a b "VALSARTAN - valsartan tablet". DailyMed. 2017-12-07. Retrieved 2019-02-06.
46. ^ a b "IRBESARTAN - irbesartan tablet". DailyMed. 2018-09-04. Retrieved 2019-02-06.
47. ^ a b "TELMISARTAN - telmisartan tablet". DailyMed. 2018-11-01. Retrieved 2019-02-06.
48. ^ a b "EPROSARTAN MESYLATE- eprosartan mesylate tablet, film coated". DailyMed. 2014-12-05. Retrieved 2019-02-06.
49. ^ a b "OLMESARTAN MEDOXOMIL - olmesartan medoxomil tablet, film coated". DailyMed. 2017-05-04. Retrieved 2019-02-06.
50. ^ a b "EDARBI- azilsartan kamedoxomil tablet". DailyMed. 2018-01-25. Retrieved 2019-02-06.
51. ^ Gu, N., Kim, B., Kyoung, S.L., Kim, S.E., Nam, W.S., Yoon, S.H., Cho, J., Shin, S., Jang, I., Yu, K. The Effect of Fimasartan, an Angiotensin Receptor Type 1 Blocker, on the Pharmacokinetics and Pharmacodynamics of Warfarin in Healthy Korean Male Volunteers: A One- Sequence, Two-Period Crossover Clinical Trial. (2012). Clinical Therapeutics. 34(7): 1592–1600.
52. ^ Chi, Yong Ha; Lee, Howard; Paik, Soo Heui; Lee, Joo Han; Yoo, Byoung Wook; Kim, Ji Han; Tan, Hyun Kwang; Kim, Sang Lin (2011-10-01). "Safety, tolerability, pharmacokinetics, and pharmacodynamics of fimasartan following single and repeated oral administration in the fasted and fed states in healthy subjects". American Journal of Cardiovascular Drugs: Drugs, Devices, and Other Interventions. 11 (5): 335–346. doi:10.2165/11593840-000000000-00000. ISSN 1179-187X. PMID 21910510. S2CID 207300735.
53. ^ Burnier, M.; Brunner, H. R. (2000), "Angiotensin II receptor antagonists", Lancet, 355 (9204): 637–645, doi:10.1016/S0140-6736(99)10365-9, PMID 10696996, S2CID 18835715
54. ^ Analogue-based Drug Discovery (Optimizing Antihypertensive Therapy by Angiotensin Receptor Blockers; Farsang, C., Fisher, J., p.157–167) Editors; Fischer, J., Ganellin, R. Wiley-VCH 2006. ISBN 978-3-527-31257-3
55. ^ Brousil, J. A.; Burke, J. M. (2003), "Olmesartan Medoxomil: An Angiotensin II-Receptor Blocker", Clinical Therapeutics, 25 (4): 1041–1055, doi:10.1016/S0149-2918(03)80066-8, PMID 12809956
56. ^ Brunner, H. R. (2002), "The new oral angiotensin II antagonist olmesartan medoxomil: a concise overview", Journal of Human Hypertension, 16 (2): 13–16, doi:10.1038/sj.jhh.1001391, PMID 11967728, S2CID 24382600, ProQuest 219966061
57. ^ Zusman, R. M.; Jullien, V.; Lemetayer, P.; Jarnier, P.; Clementy, J. (1999), "Are There Differences Among Angiotensin Receptor Blockers?", American Journal of Hypertension, 12 (2 Pt 1): 231–235, doi:10.1016/S0895-7061(99)00116-8, PMID 10090354
58. ^ Benigni A, Corna D, Zoja C, Sonzogni A, Latini R, Salio M, et al. (March 2009). "Disruption of the Ang II type 1 receptor promotes longevity in mice". The Journal of Clinical Investigation. 119 (3): 524–30. doi:10.1172/JCI36703. PMC 2648681. PMID 19197138.
59. ^ Cassis P, Conti S, Remuzzi G, Benigni A (January 2010). "Angiotensin receptors as determinants of life span". Pflügers Archiv. 459 (2): 325–32. doi:10.1007/s00424-009-0725-4. PMID 19763608. S2CID 24404339.
60. ^ Hubbert, Katherine; Clement, Ryan (April 2021). "Losartan: A Novel Treatment for Acute Skeletal Muscle Injury". JBJS Journal of Orthopaedics for Physician Assistants. 9 (2). doi:10.2106/JBJS.JOPA.20.00030. ISSN 2470-1122. S2CID 242846521. Retrieved 14 April 2022.
61. ^ Salama, Zakaria A.; Sadek, Ahmed; Abdelhady, Ahmed M.; Darweesh, Samar Kamal; Morsy, Shereif Ahmed; Esmat, Gamal (June 2016). "Losartan may inhibit the progression of liver fibrosis in chronic HCV patients". Hepatobiliary Surgery and Nutrition. 5 (3): 249–255. doi:10.21037/hbsn.2016.02.06. ISSN 2304-3881. PMC 4876242. PMID 27275467.
62. ^ Wang, J; Duan, L; Gao, Y; Zhou, S; Liu, Y; Wei, S; An, S; Liu, J; Tian, L; Wang, S (5 September 2018). "Angiotensin II receptor blocker valsartan ameliorates cardiac fibrosis partly by inhibiting miR-21 expression in diabetic nephropathy mice". Molecular and Cellular Endocrinology. 472: 149–158. doi:10.1016/j.mce.2017.12.005. PMID 29233785. S2CID 6615686. Retrieved 14 April 2022.
63. ^ Naito, T; Ma, LJ; Yang, H; Zuo, Y; Tang, Y; Han, JY; Kon, V; Fogo, AB (March 2010). "Angiotensin type 2 receptor actions contribute to angiotensin type 1 receptor blocker effects on kidney fibrosis". American Journal of Physiology. Renal Physiology. 298 (3): F683-91. doi:10.1152/ajprenal.00503.2009. PMC 2838584. PMID 20042458.
64. ^ Weinberg MS, Weinberg AJ, Cord RB, Martin H (1 May 2003). "P-609: Regression of dilated aortic roots using supramaximal and usual doses of angiotensin receptor blockers". American Journal of Hypertension. 16 (S1): 259A. doi:10.1016/S0895-7061(03)00782-9. ISSN 0895-7061. "In conclusion, we demonstrated regression of DAR using ARBs at moderate and supramaximal doses. Intensive ARB therapy offers a promise to reduce the natural progression of disease in patients with DARs."
65. ^ "FDA Updates and Press Announcements on Angiotensin II Receptor Blocker (ARB) Recalls (Valsartan, Losartan, and Irbesartan)". Food and Drug Administration (FDA). 20 August 2018. Retrieved 17 September 2019.
66. ^ "Statement on the agency's ongoing efforts to resolve safety issue with ARB medications". Food and Drug Administration (FDA). 28 August 2019. Retrieved 17 September 2019.
67. ^ "FDA's Assessment of Currently Marketed ARB Drug Products". Food and Drug Administration (FDA). 4 April 2019. Archived from the original on 30 December 2019. Retrieved 17 September 2019.
68. ^ "Search List of Recalled Angiotensin II Receptor Blockers (ARBs) including Valsartan, Losartan and Irbesartan". Food and Drug Administration (FDA). 28 June 2019. Retrieved 17 September 2019.
69. ^ "Updated: Torrent Pharmaceuticals Limited Expands Voluntary Nationwide Recall of Losartan Potassium Tablets, USP and Losartan Potassium / Hydrochlorothiazide Tablets, USP". U.S. Food and Drug Administration. 23 September 2019. Retrieved 24 September 2019.
70. ^ valsartan
71. ^ "General Advice ARB" (PDF). Food and Drug Administration (FDA). Retrieved 17 September 2019. This article incorporates text from this source, which is in the public domain.
72. ^ "M7(R1) Assessment and Control of DNA Reactive (Mutagenic) Impurities in Pharmaceuticals To Limit Potential Carcinogenic Risk" (PDF). Food and Drug Administration (FDA). 30 August 2018. Retrieved 17 September 2019.
73. ^ "Nitrosamine impurities". European Medicines Agency. 23 October 2019. Retrieved 6 August 2020. Text was copied from this source which is copyright European Medicines Agency. Reproduction is authorized provided the source is acknowledged.
74. ^ a b c d e "Nitrosamines: EMA aligns recommendations for sartans with those other medicines". European Medicines Agency (EMA) (Press release). 12 November 2020. Retrieved 13 November 2020. Text was copied from this source which is copyright European Medicines Agency. Reproduction is authorized provided the source is acknowledged.
75. ^ "Angiotensin-II-receptor antagonists (sartans) containing a tetrazole group". European Medicines Agency (EMA). 17 September 2018. Retrieved 13 November 2020.
76. ^ "Risk of presence of mutagenic azido impurities in sartan active substances with a tetrazole ring" (Press release). European Directorate for the Quality of Medicines & HealthCare. 29 April 2021. Retrieved 26 June 2022.
77. ^ "Risk of the presence of mutagenic azido impurities in losartan active substance" (Press release). European Directorate for the Quality of Medicines & HealthCare. 29 September 2021. Retrieved 26 June 2022.
78. ^ Therapeutic Goods Administration (TGA) (20 August 2021). "Azide impurity in 'sartan' blood pressure medicines". Retrieved 26 June 2022.
79. ^ "Losartana: Anvisa determina recolhimento e interdição de lotes; veja o que fazer". g1 (in Portuguese). Grupo Globo. 23 June 2022. Retrieved 26 June 2022.
80. ^ a b Chapman, Kit (29 June 2021). "Sartan contaminant recall hits generics manufacturers". Chemistry World. Retrieved 26 June 2022.
81. ^ Swissmedic (1 July 2021). "Monitoring of sartan medicines stepped up: traces of a new foreign substance detected". Retrieved 26 June 2022.
82. ^ "Process For The Preparation Of Carcinogenic Azido Impurities Free Losartan And Salts Thereof". 5 April 2022. Retrieved 26 June 2022.

## External links

[edit]

* Angiotensin II Type 1 Receptor Blockers at the U.S. National Library of Medicine Medical Subject Headings (MeSH)
* "Nitrosamine impurities in medications: Guidance". Health Canada. 4 April 2022.

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Major chemical drug groups – based upon the Anatomical Therapeutic Chemical Classification System

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Pharmacomodulation

Types|

* ♦ Enzyme: Inducer
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Classes|

| Enzyme|

see Enzyme inhibition

|

Ion channel|

See Ion channel modulators

Receptor &
transporter|

| BA/M|

| Adrenergic|

* Adrenergic receptor agonist (α
* β (1
* 2))
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* 2)
* β)
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Dopaminergic|

* Dopamine receptor agonist
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AA|

| GABAergic|

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Glutamatergic|

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Cholinergic|

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Other|

* Adenosine reuptake inhibitor (AdoRI)
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Miscellaneous|

* Cofactor (see Enzyme cofactors)
* Precursor (see Amino acids)

* v
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Antihypertensive drugs acting on the renin–angiotensin system (C09)

ACE inhibitors
("-pril")|

* Sulfhydryl-containing: Captopril
* Rentiapril
* Zofenopril
* Dicarboxylate-containing: Enalapril#
* Benazepril
* Cilazapril
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* Fosinopril (+HCT)
* Other/ungrouped: Alacepril

AIIRAs
("-sartan")|

* Azilsartan
* Candesartan
* Eprosartan
* Fimasartan
* Irbesartan (+HCT)
* Losartan (+HCT)
* Olmesartan (+amlodipine, +amlodipine and HCT, +HCT)
* Tasosartan§
* Telmisartan (+amlodipine, +HCT)
* Valsartan (+amlodipine, +amlodipine and HCT, +HCT, +nebivolol)

Renin inhibitors
("-kiren")|

* Aliskiren (+amlodipine, +HCT, +amlodipine and HCT)
* Remikiren§

Dual ACE/NEP inhibitors|

* Gemopatrilat
* Ilepatril
* Omapatrilat
* Sampatrilat

Neprilysin inhibitors|

* Sacubitril (+valsartan)

* #WHO-EM
* ‡Withdrawn from market
* Clinical trials:
* †Phase III
* §Never to phase III

* v
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* e

Angiotensin receptor modulators

ATRTooltip Angiotensin receptor|

* Agonists: Angiotensin II
* Angiotensin III
* Angiotensin IV
* L-163,491
* Saralasin

* Antagonists: Abitesartan
* Azilsartan
* Candesartan
* Elisartan
* Embusartan
* Eprosartan
* EXP-3174
* Fimasartan
* Forasartan
* Irbesartan
* Losartan
* Milfasartan
* Olmesartan
* Olodanrigan
* PD123319
* Pomisartan
* Pratosartan
* Ripisartan
* Saprisartan
* Sparsentan
* Tasosartan
* Telmisartan
* Valsartan
* Zolasartan

* ACE inhibitors: Alacepril
* Benazepril
* Captopril
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* Imidapril
* Lisinopril
* Moexipril
* Omapatrilat
* Perindopril
* Quinapril
* Quinaprilat
* Ramipril
* Rentiapril
* Rescinnamine
* Spirapril
* Spiraprilat
* Temocapril
* Trandolapril
* Zofenopril
* Zofenoprilat

* Renin inhibitors: Aliskiren
* Ciprokiren
* Ditekiren
* Enalkiren
* Imarikiren
* Pepstatin
* Remikiren
* Terlakiren
* Zankiren

* Propeptides: Angiotensinogen
* Angiotensin I

Combinations:|

* Amlodipine/valsartan
* Olmesartan/amlodipine
* Olmesartan/amlodipine/hydrochlorothiazide
* Valsartan/hydrochlorothiazide
* Valsartan/hydrochlorothiazide/amlodipine

Portal:

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*[v]: View this template
*[t]: Discuss this template
*[e]: Edit this template
*[ATR]: Angiotensin receptor
*[ACE]: Angiotensin-converting-enzyme