Telmisartan40 offers distinct pharmacokinetic advantages over other ARBs. It is highly lipophilic, and has a high volume of distribution and long elimination half-life (24h). Olmesartan has a shorter elimination half-life than telmisartan, but at the recommended clinical doses its duration of action is also 24 h. The relative potency of candesartan cilexetil, the prodrug of candesartan,41 is higher, but its bioavailability and volume of distribution are lower than those of other ARBs (Table 6). In many clinical trials the side effects of ARBs were not distinguishable from those of placebo. However, like ACEIs they may induce hyperkalemia, particularly in patients with chronic renal failure and in those receiving potassium-sparing diuretics or potassium supplements. Also in volume-depleted patients ARBs may cause excessive hypotension and deterioration of renal function. Some clinical trials suggested differences in the antihypertensive efficacy of individual ARBs at the recommended clinical doses, but these differences are most likely due to the fact that ARBs have been compared at noncomparable doses. There is no convincing evidence that 'sartans' differ from each other in their maximal obtainable antihypertensive effects. ARBs appear to be as organ-protective as ACEIs in animal studies, but their primary indication is hypertension. Valsartan is approved for the treatment of heart failure, New York Heart Association grades II-IV but only for patients who are intolerant to ACEIs. Losartan and irbesartan are also approved for the treatment of diabetic nephropathy.

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