Angiotensin II receptor blocker
ATC code: C09CA06 (Candesartan)
Brand names
Atacand, Amias, Blopress
Selectively blocks AT1 angiotensin II receptors. Reduces blood pressure and left ventricular load. Alternative to ACE inhibitors for cough-intolerant patients.
First line
Candesartan reduces cardiovascular mortality and hospitalization in heart failure with reduced ejection fraction, as shown in the CHARM program (Lancet 2003): three trials in patients with EF 40 percent or below, including CHARM-Alternative in ACE-inhibitor-intolerant patients. 2023 and NG106 recommend ARBs as an alternative to ACE inhibitors in patients with cough or a history of angioedema.
First line
Candesartan lowers blood pressure and major cardiovascular events in adults. 2024 and NG136 list ARBs as first-line therapy for hypertension as monotherapy and in combination with a thiazide diuretic or calcium channel blocker. Once-daily dosing with 24-hour effect improves adherence compared with twice-daily losartan.
In patients over 75, start at 4 mg daily. With eGFR below 30 mL/min/1.73 m², start at 4 mg with potassium and creatinine monitoring.
Sources
First line
ARBs slow the progression of diabetic nephropathy in patients with type 2 diabetes and albuminuria. Pivotal trials are RENAAL (losartan) and IDNT (irbesartan). The DIRECT-Protect 2 trial with candesartan showed a reduction in the progression rate from microalbuminuria to nephropathy. KDIGO 2022 lists ARBs as first-choice agents in patients with albuminuria alongside ACE inhibitors.
Second line
Candesartan reduces migraine attack frequency by 26 percent versus placebo in the Tronvik RCT (JAMA 2003) at 16 mg daily for 12 weeks. 2019 classifies candesartan at evidence level C: considered as second-line in patients with contraindications to topiramate, propranolol, and amitriptyline, or with co-existing hypertension. Off-label in the Russian Federation.
Boxed warning
FDA boxed warning: when pregnancy is detected, candesartan is discontinued immediately. Use in the second and third trimesters is associated with oligohydramnios, pulmonary hypoplasia, and fetal renal failure.
FDA category C in the first trimester, D in the second and third. When pregnancy is planned, switch to a safer antihypertensive (methyldopa, labetalol, extended-release nifedipine).
Data on candesartan transfer into human milk are limited. LactMed suggests choosing ACE inhibitors (captopril, enalapril) or alternative classes for breastfeeding mothers when therapy is required.
candesartan is evaluated for the following indications with varying evidence strength: Hypertension (evidence tier A), Heart failure with reduced ejection fraction (evidence tier A), Diabetic nephropathy (evidence tier B). See the full indication matrix with dosing and citations above on this page.
Common side effects of candesartan (≥ 1 in 100): Dizziness, orthostatic hypotension, Headache, Hyperkalemia, Serum creatinine increase, Upper respiratory tract infections. See the Safety section for uncommon and serious reactions.
FDA category D. FDA category C in the first trimester, D in the second and third. When pregnancy is planned, switch to a safer antihypertensive (methyldopa, labetalol, extended-release nifedipine).
Data on candesartan transfer into human milk are limited. LactMed suggests choosing ACE inhibitors (captopril, enalapril) or alternative classes for breastfeeding mothers when therapy is required.
candesartan is contraindicated in: Pregnancy; Severe hepatic impairment and/or cholestasis; Bilateral renal artery stenosis or stenosis of a solitary kidney artery; Hyperkalemia above 5.5 mmol/L; Concomitant aliskiren in patients with diabetes or eGFR below 60 mL/min/1.73 m². Full list in the Safety section.
FDA boxed warning: when pregnancy is detected, candesartan is discontinued immediately. Use in the second and third trimesters is associated with oligohydramnios, pulmonary hypoplasia, and fetal renal failure.
an FDA meta-analysis in 2018 refuted a link between ARB use and cancer incidence. The 2018–2019 recalls of losartan and valsartan batches concerned N-nitrosodimethylamine impurities at specific manufacturers, not the class.
monotherapy is less effective, but combined with a thiazide or calcium channel blocker, ARBs are effective in this population too.
at equivalent doses, candesartan provides more stable 24-hour BP control and a larger event reduction in the CHARM heart failure program.