What is required before starting sacubitril/valsartan in a patient recently treated with an ACE inhibitor?

• A. ACE inhibitor washout period (approximately 36 hours) to reduce angioedema risk.
• B. Continue ACE inhibitor and start ARNI immediately.
• C. Increase ACE inhibitor dose before starting ARNI.
• D. No need for washout; start ARNI and monitor for angioedema.

Answer: (A)

Switching to sacubitril/valsartan from an ACE inhibitor requires a washout period to lower the risk of angioedema by avoiding excessive bradykinin buildup. ACE inhibitors raise bradykinin levels, and adding a neprilysin inhibitor like sacubitril soon after an ACE inhibitor can significantly increase that risk. Therefore, the ACE inhibitor should be stopped and a washout of about 36 hours observed before starting sacubitril/valsartan. Starting the ARNI immediately while the ACE inhibitor is still active, or increasing the ACE inhibitor dose before the switch, would keep angioedema risk high and is not advised. There’s no need to proceed without a washout and simply start the ARNI while monitoring, as that would still expose the patient to unnecessary risk.