Is losartan better than lisinopril?
Not necessarily. Lisinopril and losartan lower blood pressure about equally well for most people. The biggest practical difference is that lisinopril commonly causes a dry cough, while losartan rarely does.
- →Both are first-line blood pressure medications They are widely used, effective, and available as low-cost generics.
- →Losartan is often chosen after an ACE inhibitor cough Switching medications usually resolves the cough within a few weeks.
- →Both need monitoring Either medication can affect kidney function and potassium levels.
Lisinopril and losartan are two of the most commonly prescribed blood pressure medications in the US, and people often end up on one or the other without much explanation of why. They’re both effective. They’re both available as cheap generics. They both come with similar long-term cardiovascular benefits. But they’re not interchangeable, and the choice between them can matter for how you actually feel day-to-day.
They’re from different families
Lisinopril is an ACE inhibitor (angiotensin-converting enzyme inhibitor). It blocks the enzyme that converts angiotensin I to angiotensin II — the hormone responsible for tightening blood vessels and raising blood pressure. Less angiotensin II, lower blood pressure.
Losartan is an ARB (angiotensin II receptor blocker). It works further downstream — it lets your body make angiotensin II as usual, but blocks the receptors angiotensin II needs to bind to. Same end effect, different mechanism.
The clinical effects on blood pressure are essentially equivalent. The differences come down to side effects and a few specific situations where one is preferred.
The cough is the main difference
Because ACE inhibitors block the breakdown of bradykinin (a substance involved in inflammation), they cause a dry, tickly, persistent cough in a meaningful number of people. In studies of patients with a history of ACE-inhibitor cough, lisinopril produced cough in around 72% of those rechallenged with it — versus around 29% with losartan. In the general population, the rate of cough with lisinopril is more like 10 to 35%, but the principle is the same: lisinopril causes a cough often, losartan rarely does.
The cough usually starts within the first few weeks but can develop months in. It’s dry (not productive), persistent, often worse at night, and doesn’t respond to cough medicine. People often spend months thinking they have post-nasal drip, allergies, or asthma before someone makes the connection. The give-away: it goes away within 1 to 4 weeks of stopping the medication, and comes back if you restart it.
If you develop a cough on lisinopril, switching to losartan is the standard recommendation. Most people see the cough resolve completely.
When lisinopril is preferred
- Heart failure — ACE inhibitors have the longest track record and strongest evidence for heart failure with reduced ejection fraction. Losartan is also used in heart failure but ACE inhibitors generally come first if tolerated.
- After a heart attack — lisinopril (and other ACE inhibitors) is specifically FDA-approved for reducing mortality after MI. Losartan can be used as an alternative when ACE inhibitors aren’t tolerated.
- Some evidence for insulin sensitivity — one head-to-head study showed lisinopril improved insulin sensitivity in non-diabetic hypertensive patients while losartan did not. The clinical importance is debated, but it’s a small mark in lisinopril’s column.
- Cost — both are generic and cheap, but lisinopril is sometimes a few dollars cheaper depending on the pharmacy.
Which option fits your situation?
Lisinopril may make more sense
- ✓You tolerate ACE inhibitors without a cough
- ✓You have heart failure or recently had a heart attack
- ✓You want a very common low-cost generic option
- ✓Your doctor prefers ACE inhibitors first-line
- ✓You have done well on lisinopril long-term already
Losartan may be the better fit
- ✓You developed a dry cough on lisinopril
- ✓You need kidney protection with type 2 diabetes
- ✓You have high blood pressure with left ventricular hypertrophy
- ✓You want to avoid ACE inhibitor-related side effects
- ✓You previously had swelling or intolerance with an ACE inhibitor
When losartan is preferred
- You can’t tolerate lisinopril’s cough — by far the most common reason for switching.
- Stroke prevention in left ventricular hypertrophy — losartan has specific FDA approval for reducing stroke risk in patients with high blood pressure and a thickened heart muscle.
- Kidney protection in type 2 diabetes — losartan slows the progression of kidney disease in diabetic patients with proteinuria. ACE inhibitors do this too, so the difference is partly historical (which trials were run with which drug), but losartan has the specific FDA labeling.
- History of angioedema — a rare but serious swelling reaction (face, lips, throat) that’s more common with ACE inhibitors than ARBs. People who’ve had angioedema on any ACE inhibitor should generally avoid all of them; losartan is a reasonable alternative, though small risk remains.
What they share
- Both reduce kidney function in some patients — particularly people with existing kidney disease, those on certain other medications, or in dehydration. Periodic blood tests for kidney function and potassium are standard with either one.
- Both can raise potassium levels — worth knowing if you’re on a potassium-sparing diuretic, take potassium supplements, or use salt substitutes (which often contain potassium chloride).
- Both are dangerous in pregnancy — both carry an FDA boxed warning for fetal harm, particularly in the second and third trimesters. Anyone of childbearing potential needs to know this and use reliable contraception, or switch to a safer blood pressure medication if pregnancy is being considered.
- Both interact with NSAIDs — ibuprofen, naproxen, and similar can blunt the blood-pressure-lowering effect and increase the risk of kidney problems when combined.
- Both should not be combined with each other — stacking an ACE inhibitor and ARB doesn’t add benefit but does add risks (low blood pressure, kidney problems, high potassium).
What this means in practice
If your doctor is starting you on a blood pressure medication and the choice is open, either is reasonable. Many prescribers default to lisinopril because it’s slightly cheaper and well-studied, with the plan to switch to losartan if the cough develops. Some now go straight to losartan to skip the possibility of the cough.
If you’re already on lisinopril and tolerating it well, there’s no reason to switch — it works, and the cough usually shows up early or not at all. If you’re on lisinopril and have developed a chronic dry cough, particularly one that’s come on within months of starting, raise it with your prescriber. The fix is usually a one-line change.
And keep in mind that blood pressure medication is rarely a one-size answer. Many people end up on a combination — an ACE inhibitor or ARB plus a diuretic, plus sometimes a calcium channel blocker — to actually get blood pressure to target. The art is finding the combination that controls the numbers without producing side effects you can’t live with.
For the bigger picture on managing high blood pressure long-term — lifestyle changes, monitoring, when medication is needed — the article on managing high blood pressure is the deeper read. And if you’re wondering whether the generic version of either of these works the same as the brand, the post on generic vs brand name medications covers it.
