Angiotensin receptor blockers (ARBs) may be associated with a higher risk of suicide than angiotensin-converting enzyme inhibitors (ACEIs), according to new findings from a real-world study.

Using claims data, Tony Antoniou, PharmD, PhD, of St Michael’s Hospital in Toronto, and colleagues compared 964 older adults (aged 66 years or older; 80% male) who committed suicide with 3856 controls matched by age, sex, and the presence of diabetes and hypertension. Among cases, 26.0% used ARBs and 18.4% ACEIs. Among controls, 74.0% used ARBs, and 81.6% used ACEIs.

Compared with individuals taking ACEIs, adults taking ARBs had a 63% higher risk of dying from suicide within 100 days of prescription, according to results published in JAMA Network Open. The greater risk associated with ARBs held after a sensitivity analysis excluding adults with a history of self-injury. Investigators also adjusted for Charlson Comorbidity Index score, congestive heart failure, stroke, chronic kidney disease, chronic liver disease, alcohol abuse, affective disorder, anxiety or sleep disorder, psychoses, agitation and related disorders, other mental health conditions, psychotropic drugs, cholesterol-lowering drugs, other antihypertensives, socioeconomic status, and residence in a long-term care facility.

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“Preferential use of ACEIs over ARBs should be considered whenever possible, particularly in patients with severe mental health illness,” Dr Antoniou’s team wrote.

In an accompanying editorial, Ira R. Katz, MD, PhD, of Philadelphia VA Medical Center, commented, “Overall, the findings are important, but they require replication based on data from other populations and a synthesis of the evidence. The problem is that our current system provides few incentives or rewards for replication.”

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Mamdani M, Gomes T, Greaves S, et al. Association between angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and suicide [published online October 16, 2019]. JAMA Netw Open. 2019;2(10):e1913304. doi:10.1001/jamanetworkopen.2019.13304

Katz IR. Concerns raised by a study of suicide as an adverse drug effect—Replicating findings from real-world data [published online October 16, 2019]. JAMA Netw Open. doi:10.1001/jamanetworkopen.2019.13284