Cardiovascular drugs: sacubitril-valsartan: practice question

A Pharmacology question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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Pharmacology · Cardiovascular drugs: sacubitril-valsartan

Sample item

A 60-year-old man with heart failure and an ejection fraction of 28% on enalapril is to be switched to sacubitril-valsartan. What is the key precaution?

AAdd aliskiren for fuller blockade of the renin systemBStart a potassium supplement because the drug causes hypokalaemiaCStop the ACE inhibitor at least 36 hours before the first doseDContinue enalapril for a week of overlap to avoid hypotension

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

C. Stop the ACE inhibitor at least 36 hours before the first dose

Sacubitril inhibits neprilysin, which raises natriuretic peptides and also bradykinin. With an ACE inhibitor, which also blocks bradykinin breakdown, the risk of angioedema rises sharply. A 36-hour washout is required when switching from an ACE inhibitor.

Option by option

A. Add aliskiren for fuller blockade of the renin system
Aliskiren with an ARB or ACE inhibitor adds hyperkalaemia and renal injury without benefit.
B. Start a potassium supplement because the drug causes hypokalaemia
The valsartan component tends to cause hyperkalaemia, not hypokalaemia.
C. Stop the ACE inhibitor at least 36 hours before the first dose (correct)
Correct. The washout prevents combined neprilysin and ACE inhibition and angioedema.
D. Continue enalapril for a week of overlap to avoid hypotension
Overlap is contraindicated because of the angioedema risk.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

Questions about this Pharmacology question

What is the answer to this Pharmacology question?

The best answer is C, Stop the ACE inhibitor at least 36 hours before the first dose. Sacubitril inhibits neprilysin, which raises natriuretic peptides and also bradykinin.

Why is "Add aliskiren for fuller blockade of the renin system" not the answer?

Aliskiren with an ARB or ACE inhibitor adds hyperkalaemia and renal injury without benefit.

Why is "Start a potassium supplement because the drug causes hypokalaemia" not the answer?

The valsartan component tends to cause hyperkalaemia, not hypokalaemia.

Why is "Continue enalapril for a week of overlap to avoid hypotension" not the answer?

Overlap is contraindicated because of the angioedema risk.

What concept does this question test?

It tests Cardiovascular drugs: sacubitril-valsartan in Pharmacology. With an ACE inhibitor, which also blocks bradykinin breakdown, the risk of angioedema rises sharply. A 36-hour washout is required when switching from an ACE inhibitor.

How hard is this question?

We tag it as an application question: it asks you to use a fact on a patient or a finding. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Cardiovascular drugs: sacubitril-valsartan?

Learn drugs as classes, then the exception in each class that an examiner would pick. Then use the flashcards and the other Pharmacology questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.