HYPERTENSION - RENIN-ANGIOTENSIN DRUGS, COMBINATIONS 2.1
Drug Prescribing Notes
Benazepril, captopril, cilazapril, enalapril, lisinopril, perindopril, quinapril, ramipril, trandolapril.
History of angioedema (hereditary, idiopathic or associated with previous ACE inhibitor therapy).
Aortic stenosis, outflow tract obstruction, renal artery stenosis.
Extracorporeal treatments leading to contact of blood with negatively charged surfaces, renal
artery stenosis, hypotensive or haemodynamically unstable states.
Symptomatic hypotension more likely to occur in hypertensive patients who are volume and/or sodium de-
pleted; correct before starting therapy (consider a lower starting dose). Patients with heart failure are at high
risk of hypotension (caution when increasing dose). Excessive blood pressure lowering in ischaemic cardiovas-
cular or cerebrovascular disease may increase the risk of myocardial infarction or stroke.
Renal impairment: Adjust dose according to patient's creatinine clearance; monitor potassium and creatinine
routinely. Renal artery stenosis: Initiate under close supervision with low doses, careful titration and monitor-
ing of renal function. Not recommended in recent kidney transplantation.
Cholestatic hepatitis and acute liver failure reported rarely; discontinue if patients develop jaundice or
marked elevation of hepatic enzymes.
Non-productive, persistent cough reported.
Elevations in serum potassium observed; patients at risk of hyperkalaemia include those with renal insuffi-
Neutropenia/agranulocytosis, thrombocytopenia and anaemia reported. Caution:
Collagen vascular disease,
immunosuppressant therapy; perform white blood cell count and differential counts prior to therapy, every 2
weeks during the first 3 months of therapy, and periodically thereafter. Instruct patients to report any sign of
infection (e.g. sore throat, fever). Discontinue if neutropenia detected or suspected.
Proteinuria may occur (particularly in patients with existing renal function impairment, high doses); patients
with prior renal disease should have urinary protein estimations (dip-stick on first morning urine) prior to
treatment, and periodically thereafter.
Discontinue immediately if severe angioedema occurs. Seek emergency treatment if angioedema involving
the tongue, glottis or larynx occurs. Intestinal angioedema reported very rarely.
Anaphylaxis reported during desensitisation treatment with venom, dialysis with high-flux membranes and
during low-density lipoprotein apheresis with dextran sulphate.
Major surgery: ACE inhibitors may block angiotensin II formation secondary to compensatory renin release. If
hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.
Diabetics mellitus (monitor glycaemia levels closely).
Patients with left ventricular valvular, outflow tract obstruction, aortic or mitral stenosis. Avoid:
Patients with cardiogenic shock, haemodynamically significant obstruction.
Less effective in lowering blood pressure in black patients than non-black patients.
Potassium-sparing diuretics (e.g. spironolactone, triamterene, amiloride), potassium supple-
ments, or salt substitutes containing potassium, lithium. Caution:
NSAIDs (especially in elderly or compromised renal
function). Diuretics (discontinue 3 days before). Other antihypertensives or agents that may decrease blood pressure
(e.g. nitrates, alcohol, baclofen, alfuzosin, doxazosin, prazosin, tamsulosin, terazosin). Vasodilators. Certain anaes-
thetics, tricyclic antidepressants and antipsychotics. Sympathomimetics. Antidiabetics. Injectable gold. Indomethacin.
Allopurinol, immunosuppressants, corticosteroids, procainamide, cytostatics and other substances that may change
the blood cell count. Angiotensin-receptor blockers in patients with established atherosclerotic disease, heart failure,
or with diabetes with end organ damage.
Headache, dizziness, cough, fatigue, gastrointestinal upset, orthostatic symptoms (including hypotension), rash or
dyspnoea are common with most ACE inhibitors. Other side-effects common to specific ACE inhibitors are as follows -
Palpitations, flushing, pruritis, photosensitivity, pollakiuria, upper respiratory tract infections. Captopril:
Sleep disorders, pruritus, alopecia. Cilazapril:
No additional common side-effects. Enalapril:
Depression, blurred vi-
sion, syncope, chest pain, rhythm disturbances, angina pectoris, tachycardia, hypersensitivity/angioneurotic oedema,
hyperkalemia, increases in serum creatinine. Lisinopril:
Renal dysfunction. Perindopril:
Vertigo, paresthaesia, vision
disturbance, tinnitus, pruritus, muscle cramps. Quinapril:
Pharyngitis, insomnia, hyperkalaemia, paraesthesia, back
pain, myalgia. Ramipril:
Bronchitis, sinusitis, muscle spasms, myalgia, blood potassium, syncope, chest pain.
No additional common side-effects.
See individual SPCs for more details.
Prepared March 2013 - MIMS Ireland Copyright®
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