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Accupril, Accupro, (UK) Quinil (UK)
Pharmacologic class: Angiotensin-converting enzyme (ACE) inhibitor
Therapeutic class: Antihypertensive
Pregnancy risk category D
Inhibits conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; decreases cardiac output. Increases plasma renin levels and reduces aldosterone levels, causing systemic vasodilation.
Tablets: 5 mg, 10 mg, 20 mg, 40 mg
⊘Indications and dosages
Adults: Initially, 10 to 20 mg P.O. daily for patients not receiving diuretics, with subsequent dosages adjusted at 2-week intervals according to blood pressure response at peak (2 to 6 hours) and trough (predose) blood levels; for maintenance, 20 to 80 mg/day as a single dose or in two divided doses. In patients receiving diuretics, discontinue diuretic 2 to 3 days before starting quinapril; if blood pressure isn't controlled, resume diuretic. If diuretic can't be discontinued, start therapy with 5 mg/day quinapril.
➣ Adjunct in heart failure
Adults: Initially, 5 mg P.O. b.i.d., titrated weekly until effective dosage is determined. For maintenance, 20 to 40 mg/day in two evenly divided doses.
• Renal impairment
• Elderly patients
• Aortic insufficiency
• Postoperative hypertension
• Myocardial infarction
• Diabetic or nondiabetic neuropathy
• Hypersensitivity to drug or other ACE inhibitors
• Angioedema caused by other ACE inhibitors
Use cautiously in:
• autoimmune diseases, aortic stenosis, renal artery stenosis, hypertrophic cardiomyopathy, cerebrovascular or cardiac insufficiency, collagen vascular disease, hepatic or renal impairment, hypovolemia, hyponatremia, hypotension, neutropenia, chronic cough, proteinuria, febrile illness
• family history of angioedema
• risk factors for development of hyperkalemia, including renal insufficiency, diabetes mellitus, concurrent use of potassium-sparing diuretics, potassium supplements, or potassium-containing salt substitutes
• concurrent use of nonsteroidal antiinflammatory drugs (NSAIDs) in patients who are elderly, volume-depleted (including those on diuretics), or with compromised renal function
• concurrent immunosuppressant, lithium, or diuretic therapy
• black patients
• elderly patients
• pregnant or breastfeeding patients
• children (safety not established).
• Administer with or without food, but not with high-fat meal.
• Know that if quinapril alone doesn't adequately control blood pressure, a diuretic may be added.
CNS: dizziness, drowsiness, fatigue, headache, insomnia, depression, vertigo, paresthesia, asthenia, malaise, nervousness, syncope
CV: hypotension, angina pectoris, palpitations, chest pain, tachycardia, arrhythmias
EENT: amblyopia, sinusitis, pharyngitis
GI: nausea, vomiting, diarrhea, constipation, abdominal pain, anorexia, dry mouth
GU: erectile dysfunction
Musculoskeletal: back pain
Respiratory: cough, dyspnea
Skin: rash, pruritus, alopecia, flushing, diaphoresis, photosensitivity
Other: taste disturbances, fever, viral infections, hypersensitivity reactions including anaphylaxis
Diuretics, other antihypertensives: increased hypotension
Gold (sodium aurothiomalate): increased risk of rare nitritoid reactions (including facial flushing, nausea, vomiting, and hypotension)
Lithium: increased serum lithium level and lithium toxicity
NSAIDs: may result in deterioration of renal function, including acute renal failure and attenuated ACE inhibitor antihypertensive effect
Potassium-sparing diuretics, potassium supplements: increased risk of hyperkalemia
Tetracyclines: decreased tetracycline absorption
Drug-diagnostic tests.Alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase, bilirubin, blood urea nitrogen, creatinine, potassium: increased levels
Drug-food.High-fat foods: decreased rate and extent of drug absorption
Salt substitutes containing potassium: increased risk of hyperkalemia
• Monitor vital signs and cardiovascular status. Be sure to ask patient if he's experiencing angina.
• Assess CBC and liver function tests.
• Monitor potassium level. Watch for evidence of hyperkalemia.
Watch closely for signs and symptoms of angioedema, especially in black patients after first dose.
• Assess for dry, nonproductive cough and signs and symptoms of infection.
• Monitor renal function periodically in patients receiving concurrent NSAID therapy.
• Tell patient he may take with or without food, but not with high-fat meal.
Advise patient to immediately report facial or tongue swelling or difficulty breathing.
• Instruct patient to monitor and record his blood pressure.
• Tell patient to promptly report dry, nonproductive cough and signs and symptoms of infection.
• Instruct patient to move slowly when sitting up or standing, to avoid dizziness or light-headedness from sudden blood pressure decrease.
• Tell patient that excessive fluid loss (as from sweating, vomiting, or diarrhea) and inadequate fluid intake increase the risk of light-headedness (especially in hot weather).
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
• Advise patient to avoid salt substitutes containing potassium.
• Tell female patient to notify prescriber of possible pregnancy. Caution her not to breastfeed.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.
Pharmacologic: ace inhibitors
Time/action profile (effect on BP—single dose†)
|PO||within 1 hr||2–4 hr||up to 24 hr|
Adverse Reactions/Side Effects
Central nervous system
- cough (most frequent)
- hypotension (most frequent)
- chest pain
- abdominal pain
- impaired renal function
Fluid and Electrolyte
- back pain
- angioedema (life-threatening)
Drug-Drug interactionExcessive hypotension may occur with concurrent use of diuretics.Additive hypotension with other antihypertensive agents.↑ risk of hyperkalemia with concurrent use ofpotassium supplements, potassium-sparing diuretics, or potassium-containing salt substitutes.↑ risk of hyperkalemia, renal dysfunction, hypotension, and syncope with concurrent use of angiotensin II receptor antagonists or aliskiren ; avoid concurrent use with aliskiren in patients with diabetes or CCr <60 mL/minNSAIDs and selective COX-2 inhibitors may blunt the antihypertensive effect and ↑ the risk of renal dysfunction.↑ levels and may ↑ the risk of lithium toxicity.May ↓ absorption of tetracycline,doxycycline, and fluoroquinolone antibiotics (due to magnesium in tablets).↑ risk of angioedema with temsirolimus or everolimus.
Renal ImpairmentOral (Adults) CCr >60 mL/min—Initiate therapy at 10 mg/day; CCr 30–60 mL/min—Initiate therapy at 5 mg/day;CCr 10–30 mL/min—Initiate therapy at 2.5 mg/day.
Renal ImpairmentOral (Adults) CCr 30–60 mL/min—Initiate therapy at 5 mg/day; if tolerated, increase to 5 mg twice daily on following day. CCr 10–30 mL/min—Initiate therapy at 2.5 mg/day; if tolerated, increase to 2.5 mg twice daily on following day.
Availability (generic available)
- Hypertension: Monitor BP and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes.
- Monitor frequency of prescription refills to determine compliance.
- Assess patient for signs of angioedema (dyspnea, facial swelling).
- Heart Failure: Monitor weight and assess patient routinely for resolution of fluid overload (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
- Lab Test Considerations: Monitor renal function. May cause ↑ BUN and serum creatinine.
- May cause hyperkalemia.
- Monitor CBC periodically during therapy in patients with collagen vascular disease and/or renal disease. May rarely cause agranulocytosis.
- May cause ↑ AST, ALT, alkaline phosphatase, and serum bilirubin.
Potential Nursing DiagnosesDecreased cardiac output (Indications, Side Effects)
Noncompliance (Patient/Family Teaching)
Deficient knowledge, related to medication regimen (Patient/Family Teaching)
- Do not confuse Accupril with Aciphex.
- Correct volume depletion, if possible, before initiation of therapy. Precipitous drop in BP during first 1–3 hr following first dose may require volume expansion with normal saline. Discontinuing diuretic therapy or cautiously increasing salt intake 2–3 days prior to initiation may decrease risk. Monitor closely for at least 1 hr after BP has stabilized. Resume diuretics if BP is not controlled.
- Instruct patient to take medication as directed at the same time each day, even if feeling well. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses. Warn patient not to discontinue ACE inhibitor therapy unless directed by health care professional.
- Caution patient to avoid salt substitutes containing potassium or foods high in potassium or sodium unless directed by health care professional. See.
- Caution patient to change positions slowly to minimize orthostatic hypotension. Use of alcohol, standing for long periods, exercising, and hot weather may increase orthostatic hypotension.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications especially cough, cold, or allergy medications.
- May cause dizziness. Caution patient to avoid driving and other activities requiring alertness until response to medication is known.
- Advise patient to inform health care professional of medication regimen prior to treatment or surgery.
- Instruct patient to notify health care professional if rash; mouth sores; sore throat; fever; swelling of hands or feet; irregular heart beat; chest pain; dry cough; hoarseness; swelling of face, eyes, lips, or tongue; or if difficulty swallowing or breathing occurs. Persistent dry cough may occur and may not subside until medication is discontinued. Consult health care professional if cough becomes bothersome. Also notify health care professional if nausea, vomiting, or diarrhea occurs and continues.
- Advise women of childbearing age to use contraception and notify health care professional if pregnancy is planned or suspected.
- Emphasize the importance of follow-up examinations to evaluate effectiveness of medication.
- Hypertension: Encourage patient to comply with additional interventions for hypertension (weight reduction, low sodium diet, discontinuation of smoking, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension.
- Instruct patient and family on correct technique for monitoring BP. Advise them to check BP at least weekly and to report significant changes to health care professional.
- Decrease in BP without appearance of excessive side effects.
- Decrease in signs and symptoms of heart failure.