Pharmacologic class: Angiotensin-converting enzyme (ACE) inhibitor
Therapeutic class: Antihypertensive
Pregnancy risk category D
FDA Box Warning
• Drugs that act directly on the renin-angiotensin system can cause injury to or death of a developing fetus. Discontinue drug as soon as possible when pregnancy is detected.
Inhibits conversion of angiotensin I to angiotensin II (a potent vasoconstrictor). This effect leads to decreased plasma angiotensin II, reduced vasoconstriction, enhanced plasma renin activity, and decreased aldosterone activity.
Tablets: 2 mg, 4 mg, 8 mg
Indications and dosages
➣ Essential hypertension
Adults: 4 mg P.O. daily; may titrate upward to 16 mg/day, given as a single dose or in two divided doses. (Start with 2 to 4 mg/day in patients receiving diuretics.)
➣ Coronary artery disease
Adults: Initially, 4 mg P.O. daily for 2 weeks; then increase as tolerated to a maintenance dosage of 8 mg P.O. daily.
• Renal impairment
• Elderly patients
• Heart failure
• Diabetic nephropathy
• Hypersensitivity to drug or other ACE inhibitors
• Hereditary or idiopathic angioedema
Use cautiously in:
• hepatic failure, renal impairment, renal artery stenosis, hyperkalemia, cough
• black patients
• pregnant or breastfeeding patients
• children (safety not established).
• Give without regard to food.
☞ Know that drug (especially first dose) may cause angioedema. Keep epinephrine and antihistamines at hand in case of airway obstruction.
• For elderly patient, titrate dosage upward very slowly.
• Know that drug may be given alone or with other drugs.
CNS: dizziness, fatigue, headache, insomnia, sleep disorder, weakness, asthenia, drowsiness, vertigo, depression, paresthesia
CV: hypotension, angina pectoris, palpitations, chest pain, abnormal ECG, tachycardia
EENT: ear infection, sinusitis, rhinitis, pharyngitis
GI: nausea, vomiting, diarrhea, abdominal pain, flatulence
GU: proteinuria, urinary tract infection, erectile or other male sexual dysfunction, decreased libido, menstrual disorder
Musculoskeletal: back, arm, leg, neck, or joint pain; hypertonia; myalgia; arthritis
Respiratory: cough, upper respiratory infection
Skin: rash, angioedema
Other: fever, viral infection, edema
Antihypertensives, general anesthetics, nitrates, phenothiazines: additive hypotension
Diuretics: excessive hypotension Gold (sodium aurothiomalate): increased risk of rare nitritoid reactions (including facial flushing, nausea, vomiting, and hypotension)
Lithium: increased lithium toxicity Nonsteroidal anti-inflammatory drugs: 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
Drug-diagnostic tests. Alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, creatinine, potassium, triglycerides: increased levels Hematocrit, hemoglobin: decreased values
Drug-food. Salt substitutes containing potassium: hyperkalemia
Drug-herbs. Capsaicin: cough
Drug-behaviors. Acute alcohol ingestion: additive hypotension
• Assess blood pressure. Be aware that dosage increases or concomitant diuretic use may cause severe hypotension.
☞ Watch for angioedema, especially after first dose.
• Stay alert for signs and symptoms of infection, particularly EENT and respiratory infections.
• Monitor potassium level. Watch for signs and symptoms of hyperkalemia.
• Monitor liver and kidney function tests before and during therapy.
☞ In black patients, watch closely for angioedema and monitor drug efficacy. Monotherapy may be less effective in these patients.
• Tell patient to take at same time each day, with or without food.
☞ Instruct patient to stop using drug and contact prescriber immediately if hoarseness or difficulty swallowing or breathing occurs.
• Tell patient to avoid excessive perspiration or decreased fluid intake, which may cause symptomatic blood pressure drop. Inform him that vomiting or diarrhea also may lower blood pressure.
• Tell patient to report signs and symptoms of infection.
• Advise patient not to use potassium-containing salt substitutes.
☞ Caution female patient of child-bearing age to contact prescriber immediately if she suspects pregnancy.
• 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 (plasma concentrations)
|PO||within 1–2 hr||3–7 hr||up to 24 hr|
Adverse Reactions/Side Effects
Central nervous system
- cough (most frequent)
- hypotension (most frequent)
- 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 antihypertensives.↑ risk of hyperkalemia with concurrent use of potassium supplements,potassium-containing salt substitutes, and potassium-sparing diuretics.↑ 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.May ↑ levels risk of toxicity of lithium.
Stable Coronary Artery Disease
Renal ImpairmentOral (Adults) CCr 30–60 ml/min—Initiate therapy at 2 mg once daily, may be slowly titrated up to 8 mg/day in 1–2 divided doses; CCr <30 ml/min—Not recommended.
Availability (generic available)
- 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).
- Lab Test Considerations: Monitor renal function. May cause ↑ BUN and serum creatinine.
- Monitor serum potassium periodically during therapy. May cause hyperkalemia.
- Monitor CBC periodically during therapy in patients with collagen vascular disease and/or renal disease. May rarely cause ↓ hemoglobin and hematocrit as well as neutropenia and eosinophilia.
- May cause ↑ AST, ALT, alkaline phosphatase, uric acid, and glucose.
Potential Nursing DiagnosesDecreased cardiac output (Indications, Side Effects)
Deficient knowledge, related to medication regimen (Patient/Family Teaching)
Noncompliance (Patient/Family Teaching)
- Correct volume depletion, if possible, before initiation of therapy.
- Emphasize the importance of continuing 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 containing high levels of 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 to consult health care professional before taking any Rx, OTC, or herbal products, especially cough, cold, or allergy remedies.
- 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 heartbeat; 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 of pregnancy is planned or suspected, or if breastfeeding.
- 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.
- Reduction in risk of death from cardiovascular causes and myocardial infarction in patients with stable coronary artery disease.