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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 the potent vasoconstrictor angiotensin II, promoting vasodilation. Also increases plasma renin and stimulates aldosterone secretion, inducing diuresis.
Tablets: 1 mg, 2 mg, 4 mg
Indications and dosages
Adults: For patients not receiving diuretics, 1 mg/day P.O. in nonblack patients or 2 mg/day P.O. in black patients. If response inadequate, may increase at weekly intervals up to 4 mg/day. For patients receiving diuretics, start with 0.5 mg/day P.O.
➣ Heart failure or left ventricular dysfunction after myocardial infarction
Adults: Initially, 1 mg P.O. daily. Titrate up to 4 mg daily, if tolerated.
• Renal impairment (creatinine clearance less than 30 ml/minute)
• Hepatic cirrhosis
• Hypersensitivity to drug or other ACE inhibitors
• Hereditary/idiopathic angioedema and angioedema with previous ACE inhibitor use
• Patients with diabetes mellitus taking insulin or oral hypoglycemics
Use cautiously in:
• renal or hepatic impairment, hypovolemia, hyponatremia, aortic stenosis or hypertrophic cardiomyopathy, cerebrovascular or cardiac insufficiency, surgery and anesthesia, risk factors for hyperkalemia (including renal insufficiency, diabetes mellitus, concurrent use of potassium supplements or potassium-containing salt substitutes)
• family history of angioedema
• concurrent diuretic therapy or drugs that cause increased serum potassium level
• black patients with hypertension
• elderly patients
• pregnant patients
• breastfeeding patients (avoid use)
• children (safety not established).
• Give once or twice daily as prescribed, with or without food.
CNS: insomnia, paresthesia, dizziness, drowsiness, asthenia, syncope, cerebrovascular accident
CV: chest pain, palpitations, intermittent claudication, bradycardia, first-degree atrioventricular block, cardiogenic shock
EENT: epistaxis, sinusitis, throat inflammation
GI: vomiting, diarrhea, constipation, abdominal pain or distention, gastritis, dyspepsia, intestinal angioedema, pancreatitis
GU: urinary tract infection, erectile dysfunction, decreased libido
Hematologic: agranulocytosis, neutropenia
Hepatic: syndrome of cholestatic jaundice, fulminant hepatic necrosis, and death (rare)
Metabolic: hypocalcemia, gout, increased creatinine, hyperkalemia
Musculoskeletal: muscle cramps, myalgia, extremity pain
Respiratory: cough, dyspnea, upper respiratory infection
Skin: rash, flushing, pruritus
Other: edema, angioedema (face, extremities, lips, tongue, glottis, and larynx)
Drug-drug. Diuretics, general anesthetics, other antihypertensives: increased risk of hypotension
Hypoglycemics (insulin, oral agents): increased risk of blood glucose-lowering effect with greater risk of hypoglycemia
Lithium: increased lithium blood level, greater risk of toxicity
Nonsteroidal anti-inflammatory drugs, including selective cyclooxygenase-2 inhibitors: increased risk of renal impairment, including acute renal failure in elderly patients, volume-depleted patients, or those with compromised renal function; loss of trandodolapril antihypertensive effect
Potassium-sparing diuretics, potassium supplements, salt substitutes containing potassium: additive hyperkalemia
Sodium aurothiomalate (gold): increased risk of nitritoid reactions (including facial flushing, nausea, vomiting, and hypotension)
Drug-diagnostic tests. Creatinine, potassium: increased level
Neutrophils, platelets: decreased counts
Drug-food. Salt substitutes containing potassium: hyperkalemia
• Monitor vital signs, especially for hypotension and bradycardia when therapy begins.
• Assess CBC with white cell differential. Watch for signs and symptoms of bleeding and infection.
• Monitor electrolyte levels, especially potassium. Stay alert for hyperkalemia.
• Assess renal function tests and fluid intake and output.
Stay alert for signs and symptoms of hypersensitivity reactions (including angioedema). Discontinue drug immediately if laryngeal stridor or angioedema of face, tongue, or glottis occurs, treat appropriately, and closely observe patient until swelling disappears.
Be aware that rarely ACE inhibitors have been associated with a syndrome of cholestatic jaundice, fulminant hepatic necrosis, and death. If patient develops jaundice, discontinue drug and provide appropriate followup care.
• Tell patient drug may cause bleeding tendency or increase his infection risk. Teach him which warning signs to report.
Teach patient to recognize and report signs or symptoms of hyperkalemia, infection, angioedema (including intestinal angioedema that may present as abdominal pain with or without nausea), and syndrome of cholestatic jaundice.
• Instruct patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood pressure drop.
• Caution patient not to exercise vigorously in hot environments.
• Advise patient not to use salt substitutes containing potassium. Tell him to avoid high-potassium foods.
• 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 (antihypertensive effect)
|PO||within 1–2 hr*||within 1 wk†||up to 24 hr†|
Adverse Reactions/Side Effects
Central nervous system
- cough (most frequent)
- hypotension (most frequent)
- impaired renal function
Fluid and Electrolyte
- 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-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.↑ levels and may ↑ the risk oflithium toxicity.
Renal ImpairmentOral (Adults) CCr <30 mL/min—Initiate therapy at 0.5 mg once daily, may be slowly titrated upward (max dose = 4 mg/day).
Hepatic ImpairmentOral (Adults) Initiate therapy at 0.5 mg once daily, may be slowly titrated upward (max dose = 4 mg/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, serum bilirubin, and uric acid.
Potential Nursing DiagnosesDecreased cardiac output (Indications, Side Effects)
Deficient knowledge, related to medication regimen (Patient/Family Teaching)
Noncompliance (Patient/Family Teaching)
- Due to risk for precipitous drop in BP at initiation of therapy, correct pre-existing volume depletion, if possible. Discontinuing diuretic therapy or cautiously increasing salt intake 2–3 days prior to initiation may decrease this risk. Monitor closely for at least 1 hr after BP has stabilize.
- Oral: May be taken with or without food.
- Emphasize 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 consult health care professional before taking any new medications, 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 if pregnancy is planned or suspected. If pregnancy is detected, discontinue medication as soon as possible.
- Emphasize the importance of follow-up examinations to monitor 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 side effects.
- Reduction of risk of death or heart-failure-related hospitalizations following myocardial infarction.