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.