ACE inhibitors

Angiotensin Converting Enzyme Inhibitors

HTN Lotensin 10-40 mg po daily

 HTN Capoten 12.5-50 mg po  TID

CHF Start at 12.5po TID target 50 mg PO TID

 HTN Prinivil / Zestril 5 - 40 mg po daily

CHF - Start at 5 mg po OD, target 30 mg po OD

HTN Vasotec 2.5-40 mg po daily

CHF Vasotec- Start at 2.5 po BID ;  target 10 mg po BID

HTN Altace 2.5 - 20 mg po daily

CHF Start at 2.5 mgpo BID target 5 mg po BID

Name some side effects from ACE Inhibitors.

Benazepril (Lotensin)

Captopril (Capoten)

Cliazipril(Inhibace)

Enalapril(Vasotec)

Fosinopril(Monopril)

Lisonopril(Prinivil, Zestril)

Perindopril(Coversyl)

Quinipril(Accupril)

Ramipril(Altace)

Trandolapril(Mavik)

• May precipitate hypotension ( after first dose)
• Dry Cough
• Muscle cramps
• hyperkalemia
• Renal Impairment
• Less Common: rash loss of taste, leukopenia, hypersensitivity reaction with angioedema

Name some contraindications for using ACE inhibitors.

Benazepril (Lotensin)

Captopril (Capoten)

Cliazipril(Inhibace)

Enalapril(Vasotec)

Fosinopril(Monopril)

Lisonopril(Prinivil, Zestril)

Perindopril(Coversyl)

Quinipril(Accupril)

Ramipril(Altace)

Trandolapril(Mavik)

• Pregnancy
• bilateral renal stenosis
• hypersensitivity
• Acute MI with hypotension

When is caution needed with ACE Inhibitors ?

Benazepril (Lotensin)

Captopril (Capoten)

Cliazipril(Inhibace)

Enalapril(Vasotec)

Fosinopril(Monopril)

Lisonopril(Prinivil, Zestril)

Perindopril(Coversyl)

Quinipril(Accupril)

Ramipril(Altace)

Trandolapril(Mavik

• Combined use with ARBS, NSAID, Potassium sparing diuretics
• Renal Impairment
• Hypotension with volume depletion
• Severe heart failure
• Renovascular hypertension
• Aortic stenosis or outflow obstruction

What are some benefits of using ACE inhibitors?

Benazepril (Lotensin)

Captopril (Capoten)

Cliazipril(Inhibace)

Enalapril(Vasotec)

Fosinopril(Monopril)

Lisonopril(Prinivil, Zestril)

Perindopril(Coversyl)

Quinipril(Accupril)

Ramipril(Altace)

Trandolapril(Mavik

• Treat HTN
• Reduce ventricular remodeling
• Decrease need for revascularization
• Improve hemodynamic function
• Lower mortality after acute MI in high risk clients
• Overall cardioprotective effect

What lab work should be  ordered when starting a client on an ACE Inhibitor ?

• Be sure to order serum creatinine, urea and electrolytes when starting ACE inhibitors as well as before and after dose adjustments.
• A transient rise in creatinine less than 35% is acceptable.

What happens if the client develops a cough while on ACE inhibitors?

• Do not assume the cough is because of the ACE in clients with CHF. It may worsening heart failure!
• If the dry cough is intolerable substitute with an ARB.
• May take 3 weeks to totally disappear.

• ARB stans for angiotensin receptor blockers.
• This inhibits the renin - angiotensin- aldosterone system which leads to vasodilation

HTN Atacand 8-32 mg po OD

CHF - Start at 4mg po OD, target 32 mg po daily.

 HTN Avapro 150 - 300 mg po od

 HTN Cozaar  50 - 100 mg po od

CHF - start at 12.5 mg po od  target 100 mg po od

DM 2 / Stroke Prevention - 50 - 100 mg po od

HTN Diovan 80 to 160 mg po daily

CHF start at 40 mg po bid, target 160 mg bid

• Hypotension with or W/O orthostatic
• Dizziness, fatigue, hyperkalemia, dyspesia and diarrhea
• Others: URI's, cough (less common than ACEi's) h/a, chest pain, dyspnea, rash, angioedema ( serious but uncommon when compared to ACE)

• Hypersensitivity
• Bilateral renal artery stenosis
• Pregnancy (especially 2nd and 3rd trimesters)

Use with caution in :

• Decreased volume status
• Unilateral renal artery stenosis
• pre-exisiting renal insufficiency
• significant aortic or mitral stenosis or hepatic impairment (losartin only)

• NSAIDS may decrease ARB efficiancy and further reduce renal function
• Potassium sparing diuretics, K+ supplements, and trimethoprim (if high dose) can increase hyperkalemia
• May increase effects of amiodarone, fluoxetine and warfarin.
• Carbamazepine, phenytoin and rifampin mau decrease ARB effect
• Fluconazole may increase ARB effect

• Chronic renal failure
• DM
• Volume depletion
• Advanced age
• Potassium supplements
• Drugs ( NSAID, Beta B., and heparin)

• Measure baseline creatinine and calculate eGFR
• Use in combination with a loop or thiazide diuretic
• When eGFR is low, add or switch to a loop diuretic
• Correct metabolic acidosis in CRF with oral bicarb. This will lower serum potassium.
• Avoid other drugs that cause hyperkalemia (NSAIDs, Beta blockers, heparin)
• Avoid dehydration by doing daily weights and setting target weight and adjust diuretic according to target weight.
• Use low dose spirolonactone.
• Check creatinine and k+ 1 week after initiating therapy or changing dosage.
• If K+ is consistenly >5.5 stop using these drugs.

HTN Coreg 3.125 - 25mg po bid

CHF start at 3.125mg po BID, targert 25 mg PO BID

HTN- Monitan, Sectral 100-400 mg BID

HTN - Tenormin 50 - 100 mg po daily

HTN- Monocor 2.5 - 20 mg po od

CHF start at 1.25 mg PO daily, target 10 mg po daily

HTN Trandate 100 -600 mg BID

• HTN Lopressor / Betaloc 12.5-200 mg PO BID
• CHF start Metoprolol XL at 12.5 po daily, target 200 mg

• Bradycardia
• Heart Block
• Negative inotrophic activity
• Hypotension
• Bronchospasm in patients with severe reactive disease
• Acute pulmonary edema
• Sotolol can prolong QT interval and predispose to Torsades de Pointes.
• CNS effects: fatigue, depression, nightmares, hallucinations and impotence
• Hypoglycemia unawareness in DM
• Worsens symptoms PVD

• Heart Block
• Asthma
• Bradycardia
• COPD is not condraindicated unless significant bronchspastic component

• B1 selective agents are commonly used because of less bronchospasm: acebutolol, atenolol, bisoprolol, metoprolol
• never abruptly stop a beta blocker
• metoprolol is the most common used BBlocker in hypertension. In elderly is 2nd line agent.
• Caution indicated when used with non- dihydropyridine CCB's (verapamil, diltiazem)

What is the action of Dihydropidine CCB's?

Amiodipine (Norvasc)

Felodipine( PLendil, Renedil)

Nifedipine(adalat XL)

Nimodipine ( Nimotop)

• Act by vasodilation and reduces vascular resistance. Act on the L-channel which admits calcium for muscle contraction.
• Used to treat isolated systolic hypertension, stable angina ( preferably if already on Beta B).

Dihydropyridine Calcium Channel Blocker

Norvasc 5 -10 mg daily

• Pedal edema
• Dizziness
• H/A
• Eye Pain
• Facial Flushing
• Peripheral edema can be reduced by combining with an ACE or an ARB

• When are Di-hydropyridine CCB's contraindicated?

• Nifedipine ( adalat XL) leads to vasodilation and rapid reflex activation of adrenergic system leading to tachycardia , postural hypotension causing ischemic stroke and death especially in the elderly. Short acting Nifedipine to be avoided in all clinical circumstances.
• Chronic use causes gum hyperplasia
• Abrupt w/d in angina can worsen symptoms
• aortic and carotid artery stenosis
• immediately post MI , acute HF and unstable angina

What is the action of Non Dihydropyridine-CCB's ?

• diltiazem(Cardizem, Tiazac)
• Verapamil(Isoptin)

• Act on nodal tissue slowing the heart
• Reduce myocardial contractibility and decrease cardiac oxygen demand
• Used in treatment of HTN, stable angina, coronary spasm, SVT, AF, diabetic nephropathy,migraine and Raynauds syndrome

What are the adverse reactions and contraindications when using Non Dihydropyridine-CCB's?

Diltiazem(Cardizem / Tiazac)

Verapamil (Isoptin)

• Constipation (act on gut muscle)
• Cause less pedal edema
• Impotence is rare
• Flushing

Contraindicated: Heart failure, V tach, bradycardia and heart block

• Effective when used with ACE or ARB for reducing proteinuria.
• Drug interaction more likely than with di-CCB's
• Bradycardia and Heart block when used with BBlockers or digoxin
• Inhibition of CYP3A4 can lead to toxicities of carbamazepine, theophylline, cyclosporin
• May enhance antiplatelet effect of ASA

• Most effective line of treatment for elderly, blacks, and low renin (salt sensitive) hypertension
• Useful add on for resistant and renal parenchymal hypertension
• Better at reducing stroke, however, less effective in reducing CHF or MI
• Do not have negative effect on glucose in DM, lipids or lytes
• OD can be treated with parenteral Ca

• Inhibits Na and K ATP pumpwhich leads to increased intracellular Ca resulting in positive inotropic action.
• Exerts vagotonic action which slows conduction through AV node and helps to control HR
• Used for CHF which decreased ejection fraction and AF

• Digoxin toxicity
• N&V
• Delerium
• Hyperkalemia
• Altered colored vision
• arrythmias

Contraindicated in V fib, 2nd, 3rd, degree heart block

• Loop diuretic are used to treat volume overloaded states such as CHF,  ascites, and renal failure.
• May also be used in hypercalcemia, hypernatremia, and hyperkalemia
• This drug inhibits teh Na/K/2CL co-transporter in the loop of henle
• Relief of dyspnea occurs before onset of diuresis as it causes venodilation and preload reduction.

Lasix 20 - 100 mg PO/ IV BID-TID

Some practical tips for Loop diuretics.

Ethacrynic Acid (Edecrin)

Furosemide (Lasix)

• IV works twice as good as PO i.e. 40 mg BID IV =80 mg PO BID
• Closely monitor K+ and creatinine
• Prescribe higher doses in renal failure
• Prescribe BID or TID because it has a short action
• Long term tolerance -add thiazide
• High salt diet reduces effect
• Ethacrynic Acid when sulpha allergy

• Amiloride (midamor) 5-10 mg po od
• Spirolactone(Aldactone) 12.5-100 mg po daily
• Triamterene (Dyrenium)

• Inhibit Na Cl reabsorption and the distal convoluted tubule.
• Used in treatment of Hypertension

• Hydrochlorothiazide ( Apo-Hydro, Hydrodiuril) 12.5-25 mg daily
• Indapimide ( Lozide) 1.25-2.5 mg po daily
• Chlorthalidone- 12.5 - 50 mg po daily

• Hyponatremia and hypokalemia
• Increased insulin resistance and tryglycerides
• Increased uric acid levels which precipitates gout
• Impotence
• Increased lifetime risk of DMII