lisinopril

lyse-IN-oh-pril

Therapeutic Classification: antihypertensives

Pharmacologic Classification: ace inhibitors

REMS

Hypertension.
HF.
Reduction of risk of death or development of HF after MI.

Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also ↑ plasma renin levels and ↓ aldosterone levels. Net result is systemic vasodilation.

Therapeutic effects:

Lowering of BP in hypertensive patients.
Increased survival and decreased symptoms in patients with HF.
Increased survival after MI.

Absorption: 25% absorbed following oral administration (much inter-individual variability).

Distribution: Crosses the placenta; may enter breast milk.

Metabolism/Excretion: 100% eliminated by the kidneys.

Half-Life: 12 hr (↑ in renal impairment).

(effect on BP-single dose‡)

ROUTE	ONSET	PEAK	DURATION
PO	1 hr	6 hr	24 hr

‡Full effects may not be noted for several weeks.

Contraindicated in:

Hypersensitivity;
History of angioedema with previous use of ACE inhibitors;
Concurrent use with sacubitril/valsartan; must be a 36–hr washout period after switching to/from sacubitril/valsartan;
OB: Pregnancy;
Lactation: Lactation.

Use Cautiously in:

Renal impairment, hypovolemia, hyponatremia, or concurrent diuretic therapy (initial dosage ↓ recommended);
Black patients (less effective as monotherapy in hypertension; may require additional therapy; higher risk of angioedema);
Surgery/anesthesia (hypotension may be exaggerated);
Rep: Women of reproductive potential;
Pedi: Children <6 yr (safety and effectiveness not established);
Geri: Initial dosage ↓ recommended in older adults.

Exercise Extreme Caution in:

Family history of angioedema.

CV: hypotension, chest pain

Derm: rash

F and E: hyperkalemia

GI: abdominal pain, diarrhea, nausea, vomiting

GU: erectile dysfunction, renal impairment

Neuro: dizziness, fatigue, headache, weakness

Resp: cough

Misc: ANGIOEDEMA

Drug-drug:

Concurrent use with sacubitril↑ risk of angioedema; concurrent use contraindicated; do not administer within 36 hr of switching to/from sacubitril/valsartan.
Excessive hypotension may occur with concurrent use of diuretics.
Additive hypotension with other antihypertensive agents.
↑risk of hyperkalemia with concurrent use of potassium supplements, potassium-sparing diuretics, or potassium-containing salt substitutes.
↑risk of hyperkalemia, renal dysfunction, hypotension, and syncope with concurrent use of angiotensin II receptor blockers or aliskiren; avoid concurrent use with aliskiren in patients with diabetes or CCr <60 mL/min; avoid concurrent use with angiotensin II receptor blockers
NSAIDs and selective COX-2 inhibitors may blunt the antihypertensive effect and ↑ the risk of renal dysfunction.
↑levels and may ↑ the risk of lithium toxicity.
↑risk of angioedema with temsirolimus, sirolimus, or everolimus.

Hypertension

PO (Adults ): 10 mg once daily, can be ↑ up to 20–40 mg/day (initiate therapy at 5 mg/day in patients receiving diuretics).
PO (Children ≥6 yr): 0.07 mg/kg once daily (up to 5 mg/day), may be titrated every 1–2 wk up to 0.6 mg/kg/day (or 40 mg/day).

Renal Impairment

PO (Adults ): CCr 10–30 mL/min: Initiate therapy at 5 mg daily; may be slowly titrated up to 40 mg/day.CCr <10 mL/min: Initiate therapy at 2.5 mg once daily; may be slowly titrated up to 40 mg/day.

Renal Impairment

(Children ≥6 yr): CCr <30 mL/min: Contraindicated.

Heart Failure

PO (Adults ): 5 mg once daily, may be titrated every 2 wk up to 40 mg/day; initiate therapy at 2.5 mg once daily in patients with hyponatremia (serum sodium <130 mEq/L).

Renal Impairment

(Adults ): CCr ≤30 mL/min: Initiate therapy at 2.5 mg once daily.

Acute Myocardial Infarction

PO (Adults ): 5 mg once daily for 2 days, then 10 mg daily.

Renal Impairment

PO (Adults ): Initiate with caution in patients with serum creatinine >2 mg/dL.

(Generic available)

Oral solution: 1 mg/mL
Tablets: 2.5 mg; 5 mg; 10 mg; 20 mg; 30 mg; 40 mg
In combination with: hydrochlorothiazide (Zestoretic). See Appendix [not included in this PDA edition].

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 (swelling of face, extremities, eyes, lips, tongue, difficulty in swallowing or breathing); may occur at any time during therapy. Discontinue medication and provide supportive care.
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 BUN, creatinine, and electrolyte levels periodically. Serum potassium, BUN and creatinine may be ↑, whereas sodium levels may be ↓. If ↑ BUN or serum creatinine concentrations occur, dose reduction or withdrawal may be required.
- May cause hyperkalemia.
- Monitor CBC periodically during therapy in patients with collagen vascular disease and/or renal disease. May rarely cause slight ↓ in hemoglobin and hematocrit and agranulocytosis.
- May cause ↑ AST, ALT, alkaline phosphatase, and serum bilirubin.

Do not confuse Zestril with Zegerid, Zetia, or Zyprexa.
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.
PO: Administer once daily at the same time each day. Oral solution is clear to slightly opalescent. Administer without dilution.

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 lisinopril 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 Food Sources for Specific Nutrients.
- 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.
- Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially NSAIDs and 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 before treatment or surgery.
- Instruct patient to notify health care professional immediately 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 diabetic patients to monitor blood glucose closely, especially during first mo of therapy; may cause hypoglycemia.
Rep: May cause fetal harm. Advise females of reproductive potential to use effective contraception and notify health care professional if pregnancy is planned or suspected or if breastfeeding. If pregnancy is detected, discontinue lisinopril as soon as possible.
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.
Improvement in survival and reduction of symptoms in HF.
Reduction of risk of death or development of HF after MI.

~~Prinivil,~~ Qbrelis, Zestril

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

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