Angiotensin-Converting Enzyme (Ace) Inhibitors

benazepril: ben-AYE-ze-pril

captopril: KAP-toe-pril

Enalapril/Enalaprilat: e-NAL-a-pril/e-NAL-a-pril-at

fosinopril: foe-SIN-oh-pril

lisinopril: lyse-IN-oh-pril

moexipril: moe-EKS-i-pril

perindopril: pe-RIN-do-pril

quinapril: KWIN-a-pril

ramipril: ra-MI-pril

trandolapril: tran-DOE-la-pril

Therapeutic Classification: antihypertensives

Pharmacologic Classification: ace inhibitors

REMS

Hypertension (as monotherapy or in combination with other antihypertensives).

Captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril, trandolapril:

Management of HF.

Captopril, lisinopril, ramipril, trandolapril:

Reduction of risk of death or development of HF following MI.

Enalapril:

Slowed progression of left ventricular dysfunction into overt HF.

Ramipril:

Reduction of the risk of MI, stroke, and death from cardiovascular disease in patients at risk (>55 yr old with a history of CAD, stroke, peripheral vascular disease, or diabetes with another cardiovascular risk factor).

Captopril:

↓progression of diabetic nephropathy.

Perindopril:

Reduction of risk of death from cardiovascular causes or nonfatal MI in patients with stable CAD.

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.
Improved symptoms in patients with HF (selected agents only).
↓development of overt heart failure (enalapril only).
Improved survival and ↓ development of overt HF after MI (selected agents only).
↓risk of death from cardiovascular causes or MI in patients with stable CAD (perindopril only).
↓risk of MI, stroke or death from cardiovascular causes in high-risk patients (ramipril only).
↓progression of diabetic nephropathy (captopril only).

Absorption: Benazepril — 37% absorbed after oral administration. Captopril — 60–75% absorbed after oral administration (↓ by food). Enalapril — 55–75% absorbed after oral administration. Enalaprilat — IV administration results in complete bioavailability. Fosinopril — 36% absorbed after oral administration. Lisinopril — 25% absorbed after oral administration (much variability). Moexipril — 13% bioavailability as moexiprilat after oral administration (↓ by food). Perindopril — 25% bioavailability as perindoprilat after oral administration. Quinapril — 60% absorbed after oral administration (high-fat meal may ↓ absorption). Ramipril — 50–60% absorbed after oral administration. Trandolapril — 70% bioavailability as trandolapril at after oral administration.

Distribution: All ACE inhibitors cross the placenta. Benazepril, captopril, enalapril, fosinopril, quinapril, and trandolapril — Enter breast milk. Lisinopril — Minimal penetration of CNS. Ramipril — Probably does not enter breast milk. Trandolapril — Enters breast milk.

Protein Binding: Benazepril — 95%, Fosinopril — 99.4%, Moexipril — 90%, Quinapril — 97%.

Metabolism/Excretion: Benazepril — Converted by the liver to benazeprilat, the active metabolite. 20% excreted by kidneys; 11–12% nonrenal (biliary elimination). Captopril — 50% metabolized by the liver to inactive compounds, 50% excreted unchanged by the kidneys. Enalapril, enalaprilat — Enalapril is converted by the liver to enalaprilat, the active metabolite; primarily eliminated by the kidneys. Fosinopril — Converted by the liver and GI mucosa to fosinoprilat, the active metabolite — 50% excreted in urine, 50% in feces. Lisinopril — 100% eliminated by the kidneys. Moexipril — Converted by liver and GI mucosa to moexiprilat, the active metabolite; 13% excreted in urine, 53% in feces. Perindopril — Converted by the liver to perindoprilat, the active metabolite; primarily excreted in urine. Quinapril — Converted by the liver, GI mucosa, and tissue to quinaprilat, the active metabolite: 96% eliminated by the kidneys. Ramipril — Converted by the liver to ramiprilat, the active metabolite; 60% excreted in urine, 40% in feces. Trandolapril — Converted by the liver to trandolaprilat, the active metabolite; 33% excreted in urine, 66% in feces.

Half-life: Benazeprilat — 10–11 hr. Captopril — 2 hr (↑ in renal impairment). Enalapril — 2 hr (↑ in renal impairment). Enalaprilat — 35–38 hr (↑ in renal impairment). Fosinoprilat — 12 hr. Lisinopril — 12 hr (↑ in renal impairment). Moexiprilat — 2–9 hr (↑ in renal impairment). Perindoprilat — 3–10 hr (↑ in renal impairment). Quinaprilat — 3 hr (↑ in renal impairment). Ramiprilat — 13–17 hr (↑ in renal impairment). Trandolaprilat — 22.5 hr (↑ in renal impairment).

(effect on BP — single dose†)

ROUTE	ONSET	PEAK	DURATION
Benazepril	within 1 hr	2–4 hr	24 hr
Captopril	15–60 min	60–90 min	6–12 hr
Enalapril PO	1 hr	4–8 hr	12–24 hr
Enalapril IV	15 min	1–4 hr	4–6 hr
Fosinopril	within 1 hr	2–6 hr	24 hr
Lisinopril	1 hr	6 hr	24 hr
Moexipril	within 1 hr	3–6 hr	up to 24 hr
Perindoprilat	within 1–2 hr	3–7 hr	up to 24 hr
Quinapril	within 1 hr	2–4 hr	up to 24 hr
Ramipril	within 1–2 hr	3–6 hr	24 hr
Trandolapril	within 1–2 hr	4–10 hr	up to 24 hr

†Full effects may not be noted for several wks.

Contraindicated in:

Hypersensitivity
History of angioedema with previous use of ACE inhibitors (also in absence of previous use of ACE inhibitors for benazepril)
Concurrent use with aliskiren in patients with diabetes or moderate-to-severe renal impairment (CCr <60 mL/min)
Concurrent use with sacubitril/valsartan; must be a 36–hr wash-out period after switching to/from sacubitril/valsartan
OB: Pregnancy
Lactation: Lactation.

Use Cautiously in:

Renal impairment, hepatic impairment, hypovolemia, hyponatremia, concurrent diuretic therapy
Black patients with hypertension (monotherapy less effective, may require additional therapy; ↑ risk of angioedema)
Rep: Women of reproductive potential
Surgery/anesthesia (hypotension may be exaggerated)
Pedi: Safety and effectiveness not established in children <18 yr (moexipril, perindopril, quinapril ramipril, trandolapril) or <6 yr (benazepril, fosinopril, lisinopril)
Geri: Initial dose ↓ recommended for most agents due to age-related ↓ in renal function.

Exercise Extreme Caution in:

Family history of angioedema.

CV: hypotension, chest pain, edema, tachycardia.

Derm: flushing, pruritus, rashes.

Endo: hyperuricemia.

F and E: hyperkalemia.

GI: taste disturbances, abdominal pain, anorexia, constipation, diarrhea, nausea, vomiting.

GU: erectile dysfunction, proteinuria, renal dysfunction, renal failure.

Hemat: AGRANULOCYTOSIS, neutropenia (captopril only).

MS: back pain, muscle cramps, myalgia.

Neuro: dizziness, drowsiness, fatigue, headache, insomnia, vertigo, weakness.

Resp: cough, dyspnea.

Misc: ANGIOEDEMA, fever.

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 and other antihypertensives.
↑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.
Absorption of fosinopril may be ↓ by antacids (separate administration by 1–2 hr).
↑levels and may ↑ risk of lithium toxicity.
Quinapril may ↓ absorption of tetracycline, doxycycline, and fluoroquinolones (because of magnesium in tablets).
↑risk of angioedema with temsirolimus, sirolimus, or everolimus.

Drug-Food:

Food significantly ↓ absorption of captopril and moexipril (administer drugs 1 hr before meals).

Benazepril

PO (Adults): 10 mg once daily, ↑ gradually to maintenance dose of 20–40 mg/day in 1–2 divided doses (begin with 5 mg/day in patients receiving diuretics).
PO (Children 6 yr): 0.2 mg/kg once daily; may be titrated up to 0.6 mg/kg/day (or 40 mg/day).

Renal Impairment

PO (Adults): CCr <30 mL/min — Initiate therapy with 5 mg once daily.

Renal Impairment

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

Captopril

PO (Adults): Hypertension — 12.5–25 mg 2–3 times daily, may be ↑ at 1–2 wk intervals up to 150 mg 3 times daily (begin with 6.25–12.5 mg 2–3 times daily in patients receiving diuretics) (maximum dose = 450 mg/day); HF — 25 mg 3 times daily (6.25–12.5 mg 3 times daily in patients who have been vigorously diuresed); titrated up to target dose of 50 mg 3 times daily; Post-MI — 6.25-mg test dose, followed by 12.5 mg 3 times daily, may be ↑ up to 50 mg 3 times daily; Diabetic nephropathy — 25 mg 3 times daily.
PO (Children): HF — 0.3 mg/kg–0.5 mg/kg/dose 3 times daily, titrate up to a maximum of 6 mg/kg/day in 2–4 divided doses; Older Children — 6.25–12.5 mg/dose every 12–24 hr, titrate up to a maximum of 6 mg/kg/day in 2–4 divided doses.
PO (Infants): HF — 0.15–0.3 mg/kg/dose, titrate up to a maximum of 6 mg/kg/day in 1–4 divided doses.
PO (Neonates): HF — 0.05–0.1 mg/kg/dose every 8–24 hr, may ↑ as needed up to 0.5 mg/kg every 6–24 hr; Premature neonates — 0.01 mg/kg/dose every 8–12 hr.

Renal Impairment

PO (Adults): CCr 10–50 mL/min — Administer 75% of dose; CCr <10 mL/min — Administer 50% of dose.

Enalapril/Enalaprilat

PO (Adults): Hypertension — 2.5–5 mg once daily, ↑ as required up to 40 mg/day in 1–2 divided doses (initiate therapy at 2.5 mg once daily in patients receiving diuretics); HF — 2.5 mg 1–2 times daily, titrated up to target dose of 10 mg twice daily; begin with 2.5 mg once daily in patients with hyponatremia (serum sodium <130 mEq/L); Asymptomatic left ventricular dysfunction — 2.5 mg twice daily, titrated up to a target dose of 10 mg twice daily.
PO (Children >1 mo): Hypertension — 0.08 mg/kg once daily; may be slowly titrated up to a maximum of 0.58 mg/kg/day.
IV (Adults): Hypertension — 0.625–1.25 mg (0.625 mg if receiving diuretics) every 6 hr; can be titrated up to 5 mg every 6 hr.
IV (Children >1 mo): Hypertension — 5–10 mcg/kg/dose given every 8–24 hr.

Renal Impairment

PO, IV (Adults): HypertensionCCr 10–50 mL/min — Administer 75% of dose; CCr <10 mL/min — Administer 50% of dose.

Renal Impairment

PO, IV (Children >1 mo): CCr <30 mL/min — Contraindicated.

Fosinopril

PO (Adults): Hypertension — 10 mg once daily, may be ↑ as required up to 80 mg/day. HF — 10 mg once daily (5 mg once daily in patients who have been vigorously diuresed), may be ↑ over several wk up to 40 mg/day.
PO (Children 6 yr and >50 kg): Hypertension — 5–10 mg once daily.

Lisinopril

PO (Adults): Hypertension — 10 mg once daily, can be ↑ up to 20–40 mg/day (initiate therapy at 5 mg/day in patients receiving diuretics); HF — 5 mg once daily; may be titrated every 2 wk up to 40 mg/day; begin with 2.5 mg once daily in patients with hyponatremia (serum sodium <130 mEq/L); Post-MI — 5 mg once daily for 2 days, then 10 mg daily.
PO (Children 6 yr): Hypertension — 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 — Begin with 5 mg once daily; may be slowly titrated up to 40 mg/day; CCr <10 ml/min — Begin with 2.5 mg once daily; may be slowly titrated up to 40 mg/day.

Renal Impairment

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

Moexipril

PO (Adults): 7.5 mg once daily, may be ↑ up to 30 mg/day in 1–2 divided doses (begin with 3.75 mg/day in patients receiving diuretics).

Renal Impairment

PO (Adults): CCr 40 mL/min — Initiate therapy at 3.75 mg once daily, may be titrated upward carefully to 15 mg/day.

Perindopril

PO (Adults): Hypertension — 4 mg once daily, may be slowly titrated up to 16 mg/day in 1–2 divided doses (should not exceed 8 mg/day in elderly patients) (begin with 2–4 mg/day in 1–2 divided doses in patients receiving diuretics); Stable CAD — 4 mg once daily for 2 wk, may be ↑, if tolerated, to 8 mg once daily; for elderly patients, begin with 2 mg once daily for 1 wk (may be ↑, if tolerated, to 4 mg once daily for 1 wk, then, ↑ as tolerated to 8 mg once daily).

Renal Impairment

PO (Adults): CCr 30–60 mL/min — 2 mg/day initially, may be slowly titrated up to 8 mg/day in 1–2 divided doses.

Quinapril

PO (Adults): Hypertension — 10–20 mg once daily initially, may be titrated every 2 wk up to 80 mg/day in 1–2 divided doses (initiate therapy at 5 mg/day in patients receiving diuretics); HF — 5 mg twice daily initially, may be titrated at weekly intervals up to 20 mg twice daily.

Renal Impairment

PO (Adults): CCr >60 mL/min — Initiate therapy at 10 mg/day; CCr 30–60 mL/min — Initiate therapy at 5 mg/day; CCr 10–30 mL/min — Initiate therapy at 2.5 mg/day.

Ramipril

PO (Adults): Hypertension — 2.5 mg once daily, may be ↑ slowly up to 20 mg/day in 1–2 divided doses (initiate therapy at 1.25 mg/day in patients receiving diuretics). HF post-MI — 1.25–2.5 mg twice daily initially, may be ↑ slowly up to 5 mg twice daily. Reduction in risk of MI, stroke, and death from cardiovascular causes — 2.5 mg once daily for 1 wk, then 5 mg once daily for 3 wk, then ↑ as tolerated to 10 mg once daily (can also be given in 2 divided doses).

Renal Impairment

PO (Adults): CCr <40 mL/min — Initiate therapy at 1.25 mg once daily, may be slowly titrated up to 5 mg/day in 1–2 divided doses.

Trandolapril

PO (Adults): Hypertension — 1 mg once daily (2 mg once daily in black patients); HF post-MI — Initiate therapy at 1 mg once daily, titrate up to 4 mg once daily if possible.

Renal Impairment

PO (Adults): CCr <30 mL/min — Initiate therapy at 0.5 mg once daily, may be slowly titrated upward (maximum dose = 4 mg/day).

Hepatic Impairment

PO (Adults): Initiate therapy at 0.5 mg once daily, may be slowly titrated upward (maximum dose = 4 mg/day).

Benazepril

(generic available)

Tablets: 5 mg; 10 mg; 20 mg; 40 mg;
In combination with: amlodipine (Lotrel) and hydrochlorothiazide (Lotensin HCT). See Appendix [not included in this PDA edition].

Captopril

(generic available)

Tablets: 12.5 mg; 25 mg; 50 mg; 100 mg;
In combination with: hydrochlorothiazide (Capozide). See Appendix [not included in this PDA edition].

Enalapril

(generic available)

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

Enalaprilat

(generic available)

Solution for injection: 1.25 mg/mL;

Fosinopril

(generic available)

Tablets: 10 mg; 20 mg; 40 mg;
In combination with: hydrochlorothiazide. See Appendix [not included in this PDA edition].

Lisinopril

(generic available)

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

Moexipril

(generic available)

Tablets: 7.5 mg; 15 mg;
In combination with: hydrochlorothiazide (Uniretic).

Perindopril

(generic available)

Tablets: 2 mg; 4 mg; 8 mg;
In combination with: amlodipine (Prestalia). See Appendix [not included in this PDA edition].

Quinapril

(generic available)

Tablets: 5 mg; 10 mg; 20 mg; 40 mg;
In combination with: hydrochlorothiazide (Accuretic). See Appendix [not included in this PDA edition].

Ramipril

(generic available)

Capsules: 1.25 mg; 2.5 mg; 5 mg; 10 mg; 15 mg;

Trandolapril

(generic available)

Tablets: 0.5 mg; 1 mg; 2 mg; 4 mg;
In combination with: verapamil. 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 adherence.
- 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.
HF: 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, serum 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.
- Monitor CBC periodically during therapy. Certain drugs may rarely cause slight ↓ in hemoglobin and hematocrit, leukopenia, and eosinophilia.
- May cause ↑ AST, ALT, alkaline phosphatase, serum bilirubin, uric acid, and glucose.
- Assess urine protein prior to and periodically during therapy for up to 1 yr in patients with renal impairment or those receiving >150 mg/day of captopril. If excessive or ↑ proteinuria occurs, re-evaluate ACE inhibitor therapy.
- Captopril: May cause positive ANA titer.
- Captopril: May cause false-positive test results for urine acetone.
- Captopril: Monitor CBC with differential prior to initiation of therapy, every 2 wk for first 3 mo, and periodically for up to 1 yr in patients at risk for neutropenia (patients with renal impairment or collagen-vascular disease) or at first sign of infection. Discontinue therapy if neutrophil count is <1000/mm³.

Do not confuse Accupril with Aciphex. Do not confuse benazepril with Benadryl. Do not confuse captopril with carvedilol. Do not confuse Zestril with Zegerid, Zetia, or Zyprexa.
Correct volume depletion, if possible, before initiation of therapy.
PO: Precipitous drop in BP during first 1–3 hr after first dose may require volume expansion with normal saline but is not usually considered an indication for stopping therapy. Discontinuing diuretic therapy or cautiously increasing salt intake 2–3 days before initiation may ↓ risk of hypotension. Monitor closely for at least 1 hr after BP has stabilized. Resume diuretics if BP is not controlled.

Benazepril

PO: For patients with difficulty swallowing tablets, pharmacist may compound oral suspension; stable for 30 days if refrigerated. Shake suspension before each use.

Captopril

PO: Administer 1 hr before or 2 hr after meals. May be crushed if patient has difficulty swallowing. Tablets may have a sulfurous odor.
- An oral solution may be prepared by crushing a 25-mg tablet and dissolving it in 25–100 mL of water. Shake for at least 5 min and administer within 30 min.

Enalapril

PO: For patients with difficulty swallowing tablets, oral solution is available ready to use. Shake solution before each use. Solution is stable at controlled room temperature for 60 days.

Enalaprilat

IV Administration:

IV Push:
Rate: Administer over at least 5 min.
Intermittent Infusion:
Rate: Administer as a slow infusion over at least 5 min.
Y-Site Compatibility:
- acyclovir
- alemtuzumab
- alfentanil
- allopurinol
- amifostine
- amikacin
- aminocaproic acid
- aminophylline
- amiodarone
- amphotericin B lipid complex
- amphotericin B liposome
- anidulafungin
- argatroban
- arsenic trioxide
- ascorbic acid
- atropine
- azathioprine
- azithromycin
- aztreonam
- benztropine
- bivalirudin
- bleomycin
- bumetanide
- buprenorphine
- butorphanol
- calcium chloride
- calcium gluconate
- cangrelor
- carboplatin
- carmustine
- cefazolin
- cefotaxime
- cefotetan
- cefoxitin
- ceftaroline
- ceftazidime
- ceftriaxone
- cefuroxime
- chloramphenicol
- chlorpromazine
- cisatracurium
- cisplatin
- cladribine
- clindamycin
- cyanocobalamin
- cyclophosphamide
- cyclosporine
- cytarabine
- dacarbazine
- dactinomycin
- daptomycin
- daunorubicin
- dexamethasone
- dexmedetomidine
- dexrazoxane
- digoxin
- diltiazem
- diphenhydramine
- dobutamine
- docetaxel
- dopamine
- doxorubicin
- doxorubicin liposomal
- doxycycline
- ephedrine
- epinephrine
- epirubicin
- epoetin alfa
- eptifibatide
- ertapenem
- erythromycin
- esmolol
- etoposide
- etoposide phosphate
- famotidine
- fenoldopam
- fentanyl
- filgrastim
- fluconazole
- fludarabine
- fluorouracil
- folic acid
- foscarnet
- fosphenytoin
- furosemide
- gallium nitrate
- ganciclovir
- gemcitabine
- gentamicin
- glycopyrrolate
- granisetron
- heparin
- hetastarch
- hydrocortisone
- hydromorphone
- idarubicin
- ifosfamide
- imipenem/cilastatin
- indomethacin
- insulin, regular
- irinotecan
- isoproterenol
- ketorolac
- labetalol
- lactated Ringer's
- leucovorin calcium
- levofloxacin
- lidocaine
- linezolid
- lorazepam
- magnesium sulfate
- mannitol
- melphalan
- meperidine
- meropenem
- mesna
- methadone
- methotrexate
- methylprednisolone
- metoclopramide
- metoprolol
- metronidazole
- midazolam
- milrinone
- mitomycin
- mitoxantrone
- morphine
- moxifloxacin
- multivitamins
- mycophenolate
- nafcillin
- nalbuphine
- naloxone
- nicardipine
- nitroglycerin
- nitroprusside
- norepinephrine
- octreotide
- ondansetron
- oxacillin
- oxaliplatin
- oxytocin
- paclitaxel
- palonosetron
- pamidronate
- pancuronium
- papaverine
- pemetrexed
- penicillin G
- pentamidine
- pentobarbital
- phenobarbital
- phentolamine
- phenylephrine
- phytonadione
- piperacillin/tazobactam
- potassium acetate
- potassium chloride
- potassium phosphate
- procainamide
- prochlorperazine
- promethazine
- propofol
- propranolol
- protamine
- pyridoxine
- remifentanil
- rituximab
- rocuronium
- sodium acetate
- sodium bicarbonate
- succinylcholine
- sufentanil
- tacrolimus
- tetracycline
- theophylline
- thiamine
- thiotepa
- tigecycline
- tirofiban
- tobramycin
- topotecan
- trastuzumab
- vancomycin
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- voriconazole
- zoledronic acid
Y-Site Incompatibility:
- amphotericin B deoxycholate
- caspofungin
- cefepime
- dantrolene
- diazepam
- diazoxide
- gemtuzumab ozogamicin
- phenytoin

Lisinopril

PO: Oral solution is clear to slightly opalescent. Administer without dilution.

Moexipril

PO: Administer moexipril on an empty stomach, 1 hr before a meal.

Ramipril

PO: Capsules may be opened and sprinkled on applesauce, or dissolved in 4 oz water or apple juice for patients with difficulty swallowing. Effectiveness is same as capsule. Prepared mixtures can be stored for up to 24 hr at room temperature or up to 48 hr if refrigerated.

Trandolapril

PO: May be taken with or without food.

Instruct patient to take medication as directed at the same time each day, even if feeling well. Take missed doses as soon as possible 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 or foods containing high levels of potassium or sodium unless directed by health care professional (see Appendix M).
- Caution patient to change positions slowly to minimize hypotension. Use of alcohol, standing for long periods, exercising, and hot weather may ↑ orthostatic hypotension.
- 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.
- Advise patient that medication may cause impairment of taste that generally resolves within 8–12 wk, even with continued therapy.
- 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; difficulty swallowing or breathing occur; or if taste impairment or skin rash persists. 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 during therapy and notify health care professional if pregnancy is planned or suspected. If pregnancy is detected, discontinue medication as soon as possible. Closely observe infants with histories of in utero exposure to ACE inhibitors for hypotension, oliguria, and hyperkalemia. If oliguria or hypotension occur, support blood pressure and renal perfusion. Exchange transfusions or dialysis may be required as a means of reversing hypotension and substituting for disordered renal function. Advise patient to avoid breast feeding during therapy.
- Emphasize the importance of follow-up examinations to monitor progress.
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.
Decrease in signs and symptoms of HF (some drugs may also improve survival).
Decrease in development of overt HF (enalapril).
Reduction of risk of death or development of HF following MI.
Reduction of risk of death from cardiovascular causes and MI in patients with stable CAD (perindopril).
Reduction of risk of MI, stroke, or death from cardiovascular causes in patients at high-risk for these events (ramipril).
Decrease in progression of diabetic nephropathy (captopril).

benazepril: Lotensin

captopril: Capoten

Enalapril/Enalaprilat: Epaned, Vasotec

fosinopril: Monopril

lisinopril: Prinivil

, Qbrelis, Zestril

moexipril: Univasc

perindopril: Aceon

quinapril: Accupril

ramipril: Altace

Enalapril/Enalaprilat: Vasotec IV

perindopril: Coversyl