ACE inhibitors include-
Benazepril, Captopril, Enalapril, Enalaprilat, Fosinopril, Lisonopril, Moexipril,
Perindopril, Quinapril, Ramipril, Trandolapril
Refer Captopril

Interacting drugs- summary

+ACE Inhibitors
 
Antacids  
 bioavailability of ACEIs decreased, more  likely with  captopril.
 Separate the administration times  by 1 to 2 hours

Capsicin 
capsicin cause or exacerbate  coughing associated  with ACEI treatment and vice versa
 
Indomethicin 
 reduced hypotensive effect of ACEIs . more prominent in  low-resin or volume depedent hypertensives patients

Phenothiazines
pharmacologic effects  of ACEIs  increased

Probenecid + Capotopril
 increased catopril blood levels and decreased total clearance  have occurred.

Rifampicin +   Enalapril
 pharmacologic effects of enalapril  decreased

ACEIs +

Allopurinol 
 higher risk of hypersensitivity reaction possible when these drugs   are given concurrently

Digoxin 
 increased plasma digoxin levels

Lithium
 increased  lithium levels and symptoms of toxicity occur

Pot prepn, Pot sparing  diuretics
 coadministration  result in elevated serum potasium  concen.

Quinapril +   Tetracycline  
 tetracycline absorption reduced by 28% to 37% possibly due to  the high magnesium content of quinalapril tabs

Adjunct to diuretics  & digitalis in congestive cardiac failure

ACE inhibitors include-

Benazepril, Captopril, Enalapril, Enalaprilat, Fosinopril, Lisonopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril

Refer Captopril 

Approved by FDA in 1987.

Approved by (DCI) Drug Controller  GENERAL -  India  For Marketing

Adverse reactions summary-                      

LISINOPRIL-

CARDIOVASCULAR-    Hypotension 5%   Orthostatic effects 1.4 %  Chest pain 1.3%
                                        Palpitations, Angina pectoris, Cerebrovascular  accident,
                                        Myocardial infarctn, Orthostatic hypotension,Tachycardia < 1%

CNS-                               Dizziness 6.3%,  Headache 5.3% Fatigue 3.3% 
                                        Confusion,  Insomnia, Somnolence, Depression  < 1%

GI/GU                             Diarrhea 3.2%, Nausea 2.3%, Vomiting 1.3%,
                                       Abdominal pain, Anorexia,Constipation,  Oliguria  < 1%

RESPIRATORY            Cough 4 %,  Dyspnea 1.1%, Bronchitis,  Sinusitis < 1%

DERMATOLOGIC         Rash 1.5 %, Increased sweating, Flushing, Pruritus < 1%

MISCELLANEOUS        Asthenia 1.3%, Muscle cramps, Decreased libido, Impotence
                                        Blurred vision, Syncope, Fever < 1%

Severe hypotension and renal failure. Dizziness, headache, diarrhoea, cough. Rarely skin rash or angioneurotic oedema. Occassional increase in liver enzymes and serum bilirubin. Sudden hypotension.

Hypersensitivity.Patients with angoiedema related to previous treatment with ACE inhibitors. Pregnancy,aortic stenosis, cor pulmonale,children.

Special precautions:

Assess renal function and insufficiency.Renovascular hypertension,surgery,anaesthesia,lactation In CCF it may cause oliguria and/or progressive azotemia and rarely acute renal failure.

Approved by FDA in 1987.

Indications:

Adjunct to diuretics & digitalis in congestive cardiac failure.

Dosage:

CHF- 5mg once daily with diuretics and digitalis.

Missed dose

1. If you miss a dose of this medicine, take it as soon as possible.

2. However, if it is almost time for next dose, skip the missed dose and go back to your regular dosing schedule.

3. Do not double doses.

For Availability/supplies 

List of entries

1. Congestive Heart Failure (CHF)

2. Atrial Fibrillation

3. Atrial Flutter

1. Congestive Heart Failure (CHF) Heart failure is charaterized by well known symptoms and physical signs. Heart failure is coinsidered to be pathophysiological state in which an abnormal cardiac function is responsible for the failure of the heart to pump blood at a rate communsurate with the requirement of the metabolizing tissues. Heart failure is frequently but not always caused by a defect in myocardial contraction, and then the term myocardial failure is appropiate,. Increased cardiac output results in in diuresis and general amelioration of disturbances characteristic of fight heart failure (venous congestion, edema) and left heart failure ) dyspnea, orthopnea, cardiac asthma). Digitalis is generaly most effective in "low output" failure and less effective in "high output " failure ) bronchopulmonary insufficiency, artriovenous fistula, anemia, hyperthyroidism.

2. Atrial fibrillation This is a dysrhythmia in which the effective contraction of the atria is abolished and the AV node and the ventricles are bombarded with a very rapid and irregular series of stimuli. Many of these impulses are blocked at the AV node, but many are passed through, so that the ventricular contracrtions in the untreated patient are usually rapid and irregularly irregular. Digitalis rapidly reduces ventricular rates and eliminates the pulse deficit. Palpitation,precordial distress or weakness are relieved and concomittant congestive failure ameliorated. Continue digitalis in doses necessary to maintain the desired ventricular rate, both ar rest and in response to excercise and other clinical effects.

3. Atrial flutter The dysrhythmia is less common than artial fibrillation. There is a considerable controversy regarding its mechanism. A reciprocating rhythm or circus current movement is most likely. The atria contracts at a rate of 250 to 350 rates per minute. AV block is almost always present and its ratio is usually even numbered. Digitalis slows the heart; normal sinus rhythm appear. Digitalis slows the ventricular rate, by decreasing the degree of AV block, and commonly converts flutter to fibrillation. When the drug is withdrawn , the atrial flutter will frequently revert spontaneosuly to normal sinus rhythm. If this not occur quinidine may be employed to restore sinus rhythm. Heart Failure Evidence Based Medicine (MIMS March 2003) Beneficial ACE inhibitors such as captopril, enalapril,lisonopril,and perindopril Digoxin Appropriate use of beta-blockers Spironolactoone in severe cases Likely to be beneficial Multidisciplinary intereventions (nutrition, counselling) Excercise Angiotensin II receptor blockers Amiiodarone Implatable cardiac defibrillators Unlikely to be beneficial Calcium channel blockers

Likely to beineffective or harmful Positive inotropes(non-digitalis) Non-amiodarone antiarrhythmic drugs

Key Points

1. There is conflicting evidence of the efficacy of multidisciplinary approach

2. Pescribed excercise training improves functional capacity and quality of life and reduces the rate of adverses cardiac events

3. Ace inhibitors reduce mortality, admission to hospital for heart failue and ischaemic events in patients with heart failure but are still under-used.

4. One critical trial has found that angiotensin II receptor blockers are at least as effective as ACE inhibitors for reducing clinical events(death or admission to hospitals). They confer no advantage over ACE inhibitors but can be useful if ACE inhibitors are not tolerated

5. Positve inotropic drugs improve symptoms but do not reduce mortality

6. Adding beta-blocker to ACE inhibitors decreases the rate of death and admission to hospitals

7. One clinical trial has found that in severe heart failure, adding an aldosterone receptor antagonist to an ACE inhibitor reduces mortality compared with ACE inhibitors alone.

8. ACE inhibitors delay the onset of symptoms and reduce cardiovascular events in patients with asymtomatic left ventricular systolic dysfunction

Refer Captopril 

1. Take captopril 1 hour before meals. Take moexipril in the fasting state

2. Do not interupt or discontinue medication without consulting physician

3. Notify physician if any of the following occur- sore throat, fever, swelling of hands or feet, irregular heart beat , chest pains, signs of angioedema, excessive prespiration, dehydration, vomiting and diarrhea may lead to a fall in blood pressure.

4. May cause dizziness, fainting or lightheadedness, especially during the first days of therapy; avoid sudden changes in posture. If syncope occurs, discontinue drug until physician has been contacted. Heart failure patients should avoid rapid increases in physical activity.

5. May cause skin rash or impaired taste perception. Notify physician if these persist.

6. Do not use salt substitutes containing potassium without consulting a physician

7. A persistent dry cough may occur and usually does not subside unless the medication is stopped. If this effect become bothersome, consult a physician.

Refer Captopril

Refer Captopril

Refer Captopril