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Drug overview for EPANED (enalapril maleate):
Generic name: ENALAPRIL MALEATE (en-AL-a-pril)
Drug class: Angiotensin Converting Enzyme (ACE) Inhibitors
Therapeutic class: Cardiovascular Therapy Agents
Enalaprilat and enalapril are angiotensin-converting enzyme (ACE) inhibitors; enalapril, the ethylester of enalaprilat, is a prodrug and has little pharmacologic activity until hydrolyzed in the liver to enalaprilat.
No enhanced Uses information available for this drug.
Generic name: ENALAPRIL MALEATE (en-AL-a-pril)
Drug class: Angiotensin Converting Enzyme (ACE) Inhibitors
Therapeutic class: Cardiovascular Therapy Agents
Enalaprilat and enalapril are angiotensin-converting enzyme (ACE) inhibitors; enalapril, the ethylester of enalaprilat, is a prodrug and has little pharmacologic activity until hydrolyzed in the liver to enalaprilat.
No enhanced Uses information available for this drug.
DRUG IMAGES
EPANED 1 MG/ML ORAL SOLUTION
The following indications for EPANED (enalapril maleate) have been approved by the FDA:
Indications:
Asymptomatic left ventricular dysfunction
Chronic heart failure
Hypertension
Professional Synonyms:
Asymptomatic LV dysfunction
Congestive heart failure
Elevated blood pressure
Essential hypertension
Hyperpiesia
Hyperpiesis
Hypertensive disorder
Systemic arterial hypertension
Indications:
Asymptomatic left ventricular dysfunction
Chronic heart failure
Hypertension
Professional Synonyms:
Asymptomatic LV dysfunction
Congestive heart failure
Elevated blood pressure
Essential hypertension
Hyperpiesia
Hyperpiesis
Hypertensive disorder
Systemic arterial hypertension
The following dosing information is available for EPANED (enalapril maleate):
Dosage of enalapril maleate and enalaprilat must be adjusted according to the patient's tolerance and response. Since enalapril maleate is a prodrug of enalaprilat and is well absorbed following oral administration, dosage of the two drugs is not identical and clinicians must give careful attention to dosage when converting from oral to IV therapy or vice versa.
Because of the risk of inducing hypotension, initiation of enalapril maleate or enalaprilat therapy requires consideration of recent antihypertensive therapy, the extent of blood pressure elevation, sodium intake, fluid status, and other clinical circumstances. If therapy is initiated in patients already receiving a diuretic, symptomatic hypotension may occur following the initial dose of the angiotensin-converting enzyme (ACE) inhibitor. The possibility of hypotension may be minimized by discontinuing the diuretic, reducing the diuretic dosage, or cautiously increasing salt intake prior to initiation of oral enalapril maleate or IV enalaprilat therapy.
(See Cautions: Cardiovascular Effects.) For information on initiating oral enalapril maleate or IV enalaprilat therapy when diuretic therapy is not being withheld, see the disease-specific dosage sections in Dosage and Administration: Dosage.
The manufacturer states that the usual initial adult dosage of enalapril maleate for the management of hypertension in patients not receiving a diuretic is 5 mg once daily. In patients who are receiving a diuretic, it is recommended that diuretic therapy be discontinued, if possible, 2-3 days before initiating therapy. (See Cautions: Precautions and Contraindications.) If blood pressure is not adequately controlled with the ACE inhibitor alone, diuretic therapy may be resumed cautiously.
If diuretic therapy cannot be discontinued, an initial enalapril maleate dose of 2.5 mg should be administered under medical supervision for at least 2 hours and until blood pressure has stabilized for at least an additional hour.
The usual initial pediatric (1 month to 16 years of age) dosage of enalapril maleate is 0.08 mg/kg once daily, up to 5 mg. Some experts state that the dose may be administered as a single dose or in 2 divided doses daily.
Such experts also state that the dosage may be increased every 2-4 weeks until blood pressure is controlled, the maximum dosage is reached, or adverse effects occur. The manufacturer states that dosages of enalapril maleate exceeding 0.58 mg/kg or in excess of 40 mg daily have not been studied in pediatric patients.
(For information on overall principles and expert recommendations for treatment of hypertension in pediatric patients, see Uses: Hypertension in Pediatric Patients, in the Thiazides General Statement 40:28.20.)
Dosage of enalapril maleate should be adjusted according to the patient's blood pressure response. If the blood pressure response diminishes toward the end of the dosing interval during once-daily administration, increasing the dosage or giving the drug in 2 divided doses daily should be considered. Because the reduction in blood pressure may be gradual, some clinicians suggest that enalapril maleate dosage generally be titrated at 2- to 4-week intervals if necessary.
The manufacturer states that the usual maintenance dosage of enalapril maleate in adults is 10-40 mg daily, given as a single dose or in 2 divided doses daily, although most patients can be maintained on once-daily dosing. Some experts state that the usual adult dosage is 5-40 mg daily, given as a single dose or in 2 divided doses daily. Optimum blood pressure reduction may require several weeks of therapy in some patients.
If blood pressure is not adequately controlled with enalapril alone, a second antihypertensive agent (e.g., a diuretic) may be added.
When oral therapy is initiated following IV enalaprilat therapy in adults not receiving a diuretic, the recommended initial dosage of enalapril maleate is 5 mg once daily with subsequent dosage adjustment as necessary. When oral therapy is initiated following IV enalaprilat therapy in adults receiving a diuretic, the recommended initial dosage of enalapril maleate in those who responded to enalaprilat 0.625 mg every 6 hours is 2.5
mg once daily with subsequent dosage adjustment as necessary.
When oral therapy is not feasible, the recommended initial IV enalaprilat dosage in adults not receiving a diuretic or in those converting from enalapril maleate therapy (without concomitant diuretic therapy) is 1.25 mg every 6 hours. Reduction in blood pressure usually occurs within 15 minutes, but the maximal hypotensive response after the first dose may not occur for up to 4 hours after administration.
The maximum effects of the second and subsequent doses may exceed those of the first dose. Although no regimen has been shown to be more effective than 1.25 mg every 6 hours, dosages as high as 5 mg every 6 hours were well tolerated for up to 36 hours in controlled clinical studies.
Experience with dosages greater than 20 mg daily is insufficient. In studies of patients with hypertension, enalaprilat was not administered for longer than 48 hours, but in other studies it has been administered for as long as 7 days.
When oral therapy is not feasible in adults receiving a diuretic, the recommended initial IV enalaprilat dose is 0.625 mg. A reduction in blood pressure usually occurs within 15 minutes.
Although most of the effect is usually apparent within the first hour, the maximal hypotensive response may not occur for up to 4 hours after the initial dose. If the blood pressure response after 1 hour is inadequate, another dose of 0.625 mg may be given.
Additional doses of 1.25 mg may be administered at 6-hour intervals.
To reduce blood pressure rapidly in adults with a hypertensive emergency+, an IV enalaprilat dosage of 1.25-5 mg, repeated every 6 hours as necessary, has been recommended. If IV enalaprilat is used in the management of a hypertensive emergency in adults without a compelling condition, the initial goal of such therapy is to reduce systolic blood pressure by no more than 25% within 1 hour, followed by further reduction if stable toward 160/100 to 110 mm Hg within the next 2-6 hours, avoiding excessive declines in pressure that could precipitate renal, cerebral, or coronary ischemia.
If this blood pressure is well tolerated and the patient is clinically stable, further gradual reductions toward normal can be implemented in the next 24-48 hours. Enalaprilat is most useful in hypertensive emergencies associated with high plasma renin activity.
For information on converting patients from IV to oral therapy, see Oral Dosage under Dosage: Hypertension, in Dosage and Administration.
If enalapril maleate or enalaprilat is used in patients with impaired renal function, dosage must be modified in response to the degree of renal impairment, and the theoretical risk of neutropenia must be considered. (See Cautions: Hematologic Effects.)
The manufacturer states that hypertensive adults with moderate renal impairment (i.e., creatinine clearances greater than 30 mL/minute) may receive the usual dosage of enalapril maleate. In adults with severe renal impairment (i.e., creatinine clearances of 30 mL/minute or less), dosage of enalapril maleate should be initiated at 2.5 mg daily.
If an adequate response is not achieved, dosage may then be gradually increased until blood pressure is controlled or a maximum dosage of 40 mg daily is reached. Alternatively, some clinicians suggest that patients with creatinine clearances of 10-50 mL/minute can receive 75-100% of the usual dosage and those with creatinine clearances less than 10 mL/minute can receive 50% of the usual dosage. Patients undergoing hemodialysis should receive a supplemental dose of the drug after dialysis.
The manufacturer recommends that hemodialysis patients be given a dose of 2.5 mg on dialysis days; on days between dialysis periods, enalapril maleate dosage should be adjusted according to the patient's blood pressure response.
For hypertensive adults with moderate renal impairment (i.e., creatinine clearances greater than 30 mL/minute) in whom oral therapy is not feasible, the recommended dosage of IV enalaprilat is 1.25 mg every 6 hours. In adults with severe renal impairment (i.e., creatinine clearances of 30 mL/minute or less), the initial dose of IV enalaprilat should be 0.625
mg; if the blood pressure response is inadequate after 1 hour, another dose of 0.625 mg may be given. Additional doses of 1.25
mg may be administered at 6-hour intervals. For patients undergoing dialysis, the initial dosage of IV enalaprilat should be 0.625 mg every 6 hours.
When oral therapy is initiated following IV enalaprilat therapy, the recommended initial dosage of enalapril maleate is 5 mg once daily in patients with creatinine clearances greater than 30 mL/minute and 2.5 mg once daily in patients with creatinine clearances of 30 mL/minute or less. Dosage is subsequently adjusted according to the patient's blood pressure response.
The manufacturer states that adults with heart failure and hyponatremia (serum sodium concentration less than 130 mEq/L) or serum creatinine concentration greater than 1.6 mg/dL should receive an initial enalapril maleate dosage of 2.5 mg daily under close monitoring (see Heart Failure under Dosage and Administration: Dosage).
Subsequent dosage may be increased gradually as necessary, usually at intervals of 4 or more days, to 2.5 mg twice daily, then 5 mg twice daily, and then higher, provided excessive hypotension or deterioration of renal function is not present at the time of intended dosage adjustment; dosage should not exceed 40 mg daily.
If concomitant diuretic therapy is required in patients with severe renal impairment, a loop diuretic is preferred to a thiazide diuretic. Therefore, use of commercially available preparations containing enalapril maleate in fixed combination with hydrochlorothiazide is not recommended for patients with severe renal impairment. The manufacturers state that dosage adjustment of commercially available preparations containing enalapril maleate in fixed combination with hydrochlorothiazide is not needed in patients with renal impairment whose creatinine clearance exceeds 30 mL/minute per 1.73
m2. (For information on dosage of hydrochlorothiazide in other special populations, see Dosage and Administration, in Hydrochlorothiazide 40:28.20.)
Enalapril maleate is not recommended for neonates or for pediatric patients who have a glomerular filtration rate of less than 30 mL/minute per 1.73 m2, since no data are available in such patients.
Since it is not known whether geriatric patients 65 years of age or older respond the same to enalapril in fixed combination with hydrochlorothiazide as younger adults, the manufacturer suggests that patients in this age group receive initial dosages of the fixed combination in the lower end of the usual range.
Because of the risk of inducing hypotension, initiation of enalapril maleate or enalaprilat therapy requires consideration of recent antihypertensive therapy, the extent of blood pressure elevation, sodium intake, fluid status, and other clinical circumstances. If therapy is initiated in patients already receiving a diuretic, symptomatic hypotension may occur following the initial dose of the angiotensin-converting enzyme (ACE) inhibitor. The possibility of hypotension may be minimized by discontinuing the diuretic, reducing the diuretic dosage, or cautiously increasing salt intake prior to initiation of oral enalapril maleate or IV enalaprilat therapy.
(See Cautions: Cardiovascular Effects.) For information on initiating oral enalapril maleate or IV enalaprilat therapy when diuretic therapy is not being withheld, see the disease-specific dosage sections in Dosage and Administration: Dosage.
The manufacturer states that the usual initial adult dosage of enalapril maleate for the management of hypertension in patients not receiving a diuretic is 5 mg once daily. In patients who are receiving a diuretic, it is recommended that diuretic therapy be discontinued, if possible, 2-3 days before initiating therapy. (See Cautions: Precautions and Contraindications.) If blood pressure is not adequately controlled with the ACE inhibitor alone, diuretic therapy may be resumed cautiously.
If diuretic therapy cannot be discontinued, an initial enalapril maleate dose of 2.5 mg should be administered under medical supervision for at least 2 hours and until blood pressure has stabilized for at least an additional hour.
The usual initial pediatric (1 month to 16 years of age) dosage of enalapril maleate is 0.08 mg/kg once daily, up to 5 mg. Some experts state that the dose may be administered as a single dose or in 2 divided doses daily.
Such experts also state that the dosage may be increased every 2-4 weeks until blood pressure is controlled, the maximum dosage is reached, or adverse effects occur. The manufacturer states that dosages of enalapril maleate exceeding 0.58 mg/kg or in excess of 40 mg daily have not been studied in pediatric patients.
(For information on overall principles and expert recommendations for treatment of hypertension in pediatric patients, see Uses: Hypertension in Pediatric Patients, in the Thiazides General Statement 40:28.20.)
Dosage of enalapril maleate should be adjusted according to the patient's blood pressure response. If the blood pressure response diminishes toward the end of the dosing interval during once-daily administration, increasing the dosage or giving the drug in 2 divided doses daily should be considered. Because the reduction in blood pressure may be gradual, some clinicians suggest that enalapril maleate dosage generally be titrated at 2- to 4-week intervals if necessary.
The manufacturer states that the usual maintenance dosage of enalapril maleate in adults is 10-40 mg daily, given as a single dose or in 2 divided doses daily, although most patients can be maintained on once-daily dosing. Some experts state that the usual adult dosage is 5-40 mg daily, given as a single dose or in 2 divided doses daily. Optimum blood pressure reduction may require several weeks of therapy in some patients.
If blood pressure is not adequately controlled with enalapril alone, a second antihypertensive agent (e.g., a diuretic) may be added.
When oral therapy is initiated following IV enalaprilat therapy in adults not receiving a diuretic, the recommended initial dosage of enalapril maleate is 5 mg once daily with subsequent dosage adjustment as necessary. When oral therapy is initiated following IV enalaprilat therapy in adults receiving a diuretic, the recommended initial dosage of enalapril maleate in those who responded to enalaprilat 0.625 mg every 6 hours is 2.5
mg once daily with subsequent dosage adjustment as necessary.
When oral therapy is not feasible, the recommended initial IV enalaprilat dosage in adults not receiving a diuretic or in those converting from enalapril maleate therapy (without concomitant diuretic therapy) is 1.25 mg every 6 hours. Reduction in blood pressure usually occurs within 15 minutes, but the maximal hypotensive response after the first dose may not occur for up to 4 hours after administration.
The maximum effects of the second and subsequent doses may exceed those of the first dose. Although no regimen has been shown to be more effective than 1.25 mg every 6 hours, dosages as high as 5 mg every 6 hours were well tolerated for up to 36 hours in controlled clinical studies.
Experience with dosages greater than 20 mg daily is insufficient. In studies of patients with hypertension, enalaprilat was not administered for longer than 48 hours, but in other studies it has been administered for as long as 7 days.
When oral therapy is not feasible in adults receiving a diuretic, the recommended initial IV enalaprilat dose is 0.625 mg. A reduction in blood pressure usually occurs within 15 minutes.
Although most of the effect is usually apparent within the first hour, the maximal hypotensive response may not occur for up to 4 hours after the initial dose. If the blood pressure response after 1 hour is inadequate, another dose of 0.625 mg may be given.
Additional doses of 1.25 mg may be administered at 6-hour intervals.
To reduce blood pressure rapidly in adults with a hypertensive emergency+, an IV enalaprilat dosage of 1.25-5 mg, repeated every 6 hours as necessary, has been recommended. If IV enalaprilat is used in the management of a hypertensive emergency in adults without a compelling condition, the initial goal of such therapy is to reduce systolic blood pressure by no more than 25% within 1 hour, followed by further reduction if stable toward 160/100 to 110 mm Hg within the next 2-6 hours, avoiding excessive declines in pressure that could precipitate renal, cerebral, or coronary ischemia.
If this blood pressure is well tolerated and the patient is clinically stable, further gradual reductions toward normal can be implemented in the next 24-48 hours. Enalaprilat is most useful in hypertensive emergencies associated with high plasma renin activity.
For information on converting patients from IV to oral therapy, see Oral Dosage under Dosage: Hypertension, in Dosage and Administration.
If enalapril maleate or enalaprilat is used in patients with impaired renal function, dosage must be modified in response to the degree of renal impairment, and the theoretical risk of neutropenia must be considered. (See Cautions: Hematologic Effects.)
The manufacturer states that hypertensive adults with moderate renal impairment (i.e., creatinine clearances greater than 30 mL/minute) may receive the usual dosage of enalapril maleate. In adults with severe renal impairment (i.e., creatinine clearances of 30 mL/minute or less), dosage of enalapril maleate should be initiated at 2.5 mg daily.
If an adequate response is not achieved, dosage may then be gradually increased until blood pressure is controlled or a maximum dosage of 40 mg daily is reached. Alternatively, some clinicians suggest that patients with creatinine clearances of 10-50 mL/minute can receive 75-100% of the usual dosage and those with creatinine clearances less than 10 mL/minute can receive 50% of the usual dosage. Patients undergoing hemodialysis should receive a supplemental dose of the drug after dialysis.
The manufacturer recommends that hemodialysis patients be given a dose of 2.5 mg on dialysis days; on days between dialysis periods, enalapril maleate dosage should be adjusted according to the patient's blood pressure response.
For hypertensive adults with moderate renal impairment (i.e., creatinine clearances greater than 30 mL/minute) in whom oral therapy is not feasible, the recommended dosage of IV enalaprilat is 1.25 mg every 6 hours. In adults with severe renal impairment (i.e., creatinine clearances of 30 mL/minute or less), the initial dose of IV enalaprilat should be 0.625
mg; if the blood pressure response is inadequate after 1 hour, another dose of 0.625 mg may be given. Additional doses of 1.25
mg may be administered at 6-hour intervals. For patients undergoing dialysis, the initial dosage of IV enalaprilat should be 0.625 mg every 6 hours.
When oral therapy is initiated following IV enalaprilat therapy, the recommended initial dosage of enalapril maleate is 5 mg once daily in patients with creatinine clearances greater than 30 mL/minute and 2.5 mg once daily in patients with creatinine clearances of 30 mL/minute or less. Dosage is subsequently adjusted according to the patient's blood pressure response.
The manufacturer states that adults with heart failure and hyponatremia (serum sodium concentration less than 130 mEq/L) or serum creatinine concentration greater than 1.6 mg/dL should receive an initial enalapril maleate dosage of 2.5 mg daily under close monitoring (see Heart Failure under Dosage and Administration: Dosage).
Subsequent dosage may be increased gradually as necessary, usually at intervals of 4 or more days, to 2.5 mg twice daily, then 5 mg twice daily, and then higher, provided excessive hypotension or deterioration of renal function is not present at the time of intended dosage adjustment; dosage should not exceed 40 mg daily.
If concomitant diuretic therapy is required in patients with severe renal impairment, a loop diuretic is preferred to a thiazide diuretic. Therefore, use of commercially available preparations containing enalapril maleate in fixed combination with hydrochlorothiazide is not recommended for patients with severe renal impairment. The manufacturers state that dosage adjustment of commercially available preparations containing enalapril maleate in fixed combination with hydrochlorothiazide is not needed in patients with renal impairment whose creatinine clearance exceeds 30 mL/minute per 1.73
m2. (For information on dosage of hydrochlorothiazide in other special populations, see Dosage and Administration, in Hydrochlorothiazide 40:28.20.)
Enalapril maleate is not recommended for neonates or for pediatric patients who have a glomerular filtration rate of less than 30 mL/minute per 1.73 m2, since no data are available in such patients.
Since it is not known whether geriatric patients 65 years of age or older respond the same to enalapril in fixed combination with hydrochlorothiazide as younger adults, the manufacturer suggests that patients in this age group receive initial dosages of the fixed combination in the lower end of the usual range.
No enhanced Administration information available for this drug.
| DRUG LABEL | DOSING TYPE | DOSING INSTRUCTIONS |
|---|---|---|
| EPANED 1 MG/ML ORAL SOLUTION | Maintenance | Adults take 5 milliliters (5 mg) by oral route 2 times per day |
| DRUG LABEL | DOSING TYPE | DOSING INSTRUCTIONS |
|---|---|---|
| ENALAPRIL 1 MG/ML ORAL SOLN | Maintenance | Adults take 5 milliliters (5 mg) by oral route 2 times per day |
The following drug interaction information is available for EPANED (enalapril maleate):
There are 2 contraindications.
These drug combinations generally should not be dispensed or administered to the same patient. A manufacturer label warning that indicates the contraindication warrants inclusion of a drug combination in this category, regardless of clinical evidence or lack of clinical evidence to support the contraindication.
| Drug Interaction | Drug Names |
|---|---|
| Sacubitril/ACE Inhibitors SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Sacubitril is a neprilysin inhibitor. Overlapping inhibition of Angiotensin Converting Enzyme (ACE) and neprilysin may increase the risk of angioedema.(1,2) CLINICAL EFFECTS: Concurrent use may result in angioedema.(1-3) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The concurrent use of sacubitril and an ACE inhibitor is contraindicated. Allow a 36 hour washout period when switching between an ACE inhibitor and sacubitril.(1-3) Monitor patients for signs of angioedema (swelling of the face, lips, tongue, and/or throat).(2) DISCUSSION: Higher incidence of angioedema was seen in clinical trials with omapatrilat, a combined ACE and neprilysin inhibitor. In the OCTAVE trial, the incidence and severity of angioedema was worse with omapatrilat (2.2%) than with enalapril (0.7%).(2) For this reason, overlap of sacubitril, a neprilysin inhibitor, with an ACE inhibitor is contraindicated and a 36 hour washout period is recommended when switching agents. The 36 hour window is designed to cover at least three half-lives of all ACE inhibitors.(1) |
ENTRESTO, ENTRESTO SPRINKLE |
| Selected Nephrotoxic Agents/Bacitracin SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Bacitracin may cause renal failure due to glomerular and tubular necrosis. Concurrent administration of other nephrotoxic agents may result in additive renal toxicity.(1-3) CLINICAL EFFECTS: Concurrent use of bacitracin with other potentially nephrotoxic agents may result in renal toxicity.(1-3) PREDISPOSING FACTORS: Dehydration and high-dose bacitracin may predispose to adverse renal effects.(1) PATIENT MANAGEMENT: Health Canada states that bacitracin is contraindicated in patients with renal impairment, including those taking other nephrotoxic drugs.(1) The Canadian and US manufacturers of bacitracin state that concomitant use of bacitracin with other potentially nephrotoxic agents should be avoided.(2,3) DISCUSSION: Renal impairment is a major toxicity of bacitracin. Cases of nephrotoxicity have been reported when bacitracin was used off-label.(1-3) |
BACITRACIN, BACITRACIN MICRONIZED, BACITRACIN ZINC |
There are 6 severe interactions.
These drug interactions can produce serious consequences in most patients. Actions required for severe interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration scheduling, and providing additional patient monitoring. Review the full interaction monograph for more information.
| Drug Interaction | Drug Names |
|---|---|
| ACE Inhibitors; ARBs/Lithium SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Angiotensin converting enzyme inhibitors (ACEI) or angiotensin II receptor blocker (ARB)-induced sodium loss or volume depletion may result in decreased renal clearance of lithium.(1) CLINICAL EFFECTS: Concurrent use of ACEI or ARBs may result in elevated lithium levels and lithium toxicity. Lithium has a narrow therapeutic range. Unintended increases in lithium concentrations may lead to lithium toxicity. Early symptoms of lithium toxicity may include: lethargy, muscle weakness or stiffness, new onset or coarsening of hand tremor, vomiting, diarrhea, confusion, ataxia, blurred vision, bradycardia, tinnitus, or nystagmus. Severe toxicity may produce multiple organ dysfunction (e.g. seizures, coma, renal failure, cardiac arrhythmias, cardiovascular collapse) and may be fatal.(1) PREDISPOSING FACTORS: Risk factors for lithium toxicity include: acute renal impairment, chronic renal disease, dehydration, low sodium diet, and concomitant use of multiple medications which may impair renal elimination of lithium (e.g. ACEI, ARBs, NSAIDs, diuretics).(1) Patients who require higher therapeutic lithium levels to maintain symptom control are particularly susceptible to these factors. PATIENT MANAGEMENT: If concurrent therapy cannot be avoided, monitor closely. Evaluate renal function and most recent lithium levels. If renal function is not stable, whenever possible delay initiation of concurrent therapy until renal function is stable. The onset of lithium toxicity due to concomitant therapy with an ACEI or ARB may be delayed for 3-5 weeks.(2) Patients receiving this combination should be observed for signs of lithium toxicity when the ACEI or ARB dose is increased or if additional risk factors for lithium toxicity emerge. If an ACEI or ARB is required in a patient stabilized on lithium therapy, check baseline lithium concentration, consider empirically lowering the lithium dose, then recheck lithium levels 5 to 7 days after ACEI or ARB initiation. Adjust lithium, ACEI or ARB dose as required and continue frequent (e.g. weekly) monitoring of lithium until levels have stabilized. If lithium is to be started in a patient stabilized on an ACEI or ARB, consider starting with a lower lithium dose and titrate slowly as half-life may be prolonged.(1) Monitor lithium concentrations frequently until stabilized on the combination. If an interacting drug is discontinued, the lithium level may fall. Monitor lithium concentration and adjust dose if needed.(1) Counsel patient to assure they know signs and symptoms of lithium toxicity and understand the importance of follow-up laboratory testing. DISCUSSION: Elevated lithium levels and lithium toxicity have been reported during concomitant administration of lithium and an ACEI(3-17) or an ARB(18-20). Other factors, such as dehydration, acute or worsening of chronic renal impairment, or acute changes in sodium intake may increase the occurrence of a clinically important interaction. |
LITHIUM CARBONATE, LITHIUM CARBONATE ER, LITHIUM CITRATE, LITHIUM CITRATE TETRAHYDRATE, LITHOBID |
| Colistimethate/Selected Nephrotoxic Agents SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Colistimethate can cause nephrotoxicity.(1,2) Concurrent administration of other nephrotoxic agents may result in an increased risk of nephrotoxicity.(1) It is suspected that cephalothin interferes with the excretion of colistimethate resulting in enhanced nephrotoxicity.(2,3) CLINICAL EFFECTS: Concurrent use of colistimethate with other nephrotoxic agents may result in additive nephrotoxic effects. PREDISPOSING FACTORS: Factors predisposing to nephrotoxicity include higher cumulative doses of colistimethate, longer treatment duration, hypovolemia, and critical illness. PATIENT MANAGEMENT: Concurrent use of potentially nephrotoxic agents with colistimethate should be avoided.(1,2) If concurrent use is necessary, it should be undertaken with great caution.(1) DISCUSSION: In a case control study of 42 patients on intravenous colistimethate sodium, NSAIDs were identified as an independent risk factor for nephrotoxicity (OR 40.105, p=0.044).(4) In 4 case reports, patients developed elevated serum creatinine and blood urea nitrogen following concurrent colistimethate and cephalothin (3 patients) or when colistimethate followed cephalothin therapy (1 patient).(3) A literature review found that individual nephrotoxic agents, including aminoglycosides, vancomycin, amphotericin, IV contrast, diuretics, ACE inhibitors, ARBs, NSAIDs, and calcineurin inhibitors, were not consistently associated with additive nephrotoxicity when used with colistimethate. However, when multiple agents (at least 2 additional potential nephrotoxins) were used concurrently, there was a significant correlation to colistimethate nephrotoxicity.(5) |
COLISTIMETHATE, COLISTIMETHATE SODIUM, COLY-MYCIN M PARENTERAL |
| Sodium Phosphate Bowel Cleanser/ACE Inhibitors; ARBs SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Bowel cleansing with sodium phosphate causes dehydration, decreased intravascular volume and hyperphosphatemia, which increases phosphate levels in the renal tubules. Abnormally high levels of calcium and phosphate in the renal tubules may precipitate out, resulting in renal injury.(1) CLINICAL EFFECTS: Use of sodium phosphate for bowel cleansing in patients maintained on angiotensin converting enzyme (ACE) inhibitors, angiotension receptor blockers (ARBs) may increase the risk of acute phosphate nephropathy, which is an acute kidney injury associated with deposits of calcium phosphate crystal in the renal tubules that may result in permanent renal function impairment. Acute phosphate nephropathy presents as acute kidney injury with minimal proteinuria and a bland urine sediment.(2) Use of sodium phosphate products at laxative doses has not been associated with acute kidney injury.(3) PREDISPOSING FACTORS: Patients who may be at an increased risk of acute phosphate nephropathy include those who are over age 55; are hypovolemic or have decreased intravascular volume; have baseline kidney disease, bowel obstruction, or active colitis; and who are using medications that affect renal perfusion or function (such as diuretics, ACE inhibitors, ARBs, and possibly nonsteroidal anti-inflammatory drugs (NSAIDs).(2) PATIENT MANAGEMENT: If possible, use an alternative agent for bowel cleansing.(1) Use sodium phosphate products with caution in patients taking medications that affect kidney function or perfusion, such as ACE inhibitors or ARBs. Obtain baseline and post-procedure labs (electrolytes, calcium, phosphate, BUN, creatinine, and [in smaller, frail individuals] glomerular filtration rate). Instruct patients to drink sufficient quantities of clear fluids before, during, and after bowel cleansing and to avoid other laxatives that contain sodium phosphate. Consider hospitalization and intravenous hydration during bowel cleansing to support frail patients who may be unable to drink an appropriate volume of fluid or who may be without assistance at home.(2) Use of an electrolyte solution for rehydration may decrease the risk of acute phosphate nephropathy.(4,5) DISCUSSION: Since May 2006, the FDA has received 20 reports of acute phosphate nephropathy associated with the use of Osmo Prep. Concomitant medications included ACE inhibitors or ARBs (11), diuretics (6), and NSAIDs (4).(2) In a retrospective review of colonoscopy patients, simultaneous use of ACE inhibitors or ARBs significantly increased the risk of acute kidney injury from oral sodium phosphate. Diuretic use was also a risk factor.(6) In a case series study of 21 cases of acute phosphate nephropathy in patients who had used oral sodium phosphate, 14 patients received an ACE inhibitor or ARB, 4 used a diuretic, and 3 used an NSAID.(7) Cases have also been reported with rectal products.(8) |
MB CAPS, SODIUM PHOSPHATE DIBASIC, URIMAR-T, URNEVA |
| ACE Inhibitors; ARBs/Trimethoprim SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: ACE Inhibitors, Angiotensin Receptor Blockers (ARBs), and trimethoprim have all been proven to increase serum potassium levels. The increase is achieved by reduction in potassium elimination by trimethoprim(1,2) and a decrease in angiotensin activity by ACE Inhibitors and ARBs. The use of these medications in combination can have an additive effect on serum potassium resulting in potentially dangerous levels.(1-5) CLINICAL EFFECTS: Concurrent use of trimethoprim and ACE Inhibitors or Angiotensin Receptor Blockers may result in increased serum potassium levels,(1-5) which may be fatal.(2) PREDISPOSING FACTORS: The interaction may be more significant in elderly patients and patients with renal insufficiency.(1) PATIENT MANAGEMENT: Use trimethoprim with caution in patients maintained on ACE Inhibitors or ARBs. Patients using these medications concurrently should have their serum potassium monitored. In the elderly or renally impaired, alternative antibiotic therapy should be considered. DISCUSSION: In a retrospective review of patients in Ontario maintained on an ACE inhibitor or ARB who were admitted to a hospital for hyperkalemia within 14 days of receiving a prescription for SMX-TMP, amoxicillin, ciprofloxacin, norfloxacin, or nitrofurantion, 371 patients were identified. More than half of the patients with hyperkalemia had received SMX-TMP. Patients receiving SMX-TMP had a 7-fold increased risk of hyperkalemia compared to patients receiving other antibiotics. No risk was found with the other antibiotics.(1) A retrospective review of patients in Ontario maintained on an ACE inhibitor or ARB examined those who died within 7 days of filling an outpatient prescription for amoxicillin, ciprofloxacin, norfloxacin, nitrofurantoin, or SMX-TMP. Patients receiving SMX-TMP had an increased risk of death (adjusted odds ratio 1.38) compared to amoxicillin. Risk was slightly higher at 14 days (adjusted odds ration 1.54). This corresponded to 3 sudden deaths within 14 days per 1000 SMX-TMP prescriptions.(2) A review of nine case reports of hyperkalemia with SMX-TMP found that 2 patients were receiving concurrent ACE inhibitors (enalapril and benazepril). One of these patients had severe hyperkalemia with a peak potassium level of 7.4 mEq/l.(3) Hyperkalemia has also been reported with concurrent SMX-TMP and enalapril(4) and with quinapril.(5) |
BACTRIM, BACTRIM DS, PRIMSOL, SULFAMETHOXAZOLE-TRIMETHOPRIM, SULFATRIM, TRIMETHOPRIM, TRIMETHOPRIM MICRONIZED |
| Aliskiren/ACE Inhibitors; ARBs SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: The exact mechanism is unknown. CLINICAL EFFECTS: In the ALTITUDE study, concurrent use of aliskiren for 18-24 months in patients maintained on either an ACE inhibitor or an ARB resulted in an increase in non-fatal stroke, renal complications, hyperkalemia, and hypotension.(1,2) PREDISPOSING FACTORS: Patients with Type II diabetes and/or renal impairment may be at a higher risk from this combination.(1) PATIENT MANAGEMENT: Novartis no longer recommends the concurrent use of aliskiren with either an ACE inhibitor or an ARB.(1,3) Hypertension regimens of patients receiving concurrent therapy should be re-evaluated.(1) Concurrent use of aliskiren in diabetic patients receiving either an ACE inhibitor or an ARB is contraindicated.(2,4) Avoid the combination in patients with CrCl less than 60 ml/min.(5) DISCUSSION: ALTITUDE was a multinational study designed to evaluate the use of aliskiren for more than 1 year in patients with Type II diabetes and renal impairment, who are known to have a high risk for cardiovascular and renal events. Aliskiren was given with optimal cardiovascular treatment, including an ACE inhibitor or ARB. After 18-24 months of concurrent therapy with aliskiren and either an ACE inhibitor or an ARB, there was an increase in non-fatal stroke, renal complications, hyperkalemia, and hypotension.(1,2) |
ALISKIREN, TEKTURNA |
| ACE Inhibitors/mTOR Inhibitors SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: ACE inhibitors cause reduced bradykinin metabolism, leading to an increase in bradykinin which can cause vasodilation. mTOR inhibitors may also cause a reduction in bradykinin metabolism. CLINICAL EFFECTS: Concomitant therapy can increase the risk of vasodilation leading to an increase in angioedema risk. PREDISPOSING FACTORS: History of previous angioedema. PATIENT MANAGEMENT: Patients may be more susceptible to developing angioedema if concomitantly taking an ACE inhibitor and mTOR inhibitor. Consider switching the patient to an angiotensin receptor blocker. Monitor patients receiving concurrent therapy with ACE inhibitors and mTOR inhibitors closely for signs and symptoms of angioedema (swollen skin, hoarseness, a tight or swollen throat, or trouble breathing). Instruct patients to report angioedema symptoms immediately. DISCUSSION: A retrospective, single center analysis looked at renal allograft recipients treated with mTOR inhibitors and ACE inhibitors over an 8 year-period. Out of 137 patients on concomitant ACE inhibitor and mTOR inhibitor therapy, 9 patients (6.6%) developed angioedema. Concomitant ACE inhibitor and mTOR inhibitor therapy increased the risk of developing angioedema 3.7-fold. Eight of these patients tolerated therapy with an angiotensin receptor blocker (ARB). 2 patients (1.2%) on concomitant mTOR inhibitor and ARB therapy developed angioedema. Treatment with an ACE inhibitor or mTOR inhibitor alone resulted in a significantly lower incidence of angioedema.(1) In a pooled analysis of randomized double-blind oncology clinical trials, the incidence of angioedema in patients taking everolimus with an ACE inhibitor was 6.8% compared to 1.3% in the control arm with an ACE inhibitor.(2) There are case reports of patients on concomitant ACE inhibitor and sirolimus/everolimus that developed angioedema. In the majority of cases, patients had tolerated chronic therapy with an ACE inhibitor before the addition of sirolimus/everolimus.(3-7) The interaction may be dose-dependent.(7) |
AFINITOR, AFINITOR DISPERZ, EVEROLIMUS, FYARRO, SIROLIMUS, TEMSIROLIMUS, TORISEL, TORPENZ, ZORTRESS |
There are 13 moderate interactions.
The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.
| Drug Interaction | Drug Names |
|---|---|
| ACE Inhibitors; ARBs/Loop Diuretics SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: The exact mechanism is unknown. The initial hypotensive effect of the ACE inhibitors is mainly the result of suppression of the renin-angiotensin-aldosterone system. The ACE inhibitors inhibit the formation of angiotensin II and angiotensin II receptor antagonists block the action of angiotensin II, thereby lowering aldosterone levels with subsequent sodium and water depletion. Agents such as the loop diuretics that cause sodium and water loss may exaggerate the hypotensive state. CLINICAL EFFECTS: The addition of an ACE inhibitor to a patient receiving a loop diuretic may result in severe postural hypotension. This effect is transient and is not expected to occur during long-term dosing. Symptomatic hypotension may result in patients treated with loop diuretics who are started on an angiotensin II receptor antagonist. Concurrent use of a renin-angiotensin system (RAS) inhibitor with diuretics and NSAIDs may result in increased risk of acute kidney injury (AKI). PREDISPOSING FACTORS: Addition of an ACE inhibitor or an angiotensin II receptor antagonist to a patient already receiving a diuretic or who is sodium depleted. Low water intake/dehydration, drug sensitivity, greater than 75 years of age, and renal impairment may increase an individual's susceptibility to AKI. PATIENT MANAGEMENT: In patients without heart failure, it may be advisable to discontinue the diuretic, reduce the dose of the diuretic, or increase salt intake prior to the initiation of the ACE inhibitor. If hypotension occurs, place the patient in a supine position. Hypotension is most likely when the ACE inhibitor is initiated. However, if subsequent hypotension occurs, a dosage adjustment or discontinuation of one agent may be required. Intravascular volume depletion should be corrected in patients prior to the initiation of an angiotensin II receptor antagonist. Concurrent use of a RAS inhibitor with loop diuretics and NSAIDs should be used with caution and monitored closely for signs of AKI. DISCUSSION: In a computational study, the risk of AKI using triple therapy with a diuretic, renin-angiotensin system (RAS) inhibitor, and NSAID was assessed. The study found the following factors may increase an individual's susceptibility to AKI: low water intake, drug sensitivity, greater than 75 years of age, and renal impairment.(4,5) In an observational study, current use of a triple therapy with a diuretic, RAS inhibitor, and NSAID, was associated with an increased rate of acute kidney injury (rate ratio (RR) 1.31, 95% confidence interval (CI) 1.12-1.53). The highest risk of AKI associated with triple therapy were observed in the first 30 days of use (RR 1.82, CI 1.35-2.46). (6) Severe postural hypotension(1,2) and transient postural hypotension(3) has been reported in patients receiving concurrent captopril and furosemide. The effect is transient and may be more prevalent in patients who are sodium depleted.(8) Reversible renal failure(9) and decreased renal function(10) have been reported in patients receiving concurrent administration with enalapril and furosemide. In a study in which electrolytes were replaced with saline or Ringer's solution, no postural hypotension was noted; however, significant decreases in diastolic blood pressure occurred at three, four, and six hours after concurrent administration.(11) |
BUMETANIDE, EDECRIN, ETHACRYNATE SODIUM, ETHACRYNIC ACID, FUROSCIX, FUROSEMIDE, FUROSEMIDE-0.9% NACL, LASIX, SOAANZ, TORSEMIDE |
| Azathioprine/ACE Inhibitors SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: The exact mechanism is unknown. Azathioprine-induced impairment of hematopoiesis and ACE inhibitor-induced decreases in erythropoietin may result in additive effects on bone marrow.(1,2) CLINICAL EFFECTS: The concurrent use of azathioprine and an ACE inhibitor may result in anemia or leucopenia.(1-6) ACE inhibitors have been used to correct post-transplantation erythrocytosis in patients who also received azathioprine.(7) PREDISPOSING FACTORS: Patients with reduced or absent thiopurine S-methyltransferase (TPMT) or nucleotide diphosphatase (NUDT15) activity are at higher risk of accumulating thiopurine metabolites and severe myelosuppression. Approximately 0.3 % of patients of European, Latino, or African descent have mutations of the TPMT gene resulting in little to no TPMT activity (homozygous deficiency), and approximately 10 % have intermediate TPMT activity (heterozygous deficiency). NUDT15 deficiency is not seen in patients of African descent and is seen in less than 1 % of patients of European descent. Approximately 1 % of patients of East Asian descent, 0.5 % of patients of central/south Asian descent, and 2 % of patients of Latino descent have homozygous NUDT15 deficiency. About 17 % of patients of East Asian descent, 13 % of patients of central/south Asian descent, and 8 % of patients of Latino descent have heterozygous NUDT15 deficiency.(8) PATIENT MANAGEMENT: Patients receiving concurrent therapy with azathioprine and an ACE inhibitor should be closely monitored for hematological changes. One of the agents may need to be discontinued. DISCUSSION: In a study in 15 kidney-transplant patients receiving azathioprine, enalapril and captopril were replaced by nifedipine or clonidine. Hematocrit and hemoglobin levels increased from 37.5% to 39.7% and from 12.8 g/dl to 13.5 g/dl, respectively,10 to 12 weeks after ACE inhibitor withdrawal. Reticulocytes and erythropoietin concentrations rose from 14.1/1000 to 20.6/1000 and from 14.3 mU/ml to 29.3m U/ml, respectively. There were no changes in azathioprine levels.(1) A retrospective review compared azathioprine-treated patients to patients receiving azathioprine and ACE inhibitors. Hematocrit, hemoglobin, and haptoglobin levels were significantly lower in the group receiving ACE inhibitors, 19.7%, 17.2%, and 45%, respectively.(2) Three case reports document the development of leucopenia during the concurrent administration of captopril and azathioprine.(3-5) Another case report documented the development of anemia with concurrent enalapril and azathioprine.(6) Enalapril has been used to treat post-renal transplant erythrocytosis in patients receiving azathioprine.(7) |
AZASAN, AZATHIOPRINE, AZATHIOPRINE SODIUM, IMURAN, MERCAPTOPURINE, PURIXAN |
| ACE Inhibitors/High-Dose Aspirin SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Aspirin's inhibition of prostaglandin synthesis may inhibit the release of vasodilating prostaglandins by ACE inhibitors. CLINICAL EFFECTS: Concurrent use of aspirin may result in decreased antihypertensive effects of the ACE inhibitor. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Monitor patients receiving doses of aspirin higher than 150 mg daily for decreased antihypertensive effects of their ACE inhibitor. The use of alternative agents may need to be considered. DISCUSSION: Several studies have documented decreased effectiveness of various ACE inhibitors, including captopril, enalapril, and lisinopril following the addition of aspirin therapy. Conflicting evidence exists on the use of small (less than 150 mg) daily doses of aspirin with ACE inhibitors, although some guidelines still suggest they may be beneficial. One or more of the drug pairs linked to this monograph have been included in a list of interactions that could be considered for classification as "non-interruptive" in EHR systems. This DDI subset was vetted by an expert panel commissioned by the U.S. Office of the National Coordinator (ONC) for Health Information Technology. |
ACETYL SALICYLIC ACID, ASA-BUTALB-CAFFEINE-CODEINE, ASCOMP WITH CODEINE, ASPIRIN, BUTALBITAL-ASPIRIN-CAFFEINE, CARISOPRODOL-ASPIRIN, CARISOPRODOL-ASPIRIN-CODEINE, DURLAZA, NORGESIC, NORGESIC FORTE, ORPHENADRINE-ASPIRIN-CAFFEINE, ORPHENGESIC FORTE, YOSPRALA |
| Drospirenone/ACE Inhibitors; ARBs SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Drospirenone has antimineralocorticoid activity and may cause hyperkalemia. ACE inhibitors and angiotensin II receptor antagonists may also increase potassium levels.(1) CLINICAL EFFECTS: Concurrent use of drospirenone and ACE inhibitors or angiotensin II receptor antagonists may result in hyperkalemia.(1) PREDISPOSING FACTORS: Renal insufficiency, hepatic dysfunction, adrenal insufficiency, and use of potassium supplements, potassium-sparing diuretics, heparin, and NSAIDs may increase potassium levels.(1) PATIENT MANAGEMENT: Patients receiving drospirenone with either an ACE inhibitor or an angiotensin II receptor antagonist should have their serum potassium level checked during the first treatment cycle.(1) DISCUSSION: Drospirenone has antimineralocorticoid activity comparable to 25 mg of spironolactone and may result in hyperkalemia. Concurrent use of ACE inhibitors or angiotensin II receptor antagonists may also increase potassium levels.(1) In a study in 24 mildly hypertensive postmenopausal women who received concurrent drospirenone/estradiol (3 mg/1 mg) with enalapril (10 mg), mean serum potassium levels were 0.22 mEq/L higher than in the placebo group. On day 14 of concurrent therapy, the ratios for serum potassium maximum concentration (Cmax) and area-under-curve (AUC) were 0.955 and 1.010, respectively. No patient developed hyperkalemia.(1) |
ANGELIQ, BEYAZ, DROSPIRENONE-ETH ESTRA-LEVOMEF, DROSPIRENONE-ETHINYL ESTRADIOL, JASMIEL, LO-ZUMANDIMINE, LORYNA, NEXTSTELLIS, NIKKI, OCELLA, SAFYRAL, SLYND, SYEDA, VESTURA, YASMIN 28, YAZ, ZARAH, ZUMANDIMINE |
| Selected MAOIs/Selected Antihypertensive Agents SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Both MAOIs and antihypertensive agents may increase the risk of postural hypotension.(1,2) CLINICAL EFFECTS: Postural hypotension may occur with concurrent therapy of MAOIs and antihypertensive agents.(1,2) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The manufacturer of phenelzine states all patients should be followed closely for symptoms of postural hypotension. Hypotensive side effects have occurred in patients who have been hypertensive and normotensive, as well as hypotensive at initiation of phenelzine.(1) The manufacturer of tranylcypromine states hypotension has been observed most commonly but not exclusively in patients with pre-existing hypertension. Tranylcypromine doses greater than 30 mg daily have a major side effect of postural hypotension and can lead to syncope. Gradual dose titration is recommended to decrease risk of postural hypotension. Combined use with other agents known to cause hypotension have shown to have additive side effects and should be monitored closely.(2) Monitor the patient for signs and symptoms of postural hypotension including dizziness, lightheadedness, or weakness, especially upon standing. Monitor blood pressure as well as orthostatic vitals and adjust antihypertensive therapy, including decreasing the dose, dividing doses, or scheduling doses at bedtime, as needed to maintain goal blood pressure. If blood pressure remains hypotensive, consider decreasing the dose of phenelzine or tranylcypromine. In some cases, discontinuation of one or both agents may be necessary.(3) Normotensive patients on stable antihypertensive therapy who are started on either phenelzine or tranylcypromine may be at increased risk for hypotension. Hypertensive patients on stable phenelzine or tranylcypromine who require antihypertensive therapy would be at decreased risk for hypotension. DISCUSSION: A review article describes the pharmacology of phenelzine and tranylcypromine as non-selective MAOIs which inhibit both type A and type B substrates. Orthostatic hypotension is described as the most common MAOI side effect and usually occurs between initiation and the first 3-4 weeks of therapy.(3) In a double-blind study, 71 patients were randomized to receive a 4-week trial of either tranylcypromine, amitriptyline, or the combination. The number of patients reporting dizziness at 4 weeks was not different between the three treatment groups (tranylcypromine 52.4%; amitriptyline 65%; combination 66.7%). Blood pressure (BP) assessment noted a significant drop in standing BP in the tranylcypromine group compared to baseline (systolic BP change = -10 mmHg; p<0.02 and diastolic BP change = -9 mmHg; p<0.02). Combination therapy also had a significant drop in standing BP compared to baseline (systolic BP change = -9 mmHg; p<0.02). Patients receiving amitriptyline had no significant change in BP from baseline at 4 weeks. All three groups had a trend toward increasing orthostatic hypotension in BP changes from lying to standing. The change in orthostatic hypotension was significant in the amitriptyline group with an average systolic BP orthostatic drop of -9 mmHg (p<0.05).(4) A randomized, double-blind study of 16 inpatients with major depressive disorder were treated with either phenelzine or tranylcypromine. Cardiovascular assessments were completed at baseline and after 6 weeks of treatment. After 6 weeks, 5/7 patients (71%) who received phenelzine had a decrease in standing systolic BP greater than 20 mmHg from baseline. Head-up tilt systolic and diastolic BP decreased from baseline in patients on phenelzine (98/61 mmHg v. 127/65 mmHg, respectively; systolic change p=0.02 and diastolic change p=0.02). After 6 weeks, 6/9 patients (67%) who received tranylcypromine had a decrease in standing systolic BP greater than 20 mmHg from baseline. Head-up tilt systolic and diastolic BP decreased from baseline in patients on tranylcypromine (113/71 mmHg v. 133/69 mmHg, respectively; systolic change p=0.09 and diastolic change p=0.07).(5) Selected MAOIs linked to this monograph include: phenelzine and tranylcypromine. Selected antihypertensive agents include: ACE inhibitors, alpha blockers, ARBs, beta blockers, calcium channel blockers, aprocitentan, clonidine, hydralazine and sparsentan. |
NARDIL, PARNATE, PHENELZINE SULFATE, TRANYLCYPROMINE SULFATE |
| Tizanidine/Selected ACE Inhibitors SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Tizanidine is an alpha-2 agonist. Concurrent use with ACE inhibitors may result in additive effects on blood pressure.(1) CLINICAL EFFECTS: Concurrent use of antihypertensives and tizanidine may result in hypotension.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Patients receiving concurrent therapy should be monitored for hypotension. The risk of hypotension may be decreased by careful titration of tizanidine dosages and monitoring for hypotension prior to dose advancement. Counsel patients about the risk of orthostatic hypotension.(1) DISCUSSION: Severe hypotension has been reported following the addition of tizanidine to existing lisinopril therapy.(2-4) |
TIZANIDINE HCL, ZANAFLEX |
| Selected ACE Inhibitors/Indomethacin SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: The exact mechanism is unknown. It is believed to be related to inhibition of prostaglandin synthesis by the NSAIDs. Use of an NSAID in combination with an ACE inhibitor, whose hypotensive effects may be related to the increase in hypotensive prostaglandins, may negate any decrease in blood pressure. CLINICAL EFFECTS: Concurrent use of ACE inhibitors with NSAIDs may result in decreased antihypertensive effects. In patients with existing renal impairment, the use of these agents together may also result in further deterioration of renal clearance caused by renal hypoperfusion. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Patients maintained on ACE inhibitors should be monitored for a loss of blood pressure control and a change in renal function if an NSAID is added to their regimen. Patients receiving concurrent therapy may require higher doses of ACE inhibitors. If blood pressure control cannot be achieved or if the patient's renal function deteriorates, the NSAID may need to be discontinued. Patients should be monitored for hypotension if NSAIDs are withdrawn from concurrent ACE inhibitor therapy. DISCUSSION: Indomethacin has been shown to inhibit the antihypertensive effect of captopril, cilazapril, enalapril, losartan, perindopril, and valsartan. Ibuprofen has been shown to decrease the antihypertensive effects of captopril. Two separate case reports describe individuals suspected of ACEI-associated angioedema precipitated by NSAIDs. Both cases reported symptom resolution after cessation of the NSAID. Studies have shown that sulindac does not affect the antihypertensive effects of captopril and enalapril. One or more of the drug pairs linked to this monograph have been included in a list of interactions that could be considered for classification as "non-interruptive" in EHR systems. This DDI subset was vetted by an expert panel commissioned by the U.S. Office of the National Coordinator (ONC) for Health Information Technology. |
INDOCIN, INDOMETHACIN, INDOMETHACIN ER |
| ACE Inhibitors/Acemetacin; Proglumetacin; Salsalate SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: The exact mechanism is unknown. It is believed to be related to inhibition of prostaglandin synthesis by the NSAIDs. Use of an NSAID in combination with an ACE inhibitor, whose hypotensive effects may be related to the increase in hypotensive prostaglandins, may negate any decrease in blood pressure. CLINICAL EFFECTS: Concurrent use of ACE inhibitors with NSAIDs may result in decreased antihypertensive effects. In patients with existing renal impairment, the use of these agents together may also result in further deterioration of renal clearance caused by renal hypoperfusion. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Patients maintained on ACE inhibitors should be monitored for a loss of blood pressure control and a change in renal function if an NSAID is added to their regimen. Patients receiving concurrent therapy may require higher doses of ACE inhibitors. If blood pressure control cannot be achieved or if the patient's renal function deteriorates, the NSAID may need to be discontinued. Patients should be monitored for hypotension if NSAIDs are withdrawn from concurrent ACE inhibitor therapy. DISCUSSION: Indomethacin has been shown to inhibit the antihypertensive effect of captopril, cilazapril, enalapril, losartan, perindopril, and valsartan. Ibuprofen has been shown to decrease the antihypertensive effects of captopril. Two separate case reports describe individuals suspected of ACEI-associated angioedema precipitated by NSAIDs. Both cases reported symptom resolution after cessation of the NSAID. Studies have shown that sulindac does not affect the antihypertensive effects of captopril and enalapril. One or more of the drug pairs linked to this monograph have been included in a list of interactions that could be considered for classification as "non-interruptive" in EHR systems. This DDI subset was vetted by an expert panel commissioned by the U.S. Office of the National Coordinator (ONC) for Health Information Technology. |
DISALCID, SALSALATE |
| ACE Inhibitors/Selected NSAIDs; Salicylates SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: ACE inhibitors can cause vasodilation of the efferent renal arteriole which may result in decreased glomerular filtration rate. NSAIDs inhibit prostaglandin synthesis which can lead to afferent arteriolar vasoconstriction and may negate any decrease in blood pressure. CLINICAL EFFECTS: Concurrent use of ACE inhibitors with NSAIDs may result in decreased antihypertensive effects. In patients with existing renal impairment, the use of these agents together may also result in further deterioration of renal clearance caused by renal hypoperfusion. Concurrent use of ACE inhibitors with NSAIDs and diuretics may result in increased risk of acute kidney injury (AKI). PREDISPOSING FACTORS: Low water intake/dehydration, drug sensitivity, greater than 75 years of age, and renal impairment may increase an individuals susceptibility to AKI. PATIENT MANAGEMENT: Patients maintained on ACE inhibitors should be monitored for a loss of blood pressure control and a change in renal function if an NSAID is added to their regimen. Patients receiving concurrent therapy may require higher doses of ACE inhibitors. If blood pressure control cannot be achieved or if the patient's renal function deteriorates, the NSAID may need to be discontinued. Patients should be monitored for hypotension if NSAIDs are withdrawn from concurrent ACE inhibitor therapy. Concurrent use of ACE inhibitors with NSAIDs and diuretics should be used with caution and monitored closely for signs of AKI. DISCUSSION: In a computational study, the risk of AKI using triple therapy with a diuretic, renin-angiotensin system (RAS) inhibitor, and NSAID was assessed. The study found the following factors may increase an individual's susceptibility to AKI: low water intake, drug sensitivity, greater than 75 years of age, and renal impairment.(30,31) In an observational study, current use of a triple therapy combination was associated with an increased rate of acute kidney injury (rate ratio (RR) 1.31, 95% confidence interval (CI) 1.12-1.53). The highest risk of AKI associated with triple therapy were observed in the first 30 days of use (RR 1.82, CI 1.35-2.46).(32) Indomethacin has been shown to inhibit the antihypertensive effect of captopril, cilazapril, enalapril, losartan, perindopril, and valsartan. Ibuprofen has been shown to decrease the antihypertensive effects of captopril. Two separate case reports describe individuals suspected of ACEI-associated angioedema precipitated by NSAIDs. Both cases reported symptom resolution after cessation of the NSAID. Studies have shown that sulindac does not affect the antihypertensive effects of captopril and enalapril. One or more of the drug pairs linked to this monograph have been included in a list of interactions that could be considered for classification as "non-interruptive" in EHR systems. This DDI subset was vetted by an expert panel commissioned by the U.S. Office of the National Coordinator (ONC) for Health Information Technology. |
ANAPROX DS, ANJESO, ARTHROTEC 50, ARTHROTEC 75, BISMUTH SUBSALICYLATE, BROMFENAC SODIUM, BUPIVACAINE-KETOROLAC-KETAMINE, CALDOLOR, CAMBIA, CELEBREX, CELECOXIB, CHOLINE MAGNESIUM TRISALICYLAT, COMBOGESIC, COMBOGESIC IV, CONSENSI, COXANTO, DAYPRO, DICLOFENAC, DICLOFENAC POTASSIUM, DICLOFENAC SODIUM, DICLOFENAC SODIUM ER, DICLOFENAC SODIUM MICRONIZED, DICLOFENAC SODIUM-MISOPROSTOL, DIFLUNISAL, DOLOBID, EC-NAPROSYN, ELYXYB, ETODOLAC, ETODOLAC ER, FELDENE, FENOPROFEN CALCIUM, FENOPRON, FLURBIPROFEN, HYDROCODONE-IBUPROFEN, IBU, IBUPAK, IBUPROFEN, IBUPROFEN LYSINE, IBUPROFEN-FAMOTIDINE, INFLAMMACIN, INFLATHERM(DICLOFENAC-MENTHOL), KETOPROFEN, KETOPROFEN MICRONIZED, KETOROLAC TROMETHAMINE, KIPROFEN, LODINE, LOFENA, LURBIPR, MB CAPS, MECLOFENAMATE SODIUM, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NABUMETONE MICRONIZED, NALFON, NAPRELAN, NAPROSYN, NAPROTIN, NAPROXEN, NAPROXEN SODIUM, NAPROXEN SODIUM CR, NAPROXEN SODIUM ER, NAPROXEN-ESOMEPRAZOLE MAG, NEOPROFEN, OXAPROZIN, PHENYL SALICYLATE, PHENYLBUTAZONE, PIROXICAM, R.E.C.K.(ROPIV-EPI-CLON-KETOR), RELAFEN DS, ROPIVACAINE-CLONIDINE-KETOROLC, ROPIVACAINE-KETOROLAC-KETAMINE, SODIUM SALICYLATE, SPRIX, SULINDAC, SUMATRIPTAN SUCC-NAPROXEN SOD, SYMBRAVO, TOLECTIN 600, TOLMETIN SODIUM, TORONOVA II SUIK, TORONOVA SUIK, TOXICOLOGY SALIVA COLLECTION, TRESNI, TREXIMET, URELLE, URETRON D-S, URIBEL TABS, URIMAR-T, URNEVA, URO-MP, URO-SP, VIMOVO, VIVLODEX, ZIPSOR, ZORVOLEX, ZYNRELEF |
| Selected ACE Inhibitors/Potassium Sparing Diuretics SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: ACE inhibitors may decrease the renal excretion of potassium. CLINICAL EFFECTS: Concurrent use of potassium sparing diuretics with an ACE inhibitor may result in hyperkalemia. PREDISPOSING FACTORS: Impaired renal function; diabetes mellitus. PATIENT MANAGEMENT: Monitor serum potassium and adjust the dosage accordingly in patients receiving concurrent therapy with a potassium sparing diuretic and an ACE inhibitors. In all patients taking eplerenone who start taking an ACE inhibitor, check serum potassium and creatinine levels after 3-7 days of concurrent therapy. DISCUSSION: In a nested case-control study of heart failure patients receiving continuous ACE inhibitor/ARB therapy (n = 1,491,894), the risk of hyperkalemia was significantly associated with concomitant spironolactone use (odds ratio (OR) = 13.59; confidence interval (CI) = 11.63-15.88).(20) In a systemic literature review and meta-analysis of 20 randomized controlled studies, it was found that treatment with spironolactone and ACEI/ARB combination therapy compared to ACEI/ARB therapy alone increased the mean serum potassium concentration by 0.19 mEq/L (95% CI, 0.12-0.26 mEq/L).(21) A retrospective cohort study in patients with hypertension, diabetes, and albuminuria between 2008 and 2018 examined the efficacy and safety of mineralocorticoid receptor antagonists eplerenone and spironolactone in combination with ACEI/ARB compared to ACEI/ARB alone. Hyperkalemia was more frequent in combination therapy patients (n=1,282) versus monotherapy (n=5,484) (22.3 vs 10.9 per 100 person-years for combination and monotherapy, respectively; HR = 1.78, 95% CI: 1.42, 2.24).(22) Several studies have indicated that serum potassium levels increase when ACE inhibitors and ARB therapy is initiated and decrease when the drug is lowered. There are case reports of hyperkalemia during concurrent therapy with ARBs and spironolactone and with aliskiren and spironolactone. Based on this data, serum potassium levels should be monitored in patients receiving concomitant ACE inhibitors with potassium sparing diuretics. Selected ACE inhibitors linked to this monograph include: benazepril, captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril, and trandolapril. |
ALDACTONE, AMILORIDE HCL, AMILORIDE-HYDROCHLOROTHIAZIDE, CAROSPIR, DYRENIUM, EPLERENONE, INSPRA, KERENDIA, SPIRONOLACTONE, SPIRONOLACTONE-HCTZ, TRIAMTERENE, TRIAMTERENE-HYDROCHLOROTHIAZID |
| Selected ACE Inhibitors/Potassium Supplements SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: ACE inhibitors may decrease the renal excretion of potassium. CLINICAL EFFECTS: Concurrent use of potassium supplements with ACE inhibitors may result in hyperkalemia. PREDISPOSING FACTORS: Impaired renal function; diabetes mellitus. PATIENT MANAGEMENT: Monitor serum potassium and adjust the dosage accordingly in patients receiving concurrent therapy with potassium supplements and ACE inhibitors. DISCUSSION: Several studies have indicated that serum potassium levels increase when ACE inhibitors is initiated and decrease when the drug is lowered. Based on this data, serum potassium levels should be monitored in patients receiving potassium supplements with ACE inhibitors. Selected ACE inhibitors linked to this monograph include: benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, quinapril, ramipril, and trandolapril. |
CLINIMIX E, DEXTROSE 5%-ELECTROLYTE #48, EFFER-K, K-PHOS NO.2, K-PHOS ORIGINAL, KABIVEN, KCL-D5W-0.2% NACL, KCL-D5W-0.225% NACL, KCL-D5W-0.45% NACL, KCL-D5W-0.9% NACL, KLOR-CON, KLOR-CON 10, KLOR-CON 8, KLOR-CON M10, KLOR-CON M15, KLOR-CON M20, KLOR-CON-EF, NUTRILYTE, PERIKABIVEN, POKONZA, POTASSIUM ACETATE, POTASSIUM CHLORIDE, POTASSIUM CHLORIDE IN D5LR, POTASSIUM CHLORIDE-0.45% NACL, POTASSIUM CHLORIDE-0.9% NACL, POTASSIUM CHLORIDE-DEXTROSE 5%, POTASSIUM CHLORIDE-WATER, POTASSIUM CITRATE, POTASSIUM CITRATE ER, POTASSIUM CL-LIDOCAINE-NS, POTASSIUM GLUCONATE, POTASSIUM PHOSPHATE, POTASSIUM PHOSPHATE-0.9% NACL, POTASSIUM PHOSPHATES, TPN ELECTROLYTES, UROCIT-K |
| Apomorphine/Selected Antihypertensives and Vasodilators SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Apomorphine causes dose-dependent decreases in blood pressure. Concurrent use with antihypertensive agents may result in additive effects on blood pressure.(1) CLINICAL EFFECTS: Concurrent use of antihypertensives and apomorphine may result in orthostatic hypotension with or without dizziness, nausea, or syncope.(1) PREDISPOSING FACTORS: The risk of orthostatic hypotension may be increased during dose escalation of apomorphine and in patients with renal or hepatic impairment.(1) PATIENT MANAGEMENT: Patients receiving concurrent therapy should be monitored for hypotension. Counsel patients about the risk of orthostatic hypotension.(1) DISCUSSION: Healthy volunteers who took sublingual nitroglycerin (0.4 mg) concomitantly with apomorphine experienced a mean largest decrease in supine systolic blood pressure (SBP) of 9.7 mm Hg and in supine diastolic blood pressure (DBP) of 9.3 mm Hg, and a mean largest decrease in standing SBP and DBP of 14.3 mm Hg and 13.5 mm Hg, respectively. The maximum decrease in SBP and DBP was 65 mm Hg and 43 mm Hg, respectively. When apomorphine was taken alone, the mean largest decrease in supine SBP and DBP was 6.1 mm Hg and 7.3 mm Hg, respectively, and in standing SBP and DBP was 6.7 mm Hg and 8.4 mm Hg, respectively.(1) |
APOKYN, APOMORPHINE HCL, ONAPGO |
| ACE Inhibitors/Dipeptidyl Peptidase-IV Inhibitors SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Bradykinin can cause vasodilation and increase vascular permeability both directly and by stimulating release of substance P, which also increases vascular permeability.(1) Bradykinin is primarily metabolized by angiotensin-1 converting enzyme (ACE). If ACE is inhibited by ACE inhibitors, other metabolic enzymes become more significant in bradykinin metabolism, including dipeptidyl peptidase-IV (DPP-IV). DPP-IV inhibitors can inhibit both bradykinin and substance P metabolism.(2) CLINICAL EFFECTS: Concomitant therapy can increase the risk of vasodilation leading to an increase in angioedema risk.(1-3) PREDISPOSING FACTORS: History of previous angioedema. PATIENT MANAGEMENT: Patients may be more susceptible to developing angioedema if concomitantly taking an ACE inhibitor and DPP-IV inhibitor. Consider switching the patient to an angiotensin receptor blocker or a different anti-diabetic medication. Use caution in patients receiving concurrent therapy.(3) Monitor closely for signs and symptoms of angioedema (swollen skin, hoarseness, a tight or swollen throat, or trouble breathing). Instruct patients to report angioedema symptoms immediately. DISCUSSION: A pre-marketing surveillance compared incidence of angioedema in patients on vildagliptin versus a comparator. In all patients combined regardless of ACE inhibitor therapy, there was no association between vildagliptin and angioedema. However among patients taking an ACE inhibitor, vildagliptin was associated with an increased risk of angioedema (odds ratio 9.29 (95% CI 1.22-70.70) from pooled data; odds ratio of 4.57 (95% CI 1.57-13.28) in the meta-analysis). This interaction may be dose-related.(4) In a pooled analysis of data from 19 clinical trials of patients on sitagliptin versus a comparator, there was no difference in the incidence of angioedema between patients on ACE inhibitors and sitagliptin compared to patients on ACE inhibitors alone or patients not on ACE inhibitors.(5) However, events were not adjudicated and encompassed urticaria, anaphylaxis, and hypersensitivity reactions, which may have confounded the results.(6) A disproportionality analysis of the WHO pharmacovigilance database found 340,686 reports of bradykinin-mediated angioedema. Of those, 345 reports involved patients on concomitant ACE inhibitor and DPP-IV inhibitor, with a reporting odds ratio of 42.77 (95% CI 36.93-49.53). There was no association between use of a DPP-IV inhibitor without an ACE inhibitor and angioedema.(7) |
ALOGLIPTIN, ALOGLIPTIN-METFORMIN, ALOGLIPTIN-PIOGLITAZONE, GLYXAMBI, JANUMET, JANUMET XR, JANUVIA, JENTADUETO, JENTADUETO XR, KAZANO, NESINA, OSENI, QTERN, SAXAGLIPTIN HCL, SAXAGLIPTIN-METFORMIN ER, SITAGLIPTIN, SITAGLIPTIN-METFORMIN, STEGLUJAN, TRADJENTA, TRIJARDY XR, ZITUVIMET, ZITUVIMET XR, ZITUVIO |
The following contraindication information is available for EPANED (enalapril maleate):
Drug contraindication overview.
No enhanced Contraindications information available for this drug.
No enhanced Contraindications information available for this drug.
There are 3 contraindications.
Absolute contraindication.
| Contraindication List |
|---|
| Angioedema |
| Hereditary angioedema |
| Pregnancy |
There are 7 severe contraindications.
Adequate patient monitoring is recommended for safer drug use.
| Severe List |
|---|
| Chronic kidney disease stage 4 (severe) GFR 15-29 ml/min |
| Chronic kidney disease stage 5 (failure) GFr<15 ml/min |
| Hymenoptera venom desensitization therapy |
| Hyperkalemia |
| Hyponatremia |
| Hypotension |
| Renal artery stenosis |
There are 6 moderate contraindications.
Clinically significant contraindication, where the condition can be managed or treated before the drug may be given safely.
| Moderate List |
|---|
| Aortic valve stenosis |
| Bone marrow depression |
| Disease of liver |
| Hypertrophic cardiomyopathy |
| Immunosuppression |
| Neutropenic disorder |
The following adverse reaction information is available for EPANED (enalapril maleate):
Adverse reaction overview.
No enhanced Common Adverse Effects information available for this drug.
No enhanced Common Adverse Effects information available for this drug.
There are 36 severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
|
Hypotension |
Fever Hyperkalemia |
| Rare/Very Rare |
|---|
|
Acute myocardial infarction Acute pancreatitis Acute renal failure Agranulocytosis Anaphylaxis Angioedema Atrial fibrillation Bradycardia Bronchospastic pulmonary disease Chest pain Drug-induced hepatitis Eosinophilia Eosinophilic pneumonia Erythema multiforme Exfoliative dermatitis Head and neck angioedema Ileus Intestinal angioedema Laryngeal edema Leukocytosis Myositis Neutropenic disorder Obstructive hyperbilirubinemia Pemphigus Pharyngeal edema Pulmonary edema Pulmonary thromboembolism Stevens-johnson syndrome Tachycardia Thrombocytopenic disorder Tongue swelling Toxic epidermal necrolysis Vasculitis |
There are 38 less severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
|
Cough Dizziness |
Arthralgia Bronchitis Diarrhea Dysgeusia Dyspnea Fatigue General weakness Headache disorder Orthostatic hypotension Skin rash Syncope Vertigo |
| Rare/Very Rare |
|---|
|
Acute cognitive impairment Anorexia Ataxia Black tarry stools Blurred vision Conjunctivitis Constipation Cramps Depression Drowsy Dyspepsia Erectile dysfunction Flushing Glossitis Gynecomastia Hyperhidrosis Loss of sense of smell Myalgia Pruritus of skin Raynaud's phenomenon Skin photosensitivity Stomatitis Tinnitus Urticaria |
The following precautions are available for EPANED (enalapril maleate):
No enhanced Pediatric Use information available for this drug.
Contraindicated
Severe Precaution
Management or Monitoring Precaution
Contraindicated
| None |
Severe Precaution
| None |
Management or Monitoring Precaution
| None |
Fetal and neonatal morbidity and mortality have been reported in at least 50 pregnant women who were receiving ACE inhibitors during pregnancy. Very limited epidemiologic data indicate that the rate of fetal and neonatal morbidity resulting from exposure to ACE inhibitors during the second and third trimesters may be as high as 10-20%. Hypotension, reversible or irreversible renal failure, anuria, skull hypoplasia (defective skull ossification in some cases), and/or death were reported in neonates whose mothers had received ACE inhibitors during the second and third trimesters of pregnancy.
In one premature neonate (35 weeks' gestation) born with acute, reversible renal failure following exposure to enalapril for several weeks prior to delivery, plasma ACE activity was completely suppressed at birth, and plasma active and total renin concentrations and renin activity were substantially increased in the neonate; the renal failure was managed with peritoneal dialysis, which was discontinued after 10 days. Other adverse effects associated with such use included oligohydramnios, presumably due to decreased renal function in the fetus, prematurity, fetal death, and patent ductus arteriosus; however, it is not known whether these effects were associated with ACE inhibition or underlying maternal disease. Oligohydramnios has been associated with contractures of the limbs, craniofacial deformities, hypoplasia of the lungs, and intrauterine growth retardation.
Although fetal exposure limited to the first trimester previously was considered not to be associated with substantial risk, data from an epidemiologic study have shown that infants whose mothers had taken an ACE inhibitor during the first trimester of pregnancy have an increased risk of major congenital malformations compared with infants who had not undergone first trimester exposure to ACE inhibitors. The risk of major congenital malformations, primarily affecting the cardiovascular and central nervous systems, was increased by about 2.7 times in infants whose mothers had taken an ACE inhibitor during the first trimester of pregnancy compared with infants who had not undergone such exposure.
Every effort should be made to discontinue enalapril or enalaprilat therapy as soon as possible in any woman who becomes pregnant while receiving either of the drugs, regardless of the period of gestation. In addition, all women of childbearing potential who are receiving an ACE inhibitor should be advised to report pregnancy to their clinician as soon as possible. Women of childbearing potential who are receiving an ACE inhibitor also should be advised to inform their clinician if they are planning to become pregnant or think they might be pregnant.
Nearly all women can be transferred successfully to alternative therapy for the remainder of their pregnancy. Rarely (probably less frequently than once in every 1000 pregnancies), no adequate alternative can be identified; in such rare cases, the woman should be informed of the potential hazard to the fetus and serial ultrasound examinations should be performed to assess the intra-amniotic environment. If oligohydramnios is present, enalapril therapy should be discontinued, unless use of the drug is considered life-saving for the woman.
Contraction stress testing (CST), a nonstress test (NST), or biophysical profiling may be performed, if appropriate depending on the period of gestation. However, both clinicians and patients should realize that oligohydramnios may not become apparent until after irreversible fetal injury already has occurred. Infants exposed in utero to ACE inhibitors should be observed closely for hypotension, oliguria, and hyperkalemia.
If oliguria occurs, supportive measures (e.g., administration of fluids and pressor agents) to correct hypotension and renal perfusion should be considered. Exchange transfusion or dialysis may be required to reverse hypotension and/or substitute for impaired renal function. Enalapril, which crosses the placenta, has been removed from neonatal circulation by peritoneal dialysis with some clinical benefit.
The manufacturer states that the drug theoretically may be removed by exchange transfusion; however, this latter procedure has not been used to date. Reproduction studies in rats using enalapril maleate dosages up to 200 mg/kg daily (about 333 times the maximum daily human dosage) have not revealed evidence of teratogenicity or fetotoxicity. Decreases in average fetal weight occurred in rats receiving enalapril maleate dosages of 1200 mg/kg daily, but fetotoxicity did not occur when rats received a diet supplemented with sodium chloride.
Fetotoxicity (decreased fetal weight) has been observed in rats receiving oral dosages up to 90 mg/kg of enalapril maleate combined with 10 mg/kg of hydrochlorothiazide daily (representing 26 and 1.6 times the maximum recommended human daily dosage of enalapril maleate and hydrochlorothiazide, respectively, on a mg/m2 basis) and in mice receiving combined oral therapy with up to 30 and 10 mg/kg daily of enalapril maleate and hydrochlorothiazide, respectively (representing 4.3 and 0.8 times the maximum recommended human daily dosage of enalapril maleate and hydrochlorothiazide, respectively, on a mg/m2 basis), but did not occur when lower dosages of enalapril maleate (30 and 10 mg/kg daily, respectively) were combined with 10 mg/kg of hydrochlorothiazide daily in these animals. Reproduction studies in rabbits receiving enalapril maleate dosages up to 30 mg/kg daily during days 6-18 of gestation did not reveal evidence of teratogenicity, but maternotoxicity and fetotoxicity occurred in rabbits at dosages of 1 mg/kg daily. Fetotoxicity and maternotoxicity did not occur in rabbits receiving enalapril maleate dosages of 3-10 mg/kg daily when their diet was supplemented with sodium chloride, but did occur at dosages of 30 mg/kg daily even when the diet was supplemented.
In one premature neonate (35 weeks' gestation) born with acute, reversible renal failure following exposure to enalapril for several weeks prior to delivery, plasma ACE activity was completely suppressed at birth, and plasma active and total renin concentrations and renin activity were substantially increased in the neonate; the renal failure was managed with peritoneal dialysis, which was discontinued after 10 days. Other adverse effects associated with such use included oligohydramnios, presumably due to decreased renal function in the fetus, prematurity, fetal death, and patent ductus arteriosus; however, it is not known whether these effects were associated with ACE inhibition or underlying maternal disease. Oligohydramnios has been associated with contractures of the limbs, craniofacial deformities, hypoplasia of the lungs, and intrauterine growth retardation.
Although fetal exposure limited to the first trimester previously was considered not to be associated with substantial risk, data from an epidemiologic study have shown that infants whose mothers had taken an ACE inhibitor during the first trimester of pregnancy have an increased risk of major congenital malformations compared with infants who had not undergone first trimester exposure to ACE inhibitors. The risk of major congenital malformations, primarily affecting the cardiovascular and central nervous systems, was increased by about 2.7 times in infants whose mothers had taken an ACE inhibitor during the first trimester of pregnancy compared with infants who had not undergone such exposure.
Every effort should be made to discontinue enalapril or enalaprilat therapy as soon as possible in any woman who becomes pregnant while receiving either of the drugs, regardless of the period of gestation. In addition, all women of childbearing potential who are receiving an ACE inhibitor should be advised to report pregnancy to their clinician as soon as possible. Women of childbearing potential who are receiving an ACE inhibitor also should be advised to inform their clinician if they are planning to become pregnant or think they might be pregnant.
Nearly all women can be transferred successfully to alternative therapy for the remainder of their pregnancy. Rarely (probably less frequently than once in every 1000 pregnancies), no adequate alternative can be identified; in such rare cases, the woman should be informed of the potential hazard to the fetus and serial ultrasound examinations should be performed to assess the intra-amniotic environment. If oligohydramnios is present, enalapril therapy should be discontinued, unless use of the drug is considered life-saving for the woman.
Contraction stress testing (CST), a nonstress test (NST), or biophysical profiling may be performed, if appropriate depending on the period of gestation. However, both clinicians and patients should realize that oligohydramnios may not become apparent until after irreversible fetal injury already has occurred. Infants exposed in utero to ACE inhibitors should be observed closely for hypotension, oliguria, and hyperkalemia.
If oliguria occurs, supportive measures (e.g., administration of fluids and pressor agents) to correct hypotension and renal perfusion should be considered. Exchange transfusion or dialysis may be required to reverse hypotension and/or substitute for impaired renal function. Enalapril, which crosses the placenta, has been removed from neonatal circulation by peritoneal dialysis with some clinical benefit.
The manufacturer states that the drug theoretically may be removed by exchange transfusion; however, this latter procedure has not been used to date. Reproduction studies in rats using enalapril maleate dosages up to 200 mg/kg daily (about 333 times the maximum daily human dosage) have not revealed evidence of teratogenicity or fetotoxicity. Decreases in average fetal weight occurred in rats receiving enalapril maleate dosages of 1200 mg/kg daily, but fetotoxicity did not occur when rats received a diet supplemented with sodium chloride.
Fetotoxicity (decreased fetal weight) has been observed in rats receiving oral dosages up to 90 mg/kg of enalapril maleate combined with 10 mg/kg of hydrochlorothiazide daily (representing 26 and 1.6 times the maximum recommended human daily dosage of enalapril maleate and hydrochlorothiazide, respectively, on a mg/m2 basis) and in mice receiving combined oral therapy with up to 30 and 10 mg/kg daily of enalapril maleate and hydrochlorothiazide, respectively (representing 4.3 and 0.8 times the maximum recommended human daily dosage of enalapril maleate and hydrochlorothiazide, respectively, on a mg/m2 basis), but did not occur when lower dosages of enalapril maleate (30 and 10 mg/kg daily, respectively) were combined with 10 mg/kg of hydrochlorothiazide daily in these animals. Reproduction studies in rabbits receiving enalapril maleate dosages up to 30 mg/kg daily during days 6-18 of gestation did not reveal evidence of teratogenicity, but maternotoxicity and fetotoxicity occurred in rabbits at dosages of 1 mg/kg daily. Fetotoxicity and maternotoxicity did not occur in rabbits receiving enalapril maleate dosages of 3-10 mg/kg daily when their diet was supplemented with sodium chloride, but did occur at dosages of 30 mg/kg daily even when the diet was supplemented.
Because enalapril alone or thiazide diuretics alone are distributed into human milk and potentially may cause serious adverse reactions in nursing infants, a decision should be made whether to discontinue nursing or enalapril (either alone or in fixed combination with hydrochlorothiazide), taking into account the importance of the drug(s) to the woman.
No enhanced Geriatric Use information available for this drug.
The following prioritized warning is available for EPANED (enalapril maleate):
WARNING: This drug can cause serious (possibly fatal) harm to an unborn baby if used during pregnancy. It is important to prevent pregnancy while taking this medication. Consult your doctor for more details and to discuss the use of reliable forms of birth control while taking this medication. If you are planning pregnancy, become pregnant, or think you may be pregnant, contact your doctor right away.
WARNING: This drug can cause serious (possibly fatal) harm to an unborn baby if used during pregnancy. It is important to prevent pregnancy while taking this medication. Consult your doctor for more details and to discuss the use of reliable forms of birth control while taking this medication. If you are planning pregnancy, become pregnant, or think you may be pregnant, contact your doctor right away.
The following icd codes are available for EPANED (enalapril maleate)'s list of indications:
| Asymptomatic left ventricular dysfunction | |
| I51.9 | Heart disease, unspecified |
| Chronic heart failure | |
| I50.22 | Chronic systolic (congestive) heart failure |
| I50.32 | Chronic diastolic (congestive) heart failure |
| I50.42 | Chronic combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.812 | Chronic right heart failure |
| I50.814 | Right heart failure due to left heart failure |
| Hypertension | |
| I10 | Essential (primary) hypertension |
| I11 | Hypertensive heart disease |
| I11.0 | Hypertensive heart disease with heart failure |
| I11.9 | Hypertensive heart disease without heart failure |
| I12 | Hypertensive chronic kidney disease |
| I12.0 | Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease |
| I12.9 | Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease |
| I13 | Hypertensive heart and chronic kidney disease |
| I13.0 | Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease |
| I13.1 | Hypertensive heart and chronic kidney disease without heart failure |
| I13.10 | Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease |
| I13.11 | Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease |
| I13.2 | Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease |
| I15.1 | Hypertension secondary to other renal disorders |
Formulary Reference Tool