Name of the Angiotensin Converting Enzyme Inhibitors (ACEIs) drugs
- Ramipril
- Lisinopril
- perindopril
Mechanism of Action:
Inhibit angiotensin- converting enzyme, preventing the conversion of angiotensin I to angiotensin II. This prevents angiotensin – mediated effects (arteriolar constriction and aldosterone release) resulting in reduced afterload and reduced circulating volume, thereby reducing BP.
Indications:
- Hypertension
- Heart Failure (result in improved survival in LV dysfunction)
- Prophylaxis of further cardiovascular events post- MI.
- Diabetic nephropathy (lisinopril- results in reduced progression of the disease).
- Patients at high cardiovascular risk (Ramipril)
| Ramipril |
| Availability: Capsules: 1.25 mg, 2.5 mg, 5 mg, 10 mg. |
| Administration/handling: PO: • Give without regard to food. • May mix with water, apple juice/sauce. |
| Hypertension (Monotherapy) PO: ADULTS, ELDERLY: Initially, 2.5 mg/day. Titrate to desired effect after 2–4 weeks up to 20 mg daily in 1 or 2 divided doses. Pts with volume depletion: Initially, 1.25 mg daily. Titrate to desired response. |
| HF Following MI PO: ADULTS, ELDERLY: Initially, 1.25–2.5 mg twice daily. Continue for 1 week, then titrate upward q3wks to target dose of 5 mg twice daily. |
| Risk Reduction for MI/Stroke PO: ADULTS, ELDERLY: Initially, 2.5 mg/day for 7 days, then 5 mg/day for 21 days, then 10 mg/day as a single dose (or in divided doses in hypertensive or recent post-MI pts). |
| Renal Failure and Hypertension Initially, 1.25 mg/day titrated upward. Maximum: 5 mg/day. Renal failure and HF: Initially, 1.25 mg/day, titrated up to 2.5 mg twice daily. |
Cautions & Contraindications:
1.Hypersensitivity to ACEIs.
2.Pregnancy – may cause fetal injury
3.Renal Artery stenosis (reversal of angiotensin II – mediated constriction of efferent Arteriole results in reduced GFR)
4.Caution in peripheral vascular disease as this may be associated with undiagnosed renal artery stenosis.
5.Patients taking potassium sparing diuretics like spironolactone.
6.Renal insufficiency
7.Before, during or immediately after major surgery.
Side – Effects:
1.Persistent dry cough
2.Hypotension (may get severe first- dose hypotension)
3.Renal Impairment
4.Hyperkalemia
5.Angioedema (rare)
6.Headache
7.Dizziness
8.Fatigue
9.Tachycardia
Metabolism & Half-life:
Life variable – e.g., ramipril ( t ½ 13-17 h) has an active metabolite; lisinopril (t ½ 12h) does not undergo metabolism.
Monitoring:
•Monitor U&Es for renal impairment prior to and 1- 2 weeks after commencing treatment. Once stable on therapy U&Es must be checked at least annually.
•Careful clinical monitoring is required when used in severe heart failure.
Drug Interactions:
•Risk of profound first-dose hypotension with loop diuretics and enhanced hypotensive effect with other antihypertensive agents.
•Increased risk of renal impairment with NSAIDs.
•Enhanced hypoglycaemic effect of insulin, metformin and sulfonylureas.
•Effects are antagonized by corticosteroids.
Nursing Considerations:
Baseline assessment:
•Vital signs, ECG, CBC, urine analysis, sodium, potassium, creatinine and BUN.
•Female clients of childbearing age: obtain negative pregnancy test. Let healthcare provider know if they plan to become pregnant.
•If medication is prescribed for heart failure: Assess weight, lung sounds & presence of edema or dyspnea
Patient & Family Education:
•Explain why medication is prescribed& describe common side effects
•Hypotension can occur with first few doses-hence to be mindful of any dizziness and weakness and make position changes slowly
•Angioedema – less common, but serious side effect. Seek immediate medical attention.
•Avoid potassium supplements & salt substitutes that contain potassium.
•NSAIDs can reduce antihypertensive effect of the medication. If CAPTOPRIL is prescribed– advice to take the medication on empty stomach. 1 hr before or 2 hrs after the food.
Important Points:
•Clinical effects of the different agents are similar; choice determined by t ½ (e.g. lisinopril has longer t ½, therefore suitable for Once – daily dosing) and by side-effect profile.
•ACEIs/ARBs are less effective in African- Caribbean patients due to ACE polymorphisms.
REFERENCES
- Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
- McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
- April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
- Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
- Nursebro.com, Search – Nursebro
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