Generic Name captopril

Brand Names:

Apo-Capto (CAN),
Capoten,
Gen-Captopril (CAN),
Novo-Captopril (CAN),
Nu-Capto (CAN)

Captopril (Capoten) is an ACE inhibitor and a common antihypertensive. Captopril

works by competitively inhibiting the conversion of angiotensin I to angiotensin II.

Classification
ACE inhibitor, Antihypertensive

Pregnancy Category C (first trimester)

Pregnancy Category D (second and third trimesters)

Dosage & Route

PO HTN Initial: 12.5 mg twice daily.

Maintenance: 25-50 mg twice daily.

Max: 50 mg 3 times/day.
Heart failure Initial: 6.25-12.5 mg 2-3 times/day.

Max: 50 mg 3 times/day.
Post MI Start 3 days after MI.

Initial: 6.25 mg/day, may increase after several wk to 150 mg/day in

divided doses if needed and tolerated.
Diabetic nephropathy 25 mg 3 times/day.

Therapeutic actions

Captopril competitively inhibits the conversion of angiotensin I (ATI) to

angiotensin II (ATII), thus resulting in reduced ATII levels and aldosterone
secretion. It also increases plasma renin activity and bradykinin levels. Reduction

of ATII leads to decreased sodium and water retention. By these mechanisms,

captopril produces a hypotensive effect and a beneficial effect in congestive heart
failure.

Pharmacokinetics

Absorption: 60-75% absorbed from the GI tract (oral); peak plasma

concentrations after 1 hr. Absorption may be reduced in the presence of food.
Distribution: Protein-binding: 30%; crosses the placenta and enters breast milk at
about 1% of maternal blood concentrations.
Excretion: Via urine (40-50% as unchanged, the rest as disulfide and other
metabolites); 2-3 hr (elimination half-life), may be increased in renal impairment.
Removed by hemodialysis.

Indications

Treatment of hypertension alone or in combination with thiazide-type diuretics

Treatment of CHF in patients unresponsive to conventional therapy; used with
diuretics and digitalis
Treatment of diabetic nephropathy
Treatment of left ventricular dysfunction after MI
Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid
arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to
scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema;
Bartters syndrome; Raynauds syndrome

Adverse effects

Hypotension, tachycardia, chest pain, palpitations, pruritus, hyperkalemia.

Proteinuria; angioedema, skin rashes; taste disturbance, nonproductive cough,
headache.
Potentially Fatal: Neutropenia, usually occurs within 3 mth of starting therapy
especially in patients with renal dysfunction or collagen diseases. Hyperkalaemia.
Anaphylactic reactions.

Contraindications

Known hypersensitivity to the drug.

Bilateral renal artery stenosis,
hereditary angioedema;
renal impairment;
pregnancy.

Nursing Considerations

Assessment

History: Allergy to captopril, history of angioedema, impaired renal function,

CHF, salt or volume depletion, pregnancy, lactation
Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous
membranes, bowel sounds, liver evaluation; urinalysis, LFTs, renal function tests,
CBC and differential

Interventions
Administer 1 hr before meals.
WARNING: Ensure that patient is not pregnant before beginning treatment. Encourage
use of contraceptives; if pregnancy is detected, stop drug.
WARNING: Alert surgeon and mark patients chart with notice that captopril is being
taken; the angiotensin II formation subsequent to compensatory renin release during
surgery will be blocked; hypotension may be reversed with volume expansion.[/box]

Monitor patient closely for fall in BP secondary to reduction in fluid volume (due
to excessive perspiration, and dehydration, vomiting, or diarrhea); excessive
hypotension may occur.
Reduce dosage in patients with impaired renal function.

Teaching points

Take drug 1 hour before meals; do not take with food. Do not stop without
consulting your healthcare provider.

Be careful of drop in blood pressure (occurs most often with diarrhea, sweating,
vomiting, or dehydration); if lightheadedness or dizziness occurs, consult
your healthcare provider.
Severe fetal damage can occur if captopril is taken during pregnancy. Use of
contraceptives is advised; if pregnancy should occur, stop drug and notify health
care provider.
Avoid over-the-counter medications, especially cough, cold, allergy medications
that may contain ingredients that will interact with ACE inhibitors. Consult
your healthcare provider.
You may experience these side effects: Cough, GI upset, loss of appetite,
change in taste perception (limited effects, will pass); mouth sores (frequent
mouth care may help); rash; fast heart rate; dizziness, light-headedness (usually
passes after the first few days; change position slowly, and limit your activities to
those that do not require alertness and precision).
Report mouth sores; sore throat, fever, chills; swelling of the hands or feet;
irregular heartbeat, chest pains; swelling of the face, eyes, lips or tongue; difficulty
breathing.

Generic Name : Enalapril maleate

Brand Name: Vasotec , enalaprilat , Vasotec I.V.
Classification: Antihypertensive, ACE inhibitor
Pregnancy Category D
Interactions
Dual inhibition of the renin-angiotensin system with ARBs, ACEIs, or aliskiren may
increase risk of hypotension, hyperkalemia, renal function changes; monitor closely.
Concomitant aliskiren in renal impairment (CrCl <60mL/min): not recommended.
Potentiated by, and hypotension with, diuretics. Hyperkalemia with K +-sparing diuretics
or K+ supplements. May increase lithium levels. May be antagonized by, and renal
toxicity potentiated by NSAIDs, including COX-2 inhibitors (monitor renal function
periodically in elderly and/or volume-depleted). Nitritoid reactions with concomitant
injectable gold (eg, sodium aurothiomalate).

Dosage & Route

Available forms : Tablets2.5, 5, 10, 20 mg; injection1.25 mg/mL
ADULTS
Oral
Hypertension:

Patients not taking diuretics: Initial dose is 5 mg/day PO. Adjust dosage based on
patient response. Usual range is 1040 mg/day as a single dose or in two divided
doses.

Patients taking diuretics: Discontinue diuretic for 23 days if possible. If it is not

possible to discontinue diuretic, give initial dose of 2.5 mg, and monitor for
excessive hypotension.

Converting to oral therapy from IV therapy: 5 mg daily with subsequent doses

based on patient response.

CHF: 2.5 mg PO daily or bid in conjunction with diuretics and digitalis. Maintenance
dose is 520 mg/day given in two divided doses. Maximum daily dose is 40 mg.
Asymptomatic LVD: 2.5 mg PO bid; target maintenance dose 20 mg/day in two divided
doses.
Parenteral

Give IV only. 1.25 mg q 6 hr given IV over 5 min. A response is usually seen

within 15 min, but peak effects may not occur for 4 hr.

Hypertension:
Converting to IV therapy from oral therapy: 1.25 mg q 6 hr; monitor patient response.
Patients taking diuretics: 0.625 mg IV over 5 min. If adequate response is not seen after
1 hr, repeat the 0.625-mg dose. Give additional doses of 1.25 mg q 6 hr.
PEDIATRIC PATIENTS 1 MO16 YR
Oral
Hypertension: Initial dose is 0.08 mg/kg PO once daily; maximum dose is 5 mg.
GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT
Oral

Excretion is reduced in renal failure; use smaller initial dose, and adjust upward
to a maximum of 40 mg/day PO. For patients on dialysis, use 2.5 mg on dialysis
days.

Therapeutic actions

Enalapril is de-esterified into the active enalaprilat resulting in potent inhibition of

ACE thus leading to reduced levels of angiotensin II and aldosterone. Clinically,
BP is reduced, salt and water retention is corrected. Ventricular hypertrophy is
reversed. Renal blood flow is increased but in patients with renal impairment
there may be oliguria or acute renal failure.

Indications

Treatment of hypertension alone or in combination with other antihypertensives,

especially thiazide-type diuretics

Treatment of acute and chronic CHF

Treatment of asymptomatic left ventricular dysfunction (LVD)

Unlabeled use: Diabetic nephropathy

Adverse effects

Initial hypotension may be severe and prolonged. Dizziness, headache, fatigue,

persistent dry cough, abnormal taste, lassitude, rash, neutropenia, renal
impairment or failure.

Potentially Fatal: Angioedema.

Contraindications

Hypersensitivity. History of angioedema due to previous treatment with ACE

inhibitors; bilateral renal artery stenosis. Pregnancy.

Nursing considerations
Assessment

History: Allergy to enalapril, impaired renal function, salt or volume depletion,

lactation, pregnancy

Physical: Skin color, lesions, turgor; T; orientation, reflexes, affect, peripheral

sensation; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver
evaluation; urinalysis, LFTs, renal function tests, CBC, and differential

Interventions

WARNING: Alert surgeon, and mark patient's chart with notice that enalapril is
being taken; the angiotensin II formation subsequent to compensatory renin
release during surgery will be blocked; hypotension may be reversed with volume
expansion.

Be aware that use of this drug in second and third trimesters can cause serious
injury or death to the fetus; advise contraceptive use.

Monitor patients on diuretic therapy for excessive hypotension after the first few
doses of enalapril.

Monitor patient closely in any situation that may lead to a drop in BP secondary
to reduced fluid volume (excessive perspiration and dehydration, vomiting,
diarrhea) because excessive hypotension may occur.

Arrange for reduced dosage in patients with impaired renal function.

WARNING: Monitor patient carefully because peak effect may not be seen for 4
hr. Do not administer second dose until BP has been checked.

Teaching points

Do not stop taking the medication without consulting your health care provider.

Be careful in any situation that may lead to a drop in blood pressure (diarrhea,
sweating, vomiting, dehydration).

Avoid over-the-counter medications, especially cough, cold, and allergy

medications that may interact with this drug.

You may experience these side effects: GI upset, loss of appetite, change in
taste perception (will pass with time); mouth sores (frequent mouth care may
help); rash; fast heart rate; dizziness, light-headedness (usually passes in a few
days; change position slowly, limit activities to those not requiring alertness and
precision).

Use of contraception is advised while taking the drug.

Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular
heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty
breathing.

Generic Name: Moexipril

Brandname: Univasc
Classification: Cardiovascular Agent; Angiotensin-Converting Enzyme Inhibitor;
Antihypertensive
Pregnancy Category C (first trimester); D (second and third trimesters)
Mechanism of Action/Interaction
Moexipril/hydrochlorothiazide is a fixed-combination tablet that combines an
angiotensin-converting enzyme (ACE) inhibitor, moexipril, and a thiazide diuretic,
hydrochlorothiazide
Moexipril prevents the conversion of angiotensin I to angiotensin II (a potent
vasoconstrictor) through inhibition of ACE by competing with physiologic substrate

(angiotensin I) for active site of ACE; inhibition of ACE initially results in decreased
plasma angiotensin II concentrations & consequently, blood pressure may be reduced in
part through decreased vasoconstriction, increased renin activity, and decreased
aldosterone secretion
Hydrochlorothiazide is a thiazide diuretic that inhibits Na reabsorption in distal renal
tubules resulting in increased excretion of Na+ and water, also K+ and H+ ions
Indication or Doses
Hypertension
Adult: PO 7.5 mg OD, may increase up to 30mg/d in divided doses
Renal Impairment
start with 3.75 mg QD (also if patient is volume depleted or on diuretics)

Pharmacokinetics

Half-life: 1 hr (moexepril); 2-9 hr (moexiprilat)

Duration: 24 hr
Onset: 1-2 hr (peak effect)
Total body clearance: 441 mL/min (Moexipril); 223 mL/min (moexiprilat)
Excretion: Feces (50%); urine (13%)
Peak plasma time: 1.5 hr
Bioavailability: 13-22%
Protein bound: 90% (moexepril); 50-70% (moexeprilat)
Vd: 180 L
Metabolism: extensively metabolized in liver, minimally metabolized at intestinal
wall
Metabolites: Moexiprilat (active)

Adverse Effects

Dizziness
Hypotension
Peripheral edema

Cough
Headache
Myalgia
Hyponatremia
Pharyngitis
Sinusitis
Rash
Nausea/vomiting
Hyperkalemia
Hyponatremia
Polyuria

Administration
Oral

Give 1 h before or 2 h after meals. Food greatly reduces absorption of moexipril.

May need to reduce starting dose 50% in patients with possible volume depletion
or a history of renal insufficiency.

Store at 1530 C (5986 F).

Contraindications/Cautions
Hypersensitivity to moexipril; history of angioedema related to an ACE inhibitor;
pregnancy [(category C) first trimester; (category D) second and third trimesters].
Nursing Implications
Assessment & Drug Effects

Monitor closely for systematic hypotension that may occur within 13 h of first
dose, especially in those with high blood pressure, on a diuretic or restricted salt
intake, or otherwise volume depleted.

Monitor BP and HR frequently during initiation of therapy, whenever a diuretic is

added, and periodically throughout therapy.

Determine trough BP (just before next dose) before dose adjustments are made.

Lab tests: Monitor serum electrolytes, WBC with differential, Hct and Hgb, UA,
and kidney and liver function tests periodically throughout therapy.

Supervise therapeutic response closely in patients with CHF.

Patient & Family Education

Report to physician immediately swelling around face or neck or in extremities.

Report S&S of hypotension (e.g., dizziness, weakness, syncope); nonproductive

cough; skin rash; flu-like symptoms; jaundice; irregular heartbeat or chest pains;
and dehydration from vomiting, diarrhea, or diaphoresis.

Consult physician before using potassium-containing salt substitutes.

Do not breast feed while taking this drug without consulting physician.

Ramipril (ra mi' pril)

Altace
Pregnancy Category C (first trimester)
Pregnancy Category D (second and third trimesters)
Drug classes
Antihypertensive
Angiotensin-converting enzyme (ACE) inhibitor
Therapeutic actions
Ramipril blocks ACE from converting angiotensin I to angiotensin II, a powerful
vasoconstrictor, leading to decreased BP, decreased aldosterone secretion, a small
increase in serum potassium levels, and sodium and fluid loss; increased
prostaglandin synthesis also may be involved in the antihypertensive action.

Indications

Treatment of hypertension alone or in combination with thiazide-type diuretics

Treatment of CHF in stable patients in the first few days after MI

To decrease the risk of MI, stroke, death from CV disease in patients at risk for
developing CAD
Contraindications and cautions

Contraindicated with allergy to ramipril, pregnancy (embryocidal in preclinical

studies).

Use cautiously with impaired renal function, CHF, salt or volume depletion,
lactation.
Available forms
Capsules1.25, 2.5, 5, 10 mg
Dosages
ADULTS

Hypertension: Initial dose, 2.5 mg PO daily. Adjust dose according to

BP response, usually 2.520 mg/day as a single dose or in two equally
divided doses. Discontinue diuretic 23 days before beginning therapy;
if not possible, administer initial dose of 1.25 mg.
CHF: Initial dose, 2.5 mg PO bid; if patient becomes hypotensive,
1.25 mg PO bid may be used while adjusting up to target dose of 5 mg
PO bid; increase dose q 3 wk until target dose is reached.
Decrease risk of CV events: Initial dose, 2.5 mg PO once daily for 1
wk, then 5 mg PO once daily for next 3 wk, maintenance 10 mg PO
daily.

PEDIATRIC PATIENTS
Safety and efficacy not established.
GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT
Excretion is reduced in renal failure; use smaller initial dose, 1.25 mg PO daily in
patients with creatinine clearance < 40 mL/min; dosage may be titrated upward until
pressure is controlled or a maximum of 5 mg/day.
Pharmacokinetics
Rout
Onset
e
Oral
12 hr

Peak

Duration

14 hr

24 hr

Metabolism: Hepatic; T1/2: 1317 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine and feces
Adverse effects

CV: Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF,

hypotension in salt- or volume-depleted patients, syncope

Dermatologic: Rash, pruritus, pemphigoid-like reaction, photosensitivity,

erythema multiforme, Stevens-Johnson syndrome

GI: Gastric
irritation, aphthous ulcers, dysgeusia, cholestatic jaundice, hepatocellula
r injury, anorexia, constipation, pancreatitis

GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria,

urinary frequency

Hematologic: Neutropenia, agranulocytosis, thrombocytopenia,

hemolytic anemia, pancytopenia

Other: Cough, malaise, dry mouth, lymphadenopathy, angioedema

Interactions
Drug-drug

Exacerbation of cough if taken with capsaicin

Increased serum levels and increased toxicity with lithium; monitor patient
closely
Drug-food

Rate of absorption is decreased with food

Drug-lab test

False-positive test for urine acetone

Nursing considerations
Assessment
History: Allergy to ramipril, impaired renal function, CHF, salt or volume
depletion, pregnancy, lactation
Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion;
mucous membranes, bowel sounds, liver evaluation; urinalysis, renal
and liver function tests, CBC and differential
Interventions
Discontinue diuretic for 23 days before beginning therapy, if possible,
to avoid severe hypotensive effect.

Open capsules and sprinkle contents over a small amount of

applesauce or mix in applesauce or water if patient has difficulty
swallowing capsules. Mixture is stable for 24 hr at room temperature
and 48 hr if refrigerated.
WARNING: Alert surgeon and mark chart that ramipril is being used;
the angiotensin II formation subsequent to compensatory renin release
during surgery will be blocked; hypotension may be reversed with
volume expansion.
Monitor patient closely for falling BP secondary to reduction in fluid
volume (excessive perspiration and dehydration, vomiting, diarrhea)
because excessive hypotension may occur.
Reduce dosage in patients with impaired renal function.

Teaching points
Do not stop taking without consulting your prescriber.
Be careful in any situation that may lead to a drop in BP (diarrhea,
sweating, vomiting, dehydration); if light-headedness or dizziness
should occur, consult your health care provider.
You may experience these side effects: GI upset, loss of appetite,
change in taste perception (transient) mouth sores (use frequent
mouth care); rash; fast heart rate; dizziness, light-headedness
(transient; change position slowly, and limit your activities to those that
do not require alertness and precision).
Report mouth sores; sore throat, fever, chills; swelling of the hands,
feet; irregular heartbeat, chest pains; swelling of the face, eyes, lips,
tongue, difficulty breathing.

Fosinopril sodium (foh sin' oh pril)

Brandname: Monopril
Pregnancy Category C (first trimester)
Pregnancy Category D (second and third trimesters)
Drug classes
Antihypertensive
Angiotensin-converting enzyme (ACE) inhibitor
Therapeutic actions
Renin, synthesized by the kidneys, is released into the circulation where it acts on a
plasma precursor to produce angiotensin I, which is converted by angiotensinconverting enzyme to angiotensin II, a potent vasoconstrictor that also causes release
of aldosterone from the adrenals; fosinopril blocks the conversion of angiotensinI
to angiotensin II, leading to decreased BP, decreased aldosterone secretion, a small
increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin
synthesis may be involved in the antihypertensive action.
Indications

Treatment of hypertension, alone or in combination with thiazide-type diuretics

Management of CHF as adjunctive therapy

Unlabeled use: Diabetic nephropathy

Contraindications and cautions

Contraindicated with allergy to fosinopril or other ACE inhibitors; pregnancy.

Use cautiously with impaired renal function, hyperkalemia, salt or volume

depletion, lactation.
Available forms
Tablets10, 20, 40 mg
Dosages
ADULTS
Initial dose, 10 mg PO daily. Maintenance dose, 2040 mg/day PO as a single dose or 2
divided doses. In patients receiving diuretic therapy, begin fosinopriltherapy with 10 mg.
Do not exceed maximum dose of 80 mg.
PEDIATRIC PATIENTS
Safety and efficacy not established.
Pharmacokinetics

Route
Oral

Onset
1 hr

Peak
3 hr

Duration
24 hr

Metabolism: Hepatic; T1/2: 12 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine and feces
Adverse effects

CV: Angina pectoris, orthostatic hypotension in salt- or volume-depleted

patients, palpitations

Dermatologic: Rash, pruritus, diaphoresis, flushing

GI: Nausea, abdominal pain, vomiting, diarrhea

Respiratory: Cough, asthma, bronchitis, dyspnea, sinusitis

Other: Angioedema, asthenia, myalgia, arthralgia, hyperkalemia

Interactions
Drug-drug

Decreased effectiveness if combined with indomethacin or other NSAIDs

Risk of lithium toxicity if combined with ACE inhibitors

Risk of increased potassium levels if taken with potassium-sparing diuretics

Decreased absorption when given with antacids; separate by at least 2 hr.

Nursing considerations
CLINICAL ALERT!
Name confusion has occurred between fosinopril and lisinopril; use caution.
Assessment

History: Allergy to fosinopril and other ACE inhibitors, impaired renal or hepatic
function, hyperkalemia, salt or volume depletion, lactation, pregnancy

Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous

membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function
tests, CBC, and differential
Interventions

WARNING: Alert surgeon and mark patient's chart with notice that fosinopril is
being taken; the angiotensin II formation subsequent to
compensatory reninrelease during surgery will be blocked; hypotension may be
reversed with volume expansion.

Arrange to switch to a different drug if pregnancy occurs; suggest using barrier

contraceptives.

Monitor patient closely for a fall in BP secondary to reduction in fluid volume

(excessive perspiration and dehydration, vomiting, diarrhea) because excessive
hypotension may occur.

Teaching points

Do not stop taking the medication without consulting your prescriber.

Avoid pregnancy while taking this drug; using barrier contraceptives is advised.

Be careful in any situation that may lead to a drop in BP (diarrhea, sweating,

vomiting, dehydration); if light-headedness or dizziness occurs, consult your care
provider.

You may experience these side effects: GI upset, loss of appetite (these may
be transient); light-headedness (transient; change position slowly and limit
activities to those that do not require alertness and precision); dry cough (not
harmful).

Report mouth sores; sore throat, fever, chills; swelling of the hands, feet;
irregular heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty
breathing, persistent cough.