Quinapril

DEA Class; Rx

Common Brand Names; Accupril

• ACE Inhibitors

Oral ACE inhibitor; prodrug metabolized to active quinaprilat; used 1-2 times daily for HTN; given twice daily for CHF.

Indicated for the treatment of hypertension

Hypersensitivity

History of hereditary or angioedema associated with previous ACE inhibitor treatment

Coadministration of neprilysin inhibitors (eg, sacubitril) with ACE inhibitors may increase angioedema risk; do not administer ACE inhibitors within 36 hr of switching to or from sacubitril/valsartan

Do not coadminister with aliskiren in patients with diabetes mellitus

• Dizziness (7.7%)
• Coughing (4.3%)
• Fatigue (2.6%)
• Nausea and/or vomiting (2.4%)
• Hypotension (2.9%)
• Dyspnea (1.9%)
• Diarrhea (1.7%)
• Headache (1.7%)
• Myalgia (1.5%)
• Rash (1.4%)
• Back pain (1.2%)
• Angioedema
• General: Back pain, malaise, viral infections, anaphylactoid reaction
• Cardiovascular: Palpitation, vasodilation, tachycardia, heart failure, hyperkalemia, myocardial infarction, cerebrovascular accident, hypertensive crisis, angina pectoris, orthostatic hypotension, cardiac rhythm disturbances, cardiogenic shock
• Hematology: Hemolytic anemia
• Gastrointestinal: Flatulence, dry mouth or throat, constipation, gastrointestinal hemorrhage, pancreatitis, abnormal liver function tests, dyspepsia
• Metabolism and nutrition disorders: Hyponatremia
• Nervous/psychiatric: Somnolence, vertigo, syncope, nervousness, depression, insomnia, paresthesia
• Integumentary: Alopecia, increased sweating, pemphigus, pruritus, exfoliative dermatitis, photosensitivity reaction, dermatopolymyositis
• Urogenital: Urinary tract infection, impotence, acute renal failure, worsening renal failure
• Respiratory: Eosinophilic pneumonitis
• Other: Amblyopia, edema, arthralgia, pharyngitis, agranulocytosis, hepatitis, thrombocytopenia

Discontinue STAT if pregnant (see Contraindications and Black Box Warnings)

Less effective in blacks

ACE inhibitors associated with a syndrome that starts with cholestatic jaundice and progresses to fulminant hepatic necrosis and (sometimes) death; mechanism of this syndrome is not understood; patients receiving ACE inhibitors who develop jaundice or marked elevations of hepatic enzymes should discontinue ACE inhibitor and receive appropriate medical follow-up

Use caution in severe aortic stenosis

Hyperkalemia may occur; risk factors may include renal insufficiency, diabetes mellitus, and concomitant use of other drugs that raise serum potassium levels; monitor serum potassium in such patients

Dual blockade of the renin-angiotensin system with ARBs, ACE inhibitors, or aliskiren associated with increased risk for hypotension, hyperkalemia, and renal function changes (including acute renal failure) compared to monotherapy

Anaphylactoid reactions reported in patients dialyzed with high-flux membranes and treated concomitantly with an ACE inhibitor; anaphylactoid reactions also reported in patients undergoing low-density lipoprotein apheresis with dextran sulfate absorption

Decreased absorption (25-30%) with high-fat meal

ACE inhibition also causes increased bradykinin levels which putatively mediates angioedema

Angioedema of the face, extremities, lips, tongue, glottis, and larynx reported in patients treated with angiotensin-converting enzyme inhibitors; in instances where swelling is confined to face and lips, condition generally resolves without treatment; antihistamines may be useful in relieving symptoms; when there is involvement of tongue, glottis, or larynx, likely to cause airway obstruction, administer emergency therapy including, but not limited to, subcutaneous epinephrine solution 1:1000 (0.3 to 0.5 mL)

Patients receiving coadministration of ACE inhibitor and mTOR (mammalian target of rapamycin) inhibitor (e.g. temsirolimus, sirolimus, everolimus) therapy or a neprilysin inhibitor may be at increased risk for angioedema

Intestinal angioedema has been reported in patients treated with ACE inhibitors

Presumably due to inhibition of degradation of endogenous bradykinin, persistent non-productive cough reported with all ACE inhibitors, always resolving after discontinuation of therapy; ACE inhibitor-induced cough should be considered in differential diagnosis of cough

Pregnancy Category: C (1st trimester); D (2nd & 3rd trimester)

Discontinue as soon as pregnancy detected; during the second and third trimesters of pregnancy, drugs that act directly on the renin-angiotensin have been associated with fetal injury that includes hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, and death

Lactation: excreted in breast milk; use caution