Adverse effects of ACE inhibitors

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a. Hypotension is especially a problem with elderly patients, volume depleted patients, and those on diuretics. These agents can worsen renal function. They should be used with caution in patients with serum creatinine levels of >3.0 mg/dL.ACE inhibitors should be used with caution in unilateral renal artery stenosis (RAS) and are contraindicated in bilateral RAS. Patients should be monitored for hyperkalemia.

b. A dry, bothersome cough is the most common adverse effect, occurring in 6-20%.

c. Angioedema is a rare (0.1%-0.2%) but potentially fatal side effect.

Angiotensin-Converting Enzyme Inhibitors

Drug

Usual doses

Maximum dose

Benazepril (Lotensin)

20-40 mg qd or divided bid

80 mg/d

Captopril (Capoten)

50 mg bid-qid

450 mg/d

Enalapril (Vasotec, Vasotec IV)

10-40 mg qd or divided bid

40 mg/d

Fosinopril (Monopril)

20-40 mg qd or divided bid

80 mg/d

Lisinopril (Prinivil, Zestril)

20-40 mg qd

40 mg/d

Moexipril (Univasc)

15-30 mg qd

30 mg/d

Quinapril (Accupril)

20-80 mg qd or divided bid

80 mg/d

Ramipril (AItace)

5-20 mg qd or divided bid

20 mg/d

Trandolapril (Mavik)

2-4 mg qd

8 mg/d

VI. Angiotensin II receptor blockers

A. Angiotensin II receptor blockers (ARBs) decrease BP by inhibiting the coupling of AII to the angiotensin receptor. ARBs are as effective as other major classes of antihypertensives at reducing BP. In contrast to ACE inhibitors, ARBs have not been shown to slow the progression to renal failure in patients with diabetes. ARBs do not cause cough or angioedema, but they may cause hyperkalemia.

B. These agents are appropriate alternatives for patients who are candidates for an ACE inhibitor but cannot tolerate these agents due to cough or angioedema.

Angiotensin II Receptor Blockers

Drug

Usual dose

Maximum dose

Candesartan (Atacand)

4-8 mg qd

16 mg/d

Irbesartan (Avapro)

150-300 mg qd

300 mg/d

Drug

Usual dose

Maximum dose

Losartan (Cozaar)

50 mg qd

100 mg/d

Valsartan (Diovan)

80 mg qd

320 mg/d

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