ACE Inhibitors Flashcards
(11 cards)
What is the mode of action and indication
Inhibits the conversion of Angiotensin 1 to angiotensin 11
Has many uses, used for heart failure, hypertension, diabetics nephropathy, prophylaxis of cardiac events
Ace contraindications
Ace inhibitors in combo with aliskiren in patients with diabetes myelitis and patients with and eGFR greater than 60.
ACE cautions
- Afro Caribbean patients (many respond less well)
- concomitant diuretics
- first dose hypotension (especially patients on high doses of diuretics, low sodium diet, on dialysis,dehydrated or with heart failure)
Ace inhibitors in heart failure
- They are used in all grades of heart failure, usually combined with a beta blocker
- discontinue potassium sparing diuretics may cause and potassium supplements before starting ACE I because there is a risk of hyper kalaemia (low dose spironolactone can be used but closely monitored)
- profound first doe hypotension with patients with heart failure already taking a high dose of loop diuretic ( eg. Furosemide 80 mg daily or more)
Ace inhibitors should be initiated under specialised supervision under which conditions?
-severe heart failure
- patients receiving multiple or high doses of diuretics (more than 80 mg furosemides or equivalent)
- receiving concomitant ace II receptor antagonist or aliskiren - renin inhibitor)
- patients with hypokalaemia
- unstable heart failure already taking
- known renovascular disease
- hyponatraemia (more than 120mmol/l)
- hypotension (systolic by more than 90mm/hg)
Main side effects of ace inhibitors
- alopecia
-angioedema (may be delayed, more common in afrocaribbean) - angina pectoris
- persistent dry cough
- electrolyte imbalance
- skin reaction
- constipation
- GI disturbance
Renal effects
Check renal and electrolytes before starting ACEi
Hyperkalaemia and other side effects more common in patients with renal impairment (dose may need to be reduced)
ACEi, may also sometimes cause renal impairment (especially if elderly, specialist supervision needed)
- concomitant treatment with NSAIDS increase risk of renal damage
- concomitants treatment with potassium sparing diuretics may increase risk of hyperkalaemia
- better avoided in patients in renoventricular disease
Contraindications
- ACEi and aliskiren(contraindicated in patients with an eGFR more than 60)
- combination of ACE i and aliskiren is contraindicated in patients with diabetes
- Discontinue if marked elevation of hepatic enzymes or jaundice occurs
Cautions and further information
- avoid during dialysis - to prevent anaphylactic reactions
- pregnancy - avoid in pregnancy (affects fetal and neonatal BP and renal function. Skull defects reported)
Renal impairment - use with caution. Start with low dose and adjust according to response. - Monitoring - renal function amd electrolytes should be monitored
- directions for admin: for hypertension, first dose should be preferably given at bedtime - due to postural hypotension
ARBS - Angiotensin 2 receptor antagonist
Candesartan,eprosartan, ibesartan,losartan and valsartan
- less likely to cause persistent dry cough - does not inhibit break down of bradykinin and other kinins
- use when ace is contraindicated or not tolerated
- avoid in pregnancy and use with caution in renal impairment and in the elderly
Side effects - hypotension, dizziness and hyper kalaemia
Renin inhibitors
Eg. Aliskiren
- inhibits renin directly (renin converts angiotensin 11 to angiotensin 1)
- Aliskiren is licensed for treatment of hypertension alone or in combo with other hypertensives
- Ace i and aliskiren should not be given together due to increased risk of hyperkalaemia,hypotension or renal impairment, compared to a single drug
