ACE Inhibitors

Question 1

What are the side effects ACE-I?

Answer 1

• Cough: ~15% (Due to increased bradykinin levels)
• Angioedema (Can occur up to 1 year after starting)
• Hyperkalaemia
• First dose hypotension: Common if taking diuretics.

Question 2

What conditions should ACE-I not be used in?

Answer 2

• Renal artery stenosis
• Pregnancy
• Breastfeeding
• Aortic stenosis - can cause hypotension
• People using significantly high doses of diuretics (80mg Furosemide) - risk of hypotension.
• Hereditary idiopathic angioedema.

Question 3

How should ACE-I be monitored?

Answer 3

Checked before treatment and after increasing the dose.

Question 4

After initiating ACE-I, they can cause a rise in potassium and creatinine. What is an acceptable rise in both?

Answer 4

Rise in Creatine up to 30% from baseline

eGFR fall up to 25%

Potassium increase up to 5.5mmol/l

Question 5

You review a 67-year-old woman who has a history of chronic obstructive pulmonary disease and hypertension. She has develop cor pulmonale and her current medications include frusemide 80 mg bd, amlodipine 10mg od and atenolol 50 mg od. You want to initiate an ACE inhibitor. What is the most appropriate action?

• Stop frusemide for 2 days + start ramipril 1.25 mg od + check U&Es in 2 weeks
• Start ramipril 1.25 mg od + check U&Es in 2 weeks
• Refer to secondary care
• Reduce frusemide to 80mg od + start ramipril 1.25 mg od + check U&Es in 2 weeks
• Start ramipril 1.25 mg od + check U&Es in 5 days

Answer 5

Refer to secondary care

If on large doses of diuretics, refer to a specialist for initiation of ACE inhibitors.