Quinapril

ADMINISTRATION ROUTES:

PO

ALTERNATIVE NAMES:

Accupril, Accuretic (quinapril + hydrochlorothiazide)

ICU INDICATIONS:

1. Hypertension
2. Congestive heart failure or left ventricular dysfunction after myocardial infarction
3. Diabetic nephropathy

PRESENTATION AND ADMINISTRATION:

PO:

Accupril tablets 5mg, 10 mg & 20 mg (reddish-brown)

Accuretic tablets 10 mg quinapil & 12.5mg hydrochlorthiazide (pink)

DOSAGE:

PO:

5 - 10 mg OD

Increase to 20 - 40 mg as required

DOSAGE IN RENAL FAILURE AND RENAL REPLACEMENT THERAPY:

Dose in renal impairment

Dose in renal replacement therapy

Note: Clinical observations have shown an association of hypersensitivity-like (anaphylactoid) reactions during haemodialysis with high-flux dialysis membranes (AN69) in patients receiving ACE inhibitors.

DOSAGE IN PAEDIATRICS:

PO:

0.2 - 0.8 mg/kg OD

CLINICAL PHARMACOLOGY:

Quinapril is a specific competitive inhibitor of angiotensin I-converting enzyme (ACE), the enzyme responsible for the conversion of angiotensin I to angiotensin II.

CONTRAINDICATIONS:

1. Hypersensitivity to quinapril or any other angiotensin-converting enzyme inhibitor (e.g. a patient who has experienced angioedema during therapy with any other ACE inhibitor)
2. Cardiogenic shock

WARNINGS:

Anaphylactoid and Possibly Related Reactions

Quinapril can cause anaphylactoid reactions

Head and Neck Angioedema

Angioedema involving the extremities, face, lips, mucous membranes, tongue, glottis or larynx has been seen in patients treated with ACE inhibitors. If angioedema involves the tongue, glottis or larynx, airway obstruction may occur and may be fatal. Swelling confined to the face, mucous membranes of the mouth, lips and extremities usually resolves with discontinuation of the ACE inhibitor. Some cases required medical therapy.

Intestinal Angioedema

Intestinal angioedema has been reported in patients treated with ACE inhibitors. These patients presented with abdominal pain (with or without nausea or vomiting). In some cases there was no prior history of facial angioedema and C-1 esterase levels were normal.

Neutropaenia/Agranulocytosis

Neutropaenia (< 1 x 10⁹/L) with myeloid hypoplasia has resulted from use of quinapril.

Hypotension in Heart Failure Patients

Caution should be observed when initiating therapy in patients with heart failure. Patients with heart failure given quinapril commonly have some reduction in blood pressure. In patients with symptomatic hypotension this may require temporarily reducing the dose of quinapril, or diuretic, or both, and volume repletion.

Hepatic Failure

Rarely, ACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice and progresses to fulminant hepatic necrosis and (sometimes) death. The mechanism of this syndrome is not understood. Patients receiving ACE inhibitors who develop jaundice or marked elevations of hepatic enzymes should discontinue the ACE inhibitor.

PRECAUTIONS:

General:

Some patients with renal disease, particularly those with severe renal artery stenosis, have developed increases in serum creatinine after reduction of blood pressure with quinapril. Dosage reduction and/or discontinuation of diuretic may be required. Elevations in serum potassium have been observed in some patients treated with ACE inhibitors.

Persistent nonproductive cough due to the inhibition of the degradation of endogenous bradykininhas been reported with all ACE inhibitors, always resolving after discontinuation of therapy. ACE inhibitor-induced cough should be considered in the differential diagnosis of cough.

Laboratory Tests:

No tests in addition to routine ICU tests are required.

Drug/Laboratory Test Interactions :

None known.

IMPORTANT DRUG INTERACTIONS IN ICU:

Increased serum lithium levels and symptoms of lithium toxicity have been reported in patients receiving concomitant lithium and ACE inhibitor therapy.

The risk of hypotension increases if quinapril is co-administered with other antihypertensives.

ADVERSE REACTIONS:

Body as a Whole:

Gynaecomastia, anaphylactoid reactions, angioedema

Cardiovascular:

Cardiac arrest, cerebrovascular accident / insufficiency, rhythm disturbances, orthostatic hypotension, syncope

Dermatological:

Bullous pemphigus, erythema multiforme (Stevens Johnson syndrome), exfoliatice dermatitis

Gastrointestinal:

Pancreatitis, glossitis, dyspepsia, jaundice, hepatitis, rare causes of hepatic necrosis, cholestasis

Haematological:

Anaemia (including cases of haemolytic anaemia), thrombocytopaenia, neutropaenia

Metabolic:

Hyponatraemia

Musculoskeletal:

Myalgia, myasthenia

Nervous system:

Ataxia, confusion, depression, nervousness, somnolence

Respiratory system:

Bronchospasm, eosinophilic pneumonia, angioedema

Urogenital system:

Renal failure, proteinuria