ACEi

Question 1

MOA

Answer 1

by inhibiting the conversion of angiotensin I to angiotensin II

Question 2

List some examples of ACE-inhibitors?

pril

Answer 2

• Ramipril
• Lisinopril
• Enalapril
• Perindopril
• Captopril

Question 3

Indication

Answer 3

1. HF
2. HT
3. DN
4. Prophylaxis of CV events
5. CKD

Question 4

If heart failure patients are taking a high dose loop diuretic (e.g. > furosemide 80mg OD) and have just started an ACE inhibitor, what can occur?

Answer 4

• profound first dose hypotension
• Take first dose at bedtime
• Temporary withdrawal of loop diuretic reduces the risk

Question 5

If the withdrawal of loop diuretic is needed in heart failure patients to reduce the risk of profound first-dose hypotension because they are starting an ACE inhibitor, what is the risk in doing that?

Answer 5

withdrawal may reduce risk of hypotension but can cause severe rebound pulmonary oedema

Question 6

If a heart failure patient is taking a low dose loop diuretic and is initiated on an ACE/ 1, is there a risk?

Answer 6

• care is still required, even for those who are at low risk of severe hypotension
• a low dose ACE-inhibitor should be given initially

Question 7

Which patients tend to respond less well to ACE/l in hypertension?

Answer 7

• Black
• 55+
  hence why they are not first-line for these patients in hypertension
• primary aldosteronism

Question 8

CI

Answer 8

• pregnancy
• bilateral renal atery/ aortic stenosis
• AKI
• Very low BP
• Hyperkalaemia (5.5 +)

Question 9

Monitoring before starting ACEi

Answer 9

• Renal function
• electrolytes - SE = hyperkalaemia
• BP

these should be checked whenever there’s a dose increase as well)

Question 10

ACEi - renal impairment

Answer 10

• ACE inhibitors can be used in some renal diseases e.g. CKD
• However, they can occasionally cause renal impairment
• Side effects such as hyperkalemia are more likely to occur in renal impaired patients

Question 11

SE

Answer 11

Cough (give ARB instead) - due to breakdown of bradykinin
Hyperkalaemia
Hepatic Failure
Angioedema
Renal Impairment
Dizziness and Headaches
CHHAReD

Question 12

Which patients are at high risk of developing hyperkalemia whilst on ACE-inhibitors?

Answer 12

• renal insufficiency/ impairment
• > 70
• uncontrolled DM
• those using potassium salts, potassium retaining diuretics and other plasma potassium increasing active substances
• conditions such as: dehydration, acute cardiac decompensation, metabolic acidosis

Question 13

Serious side effects

Answer 13

1. Hypotension on first dose
2. Angioedema

Question 14

Hypotension on first dose

Answer 14

• Symptoms include dizziness or fainting
• Common when taking with other drugs that cause hypotension e.g. diuretics
• Take first dose at night

Question 15

Angiodoema

Answer 15

• Serious allergic reaction causing swelling of face, lips, tongue or throat
• Uncommon but serious side effect
• Requires urgent referral

Question 16

Which ethnic origin is angioedema most likely to occur in whilst taking ACE inhibitors?

Answer 16

Black

Question 17

Can ACE-inhibitors be taken during pregnancy?

Answer 17

• NO!!
• May cause congenital malformations

Question 18

Can ACE-inhibitors be taken by breastfeeding patients?

Answer 18

• Low levels of present in breast milk, information on use is limited
• Enalapril preferred

Question 19

Interactions

Answer 19

1. ARBs
2. K supps, K sparing diuretics (increased hyperk)
3. Lithium
4. NSAIDs (can reduce effect of ACEi)
5. Diuretics (hypotension)

Question 20

ACE inhibitors and
Alcohol

Answer 20

Alcohol and ACE inhibitors can increase the risk of hypotension
Recommend no excessive alcohol drinking, so 2 units a day for both men and women

Question 21

ACE inhibitors concomitant treatment with NSAIDS

Answer 21

• Increases the risk of renal damage
• Advise patients to avoid buying OTC NSAIDs (e.g.
  Ibuprofen)