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Let’s recap on ACEIs for hypertension

Angiotensin-converting enzyme inhibitors are used to treat a range of conditions, including high blood pressure, heart failure, diabetic neuropathy and post myocardial infarction. The new medicine service in England can be offered to patients starting a medicine for hypertension but how can you tell that this is the indication when a patient hands you a prescription for an ACE inhibitor? Of course, the patient may be able to confirm this but, if he or she is unsure, other medicines prescribed can give you a few clues.

ACE inhibitors are currently a first-line choice for most hypertensive patients under 55 years old. For black African or Caribbean patients and patients aged over 55 an ACE inhibitor is likely to be added to existing treatment with either a calcium channel blocker or diuretic. In contrast, heart failure patients are also likely to be prescribed a beta-blocker, a diuretic and be on an increasing dose of the ACE inhibitor. And, after a heart attack, a patient’s medicines regimen is likely to include a statin, low dose aspirin (and/or clopidogrel) and a beta-blocker. However, it may still be necessary to check the indication with the prescriber

Explain why treatment is needed

The benefits of taking a medicine to reduce blood pressure may not be clear to many patients. Except in the most extreme circumstances high blood pressure has no obvious symptoms so explaining why treatment is needed and how it works can help patients decide to take their medicine.

Blood pressure treatments reduce the likelihood of having other serious vascular problems such as a stroke or heart attack. ACE inhibitors cause vasodilation, reducing peripheral vascular resistance and promoting blood flow. Regular blood pressure checks will be needed to establish whether or not the treatment is working effectively.

Causes of high blood pressure are often unclear, but all the usual healthy lifestyle messages (exercise, healthy diet and weight, not smoking, lowering salt intake and avoiding excess alcohol) apply. It is important to support these messages because people may be particularly motivated to make lifestyle changes if this might reduce the need for long-term medication.

Clear on what to do?

The recommended dosing schedules vary for different ACE inhibitors. For example, the manufacturers advise that perindopril is taken before food because food decreases conversion to its active metabolite perindoprilat, whereas most others are unaffected by food. However, patients need a regimen that suits them, which may require some compromise, such as taking the medicine at whatever time of day they find easiest to remember, but at the same time each day.

If one day’s dose is missed, they should not take a double dose to make up for the forgotten dose.

Side effects and interactions

Giving clear advice about side effects can seem a daunting task, but this information is a high priority for patients. Where do you start with the never ending list of side effects in medicine information leaflets and differing patient perceptions of severity? Knowledge of a few key side effects combined with unashamed referral to the manufacturers’ literature or BNF is one way forward.

Hypotension is a well recognised side effect when ACE inhibitors are started, particularly in patients also taking diuretics, so it is advisable for the first dose to be taken at bedtime. Getting out of bed in stages, standing up slowly and counting to 10 before starting to walk can all help avoid problems. Hypotension usually resolves within a couple of days and patients can continue treatment unless dizziness or faintness is severe.

The most common ACE inhibitor-associated side effect is cough, possibly affecting one in 10 people. This dry cough can appear at any time and seems to be more common in women, east Asians and, possibly, black people. If this side effect is troublesome, a treatment change is likely to be necessary (eg, to an angiotensin II receptor blocker).

Swelling (angioedema) of the face, lips, tongue or throat is an uncommon but serious side effect of ACE inhibitor therapy. It can occur at any time during treatment and requires urgent referral. Incidence is reportedly higher in black people.

Other side effects may need referral if they are serious or persistent; all serious side effects and minor side effects not listed in the product literature should be reported using a Yellow Card.

Non-steroidal anti-inflammatory drugs can reduce the antihypertensive effect of ACE inhibitors and increase the risk of renal problems, so patients should be advised to avoid over-the-counter ibuprofen, diclofenac, naproxen and aspirin.

There is a significantly increased risk of hyperkalaemia if ACE inhibitors are taken with potassium-sparing diuretics, potassium supplements, potassium-containing salt substitutes or ciclosporin.

ACE inhibitors can significantly increase serum lithium levels, causing toxicity, so if such a combination is warranted regular monitoring is needed.

Quick reference

The Panel suggests counselling points for handing out ramipril. This list can be used as a quick reference. It is not intended to be comprehensive but to cover some important issues.

 

Advice to patients

 

Ramipril (for hypertension)

  • Having high blood pressure increases your risk of having a heart attack or stroke. Ramipril acts to reduce blood pressure and so reduces this risk.
  • Occasionally, the first dose of ramipril can make you feel a bitdizzy or faint, but this usually only lasts a short time. Taking your first dose at bedtime should help prevent any problem.
  • Ramipril tablets (or capsules) work best if you take them regularly. Try to take them at the same time each day.
  • Like all medicines, ramipril can have some unwanted effects. These include skin rashes, upset stomach and headache. Tell your doctor if any unwanted effects are persistent or troublesome. A few people get apersistent dry cough, which may mean changing to another medicine.
  • Problems can occur if ramipril is taken with some other medicines, including medicines you can buy from many shops. Ask me or your doctor before you take anything else.

 

Citation: The Pharmaceutical Journal URI: 11093214

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