Lisinopril

lisinopril (lyse in' oh pril) Apo-Lisinopril (CAN), Prinivil, Zestril Pregnancy Category C (first trimester) Pregnancy Category D (second and third trimesters) Drug classes

Antihypertensive Angiotensin-converting enzyme (ACE) inhibitor Therapeutic actions

Renin, synthesized by the kidneys, is released into the circulation where it acts on a plasma precursor to produce angiotensin I, which is converted by angiotensin-converting enzyme to angiotensin II, a potent vasoconstrictor that also causes release of aldosterone from the adrenals. Lisinopril blocks the conversion of angiotensin I to angiotensin II, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss. Indications

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Treatment of hypertension alone or in combination with thiazide-type diuretics Adjunctive therapy in CHF for patients unresponsive to diuretics and digitalis alone Treatment of stable patients within 24 hr of acute MI to improve survival with beta blocker, aspirin, or thrombolytics

Contraindications and cautions

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Contraindicated with allergy to lisinopril or enalapril. Use cautiously with impaired renal function, CHF, salt or volume depletion, pregnancy, lactation.

Available forms

Tablets—2.5, 5, 10, 20, 40 mg Dosages ADULTS NOT TAKING DIURETICS

Initial dose, 10 mg/day PO. Adjust dosage based on response. Usual range is 20– 40 mg/day as a single dose. ADULTS TAKING DIURETICS

Discontinue diuretic for 2–3 days. If it is not possible to discontinue, give initial dose of 5 mg, and monitor for excessive hypotension. • CHF: 5 mg PO daily with diuretics and digitalis. Effective range: 5–20 mg/day. • Acute MI: Start within 24 hr of MI with 5 mg PO followed in 24 hr by 5 mg PO; 10 mg PO after 48 hr, then 10 mg PO daily for 6 wk. PEDIATRIC PATIENTS

Safety and efficacy not established.

GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT

Excretion is reduced in renal failure. Use smaller initial dose, and adjust upward to a maximum of 40 mg/day PO. Creatinine Clearance (mL/min) > 30 > 10–30 < 10

Initial Dose 10 mg/day 5 mg/day (2.5 mg for CHF) 2.5 mg/day

For patients on dialysis, give 2.5 mg on day of dialysis. Pharmacokinetics Route Oral

Onset 1 hr

Peak 7 hr

Duration 24 hr

Metabolism: Hepatic; T1/2: 12 hr Distribution: Crosses placenta; enters breast milk Excretion: Urine Adverse effects

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CNS: Headache, dizziness, insomnia, fatigue, paresthesias CV: Orthostatic hypotension, tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, severe hypotension in salt- or volume-depleted patients GI: Gastric irritation, nausea, diarrhea, peptic ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, frequency Hematologic: Neutropenia, agranulocytosis, thrombocytopenia, hemolytic anemia, pancytopenia Other: Angioedema (particularly of the face, extremities, lips, tongue, larynx); death has been reported with airway obstruction; cough, muscle cramps, impotence, rash, pruritis

Interactions

Drug-drug • Decreased antihypertensive effects if taken with indomethacin • Exacerbation of cough if combined with capsaicin Nursing considerations CLINICAL ALERT!

Name confusion has occurred between lisinopril and fosinopril; use caution. Assessment

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History: Allergy to lisinopril or enalapril, impaired renal function, CHF, salt or volume depletion, lactation, pregnancy Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function tests, CBC and differential

Interventions

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Begin drug within 24 hr of acute MI; ensure that patient is also receiving standard treatment (eg thrombolytics, aspirin, beta blockers). Keep epinephrine readily available in case of angioedema of the face or neck region; if breathing difficulty occurs, consult physician, and administer epinephrine. Alert surgeon, and mark patient's chart with notice that lisinopril is being taken. The angiotensin II formation subsequent to compensatory renin release during surgery will be blocked. Hypotension may be reversed with volume expansion. Monitor patients on diuretic therapy for excessive hypotension following the first few doses of lisinopril. Monitor patients closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive hypotension may occur. Arrange for reduced dosage in patients with impaired renal function.

Teaching points

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Take this drug once a day. It may be taken with meals. Do not stop taking without consulting your prescriber. Be careful in situations that may lead to a drop in BP—diarrhea, sweating, vomiting, dehydration. If light-headedness or dizziness occurs, consult your health care provider. These side effects may occur: GI upset, loss of appetite, change in taste perception (may be transient; take with meals); rash; fast heart rate; dizziness, lightheadedness (transient; change position slowly, and limit activities to those that do not require alertness and precision); headache, fatigue, sleeplessness. Report mouth sores; sore throat; fever; chills; swelling of the hands or feet; irregular heartbeat; chest pains; swelling of the face, eyes, lips, or tongue; and difficulty breathing.

Adverse effects in Italic are most common; those in Bold are life-threatening.