ACE Inhibitors Names of ACE Inhibitors: quinapril (Accupril ), enalapril (Vasotec ), ramipril (Altace ), captopril (Capoten ), fosinopril (Monopril ), benazepril (Lotensin ), lisinopril (Zestril, Prinivil ), moexipril (Univasc ), trandolapril (Mavik ) Angiotensin converting enzyme inhibitors or ACE inhibitors, dilate the arteries, making it easier for the heart to pump. ACE inhibitors are used by people who have high blood pressure, heart attack, congestive heart failure, and diabetes. They lower blood pressure, increase the blood flow from the heart called cardiac output, and protect the kidneys from leaking protein in diabetics. ACE inhibitors can cause a rise in blood potassium, an electrolyte, and also a measurement of kidney function called BUN and creatinine. Periodic blood tests are necessary to monitor the electrolytes and kidney function. The ACE inhibitors are usually well tolerated. The most common side effects include a dry, non-productive cough, which in some cases resolves with time. Weakness, dizziness, light-headedness, headache, nausea, vomiting, fatigue, sexual dysfunction, impairment of kidney function and abnormal liver tests, and a rise in potassium can sometimes occur. Allergic reactions include: swelling of the lips, tongue, face, throat, hives, and rash. If any allergic reactions occur, the medication should be stopped. Patients with poor liver functions should avoid some ACE inhibitors; consult your health care provider. Avoid ACE inhibitors in the 2 nd and 3 rd trimester of pregnancy. Nursing mothers should avoid taking most ACE inhibitors. When used with an ACE inhibitor, the following medications can cause a significant elevation of potassium in your body. Periodic blood tests are necessary to monitor your potassium level if you are taking: Angiotensin II receptor blockers (ARBs); triamterene (Dyazide, Maxzide ); spironolactone (Aldactone ); amiloride (Moduretic ) Direct renin inhibitor, aliskiren (Tekturna ) Aluminum- or magnesium- based antacids, such as Mylanta and Maalox, can decrease the absorption of ACE inhibitors. Take the ACE inhibitor either two hours before or two hours after taking the antacid. Other drug interactions: When an ACE inhibitor and lithium are taken together, it may cause increased levels of lithium in the blood. This may result in side effects from the lithium. Salt substitutes may cause unsafe levels of potassium in your blood. Please check with your health care provider before using salt substitutes. Ibuprofen (Advil, Nuprin ) and naproxen sodium (Aleve ) decrease the effectiveness of the ACE inhibitors and can cause a decrease in kidney function. Potassium supplements may significantly increase the blood potassium levels. Please take this times/day. Additional 4-I.A
Angiotensin Receptor Blockers (ARBs) Names of ARBs: candesartan (Atacand ), irbesartan (Avapro ), losartan (Cozaar ), valsartan (Diovan ), telmisartan (Micardis ), eprosartan mesylate (Teveten ), olmesartan (Benicar ) Angiotensin Receptor Blockers or ARBs, dilate the arteries making it easier for the heart to pump. ARBs are used in people with high blood pressure, heart attack, heart failure, and diabetes. They lower blood pressure, increase the blood flow from the heart called cardiac output, and protect the kidneys from leaking protein in diabetics. The ARBs are similar to ACE inhibitors in their effects and are often used when patients do not tolerate the ACE inhibitors. They may also be used in conjunction with an ACE inhibitor if needed. The ARBs can sometimes cause a rise in blood potassium, an electrolyte, and also a measurement of kidney function called BUN and creatinine. Because of this, periodic blood tests are necessary to monitor the electrolytes and kidney function. Speak with your health care provider before drinking alcohol as the alcohol can increase the blood pressure lowering effects of the ARBs. Some of the ARBs may cause problems if you become pregnant. Be sure to notify your health care providers if that happens. The ARBs are usually well tolerated. The most common side effects include elevated potassium levels, dizziness, headache, drowsiness, vomiting, diarrhea, sexual dysfunction, impairment of kidney function and abnormal liver tests, a dry, non-productive cough, although this occurs much less often than with the ACE inhibitors. Allergic reactions include: swelling of the lips, tongue, face, throat, hives, and rash. If any allergic reaction occurs, the medication should be stopped. The ARBs should not be used during pregnancy. The following medications when used in combination the ARBs can cause a significant elevation of potassium in your body. They should be used with caution. ACE inhibitors, spironolactone (Aldactone ), amiloride (Moduretic ), hydrodiuril, (Dyazide ) Salt substitutes may cause unsafe levels of potassium in your blood. Please check with your health care provider before using salt substitutes. Potassium supplements may cause excessive potassium levels in the blood. Direct renin inhibitor, aliskiren (Tekturna ) Other drug interactions: When an ARB and lithium are taken together, it may cause increased levels of lithium in the blood. This may result in side effects from the lithium. Ibuprofen (Advil, Nuprin, Motrin ) and naproxen sodium (Aleve) decrease the effectiveness of the ARB and can cause a decrease in kidney function. Rifampin decreases blood levels of Losartan (Cozaar). Fluconazole (Diflucan ) decreases the level of Losartan (Cozaar). Digoxin levels increase significantly when administered with Telmisartan (Micardis). Additional 4-I.B
Direct Renin Inhibitor Name of direct renin inhibitor: Aliskiren (Tekturna ) Works as a direct renin inhibitor in the kidney to lower blood pressure. This can be used alone or in combination with other medications to lower blood pressure. The direct renin inhibitors can cause a rise in blood potassium and also a measurement of kidney function called BUN and creatinine. Periodic blood tests are necessary to monitor these levels. The direct renin inhibitors are generally well tolerated. The most common side effects include mild diarrhea, mild abdominal pain, dizziness, and cough. As with any blood pressure lowering medication, if you feel lightheaded or dizzy, drink fluid and lie down and notify your health care provider. ALLERGIC reactions include: swelling of the lips, tongue, face, eyes, throat, hives, and rash. Geriatric (age 65 or older): diarrhea more common. Pregnant Women: This medication should not be taken if you are pregnant. Report to your health care provider as soon as possible if you become pregnant. When given with furosemide (Lasix ), the effect of furosemide was significantly reduced. When furosemide is taken with a direct renin inhibiotor, it may require a higher dose of furosemide. Discuss possible dose adjustment with your healthcare provider. Additional 4-I.C
Combination Therapy: ACE Inhibitor/Diuretic Names of combination medications: benazepril and HCTZ (Lotensin HCT ), captopril and HCTZ (Capozide ), enalapril and HCTZ (Vaseretic ), lisinopril and HCTZ (Prinzide, Zestoretic ), moexipril and HCTZ (uniretic ), quinapril and HCTZ (Accuretic ) The Angiotensin converting enzyme inhibitor, or ACE inhibitor, dilates the arteries, making it easier for the heart to pump. The hydrochlorothiazide decreases the amount of salt and water in the body by increasing urine output. Alone or in combination, these two medications help to reduce blood pressure. Tell your health care provider if you have any allergies before taking this medication, whether it is food, medications, or other sources. Patients with poor liver functions should avoid some ACE inhibitors; consult your provider. Do not take this medication if you are pregnant or considering becoming pregnant. Nursing mothers should avoid taking most ACE inhibitors. The combination of an ACE inhibitor and HCTZ are generally well tolerated. The most common side effects include: dry, non-productive cough, weakness, dizziness, light-headedness, headache, nausea, vomiting, fatigue, and sexual dysfunction. Allergic reactions include: swelling of the lips, tongue, face, throat, hives, and rash. If you experience any allergic reactions, the medication should be stopped. If you have difficulty breathing, report to the nearest emergency room immediately. The following medications when used with an ACE inhibitor and HCTZ may cause the following problems: Cholestyramine or colestipol- May prevent the diuretic (HCTZ) from working. The HCTZ should be taken 1 hour before or 4 hours after the cholestyramine or colestipol. When and ACE inhibitor/diuretic and lithium are taken together, it may cause increase levels of lithium in the blood. This may result in side effects from the lithium. Ibuprofen (Motrin, Advil, Nuprin ) and naproxen sodium (Aleve ) decrease the effectiveness of the ACE inhibitor and the diuretic and can cause a decrease in kidney function. Potassium supplements may significantly increase the blood potassium levels. Aluminum or magnesium based antacids (Mylanta and Maalox ) can decrease the absorption of ACE inhibitors. Take the ACE inhibitor either two hours before or two hours after taking the antacid. Salt substitutes may cause unsafe levels of potassium in your blood. Please check with your health care provider before using salt substitutes. Additional 4-I.D
Combination Therapy: ARB/Diuretic Names of ARB/Diuretic combinations: losartan and HCTZ (Hyzaar ), irbesartan and HCTZ (Avalide ), candesartan and HCTZ (Atacand HCT ), olmesartan and HCTZ (Benicar HCT ), valsartan and HCTZ (Diovan HCT ), telmisartan and HCTZ (Micardis HCT ), eprosartan mesylate and HCTZ (Teveten HCT ) Angiotensin II Receptor Blockers or ARBs, dilate the arteries making it easier for the heart to pump. When this medicine is combined with a thiazide diuretic, such as hydrocholorthiazide (HCTZ), it enhances blood pressure lowering. The ARB and HCTZ are usually well tolerated. The most common side effects include: dizziness, lightheadedness, headache, drowsiness, vomiting, diarrhea, sexual dysfunction, impairment of kidney function. A dry, non-productive cough is a rare side effect. Allergic reactions include: swelling of the lips, tongue, face, throat, hives, and rash. If any allergic reaction occurs, the medication should be stopped. The ARBs should NOT be used during pregnancy. The following medications when used in combination with the ARBs can cause a significant elevation of potassium in your body. Please discuss monitoring with your health care provider. ACE inhibitors Salt substitutes may cause unsafe levels of potassium in your blood. Please check with your health care provider before using salt substitutes. Potassium supplements may cause excessive potassium levels in the blood. Other drug interactions: When an ARB/diuretic and lithium are taken together, it may cause increased levels of lithium in the blood. This may result in side effects from the lithium. Ibuprofen (Advil, Nuprin, Motrin ) and naproxen sodium (Aleve ) decrease the effectiveness of the ACE inhibitors and can cause a decrease in kidney function. Rifampin decreases blood levels of losartan. Fluconazole (Diflucan ) decreases the level of losartan. If you have an allergy to sulfa, you may also be allergic to HCTZ. Talk with your health care provider. Please take this times/day. Additional 4-I.E
Beta Blockers Names of Beta Blockers: acebutolol (Sectral ), atenolol (Tenormin ), bextaxolol (Kerlone ), bisoprolol (Zebeta ), carteolol (Cartrol ), carvediolol (Coreg ), labetalol (Trandate, Normodyne ), metoprolol (Lopressor, Toprol XL ), nadolol (Corgard ), penbutolol (Levatol ), pindolol (Visken ), propranolol (Inderal ), sotalol (Betapace ), timolol (Blocadren ) Beta blockers are used after a heart attack and improve survival rates. They are also used to treat angina, heart failure, high blood pressure, rapid heart rates, abnormal heart beats, and hypertrophic cardiomyopathy, to reduce the risk of non-cardiac surgery, migraine headaches, and tremors. The beta blockers are generally well tolerated, but it may take a few weeks to adjust to them. The most common side effects include: drowsiness and fatigue, dizziness, weakness, sensitivity to cold, sexual dysfunction, slight increase in blood sugar, and bronchospasm. Avoid most beta blockers if you become pregnant; consult your health care provider. Do not take beta blockers if you are breastfeeding. Special Consideration: Do not stop taking the beta blocker suddenly as it can cause a rebound rapid heart rate and possible angina. Talk with your health care provider before stopping the beta blocker. Cimetidine (Tagamet ) increases the blood levels of beta blockers. Aluminum salt antacids (Basaljel, Amphojel, Donnagel, Kaodene, Riopan ) decrease the effectiveness of the beta blockers. Separate the doses of each medication by 2 hours. Diphenhydramine (Benadryl ) may increase blood levels of some beta blockers. Avoid using both together. Calcium Salts (Os-Cal 500, Citracal, Neo-Calglucon, calcium gluconate, calcium lactate, Posture ) decreased the absorption of atenolol. A higher dose of atenolol may be needed when these medications are given. Discuss other interactions with your health care provider and pharmacist. Your heart rate goal is. Additional 4-I.F
Calcium Channel Blockers Names of Calcium Channel Blockers: verapamil (Verelan, Covera-HS ), diltiazem (Cardizem, Tiazac ), nifedipine (Procardia, Adalat ), amlodipine (Norvasc ), felodipine (Plendil ), isradipine (DynaCirc ), nisoldipine (Sular ) The calcium channel blockers are used to treat angina, high blood pressure, supraventricular and ventricular arrhythmias (abnormal heartbeats), hypertrophic cardiomyopathy, following a heart attack, diabetic nephropathy, and intermittent claudication. The calcium channel blockers are typically well tolerated. Possible side effects include: lightheadedness, dizziness, headache, ankle swelling, constipation, abnormal slowing of the heart rate, and rare skin rash. Nifedipine or verapamil may worsen heart failure. Special Consideration: If you are taking calcium channel blockers for angina, do not stop suddenly as chest pain may worsen. Blood levels of lithium may rise or fall when given with calcium channel blockers. Levels of cyclosporine can increase when taken with some calcium channel blockers or cause increased blood levels of certain calcium channel blockers. Cimetidine (OTC Tagamet ) increases blood levels of nifedipine. Large quantities of grapefruit juice may increase blood levels of calcium channel blockers. Discuss other interactions with your health care provider and pharmacist. Additional 4-I.G
Loop Diuretics Names of Loop Diuretics: bumetanide (Bumex ), ethacrynic acid (Edecrin ), furosemide (Lasix ), torsemide (Demadex ) Diuretics stimulate the kidney to remove excess fluid from the body by producing more urine. They are used to treat heart failure, hypertension, swelling in the legs, abdomen, brain, kidney insufficiency, and other diseases. Loop diuretics- The loop diuretic is the strongest diuretic and is often used in heart failure and swelling in the extremities. The diuretics are generally well tolerated but when they are not, the side effects follow: May cause a decrease in blood potassium, sodium and chlorides, increased uric acid causing gout, fatigue, dizziness, headache, nausea, and impotence. They may also cause a mild increase in blood sugar and mild increase in cholesterol levels by 4 to 8 mg/dl. A mild increase in triglycerides may also occur. If you are allergic to sulfonamides (sulfur drugs), you may be sensitive to most of the diuretics. Talk to your health care provider. Ethacrynic acid (Edecrin) and spironolactone (Aldactone) are the only two diuretics that are nonsulfonamides. They may be used in the case of sulfa drug allergies. Non steroidal anti-inflammatories (Nuprin, Advil, ibuprofen, Motrin, naproxyn, Aleve, indomethacin) block the effect of all of the diuretics. Probenecid and lithium block the excretion of loop diuretics, resulting in a poor response to the diuretic. Phenytoin (Dilantin ) may reduce the diuretic effect of loop diuretics. Captopril decreases the potency effects of furosemide. Discuss other interactions with your health care provider and pharmacist. Additional 4-I.H
Potassium Sparing Diuretics Names of Potassium Sparing Diuretics: amiloride (Midamor, Moduretic ), triamterene (Dyrenium ), spironolactone (Aldactone ), eplerenone (Inspra ) Potassium sparing diuretics stimulate the kidney to remove excess fluid from the body by producing more urine. They are used to treat heart failure, hypertension, swelling in the legs, abdomen, brain, kidney insufficiency, and other diseases. Potassium Sparing diuretics- Less potent than the loop diuretics. This diuretic is used to reduce excess loss of potassium. The diuretics are generally well tolerated. Some uncommon side effects include: fatigue, dizziness, headache, nausea, and impotence. Potassium sparing diuretics: May cause high potassium levels especially in the presence of kidney disease, diabetes, in elderly patients, and also when given with an ACE inhibitor, ARB, or salt substitute. Non-steroidal anti-inflammatories (Nuprin, Advil, ibuprofen, Motrin, naproxyn, Aleve, indomethacin) block the effect of all of the diuretics. ACE inhibitors administered with potassium sparing diuretics may result in high potassium levels. Lithium levels may rise when given with potassium sparing diuretics. Discuss any further interactions with your health care provider and pharmacist. Additional 4-I.I
Thiazide Diuretics Names of Thiazide Diuretics: hydrochlorothiazide (HydroDiuril, Esidrix, Thiuretic ), hydroflumethiazide, chlorthalidone (Hygroton ), metolazone (Zaroxolyn ), bendroflumethiazide (Naturetin ), polythizaide (Renese ), benzthiazide (Aquatag, Exna ), chlorothiazide (Diuril ), trichlormethiazide (Metahydrin, Naqua ), indapamide (Lozol ) Diuretics stimulate the kidney to remove excess fluid from the body by producing more urine. They are used to treat heart failure, hypertension, swelling in the legs, abdomen, brain, kidney insufficiency, and other diseases. Thiazide diuretics are often used in combination with other blood pressure lowering medications to reduce blood pressure and in combination with a loop diuretic to treat heart failure. The diuretics are generally well tolerated but when they are not, the side effects follow: a decrease in blood potassium, sodium and chlorides, increase uric acid causing gout, fatigue, dizziness, headache, nausea, and impotence. They may also cause a mild increase in blood sugar and mild increase in cholesterol levels by 4 to 8 mg/dl. A mild increase in triglycerides may occur. If you are allergic to sulfonamides (sulfa drugs), you may be sensitive to most of the diuretics. Thiazides rarely cause the sulfur side effects. Talk to your health care provider. Ethacrynic acid (Edecrin ) and spironolactone (Aldactone ) are the only two diuretics that are nonsulfonamides (not a sulfa drug). They may be used in the case of sulfa allergies. Thiazide diuretics may also cause pancreatitis or jaundice. Non-steroidal anti-inflammatories (Nuprin, Advil, ibuprofen, Motrin, naproxyn, Aleve, indomethacin)- Block the effect of all of the diuretics. Probenecid and lithium Block the excretion of thiazides and loop diuretics, resulting in a poor response to the diuretic. There is an increased risk of lithium toxicity when taken with thiazide diuretics. Steroids may cause salt retention and block the effect of the thiazide diuretics. Some antibiotics may increase in the blood when taken with thiazide diuretics. Discuss any other side effects with your health care provider and pharmacist. Additional 4-I.J
Alpha Blockers Names of Alpha Blockers: prazosin (Minipress ), terazosin (Hytrin ), doxazosin (Cardura ), alfuzosin (Uroxatral ), tamsulosin (Flomax ) Alpha blockers dilate the blood vessels and allow blood to flow more easily. Terazosin (Hytrin), prazosin (Minipress), and doxazosin (Cardura) are used to treat high blood pressure and benign prostatic hyperplasia (BPH) (enlarged prostate gland). Prazosin has been used to treat nightmares. Alfuzosin (Uroxatral) and tamsulosin (Flomax) are used to treat BPH. The alpha blockers are generally used along with other blood pressure lowering medications. The first dose may cause a significant lowering of the blood pressure. It is recommended that these medications be taken at night prior to going to bed to prevent the risk of sudden drop in blood pressure. Should you feel lightheadedness and weakness upon standing, contact your health care professional. Avoid alcohol as that may cause an unusual drop in blood pressure. Alpha blockers are generally well tolerated. The most common side effects include: dizziness, lightheadedness, heart palpitations, headache, swollen feet, ankles, fainting, decreased libido, and impotence. Indocin and other non-steroidal anti-inflammatories (Advil, ibuprofen, Nupren, naprosyn, etc.) may block the blood pressure lowering effect of the alpha blockers. Drinking alcohol while taking alpha-blockers can cause very low blood pressure. Prazosin may decrease the blood pressure effectiveness of clonidine (Catapres ). Discuss any other interaction with your health care provider and pharmacist. Additional 4-I.K