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Pronunciation |
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(ben
AY ze
pril) |
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U.S. Brand
Names |
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Lotensin® |
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Generic
Available |
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No |
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Synonyms |
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Benazepril Hydrochloride |
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Pharmacological Index |
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Angiotensin-Converting Enzyme (ACE) Inhibitors |
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Use |
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Treatment of hypertension, either alone or in combination with other
antihypertensive agents; treatment of left ventricular dysfunction after
myocardial infarction |
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Pregnancy Risk
Factor |
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C/D (2nd and 3rd trimesters) |
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Pregnancy/Breast-Feeding
Implications |
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It is not known whether benazepril is excreted in human milk
Breast-feeding/lactation: Crosses into breast milk. American Academy of
Pediatrics considers compatible with breast-feeding.
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Contraindications |
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Hypersensitivity to benazepril or any component; angioedema or serious
hypersensitivity related to previous treatment with an ACE inhibitor; bilateral
renal artery stenosis; primary hyperaldosteronism; patients with idiopathic or
hereditary angioedema; pregnancy (2nd and 3rd trimesters) |
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Warnings/Precautions |
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Anaphylactic reactions can occur. Angioedema can occur at any time during
treatment (especially following first dose). Careful blood pressure monitoring
with first dose (hypotension can occur especially in volume depleted patients).
Dosage adjustment needed in renal impairment. Use with caution in hypovolemia;
collagen vascular diseases; valvular stenosis (particularly aortic stenosis);
hyperkalemia; or before, during, or immediately after anesthesia. Avoid rapid
dosage escalation which may lead to renal insufficiency. Hypersensitivity
reactions may be seen during hemodialysis with high-flux dialysis membranes (eg,
AN69). Deterioration in renal function can occur with initiation. Use with
caution in unilateral renal artery stenosis and pre-existing renal
insufficiency. |
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Adverse
Reactions |
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1% to 10%:
Cardiovascular: Postural dizziness (1.5%)
Central nervous system: Headache (6.2%), dizziness (3.6%), fatigue (2.4%),
somnolence (1.6%)
Endocrine & metabolic: Hyperkalemia (1%), increased uric acid
Gastrointestinal: Nausea (1.3%)
Renal: Increased serum creatinine (2%), worsening of renal function may occur
in patients with bilateral renal artery stenosis or hypovolemia
Respiratory: Cough (1.2% to 10%)
<1% (Limited to important or life-threatening symptoms): Hypotension,
postural hypotension (0.3%), syncope, angina, palpitation, peripheral edema,
angioedema, laryngeal edema, shock, Stevens-Johnson syndrome, pemphigus,
hypersensitivity, dermatitis, rash, pruritus, photosensitivity, flushing,
pancreatitis, constipation, gastritis, vomiting, melena, thrombocytopenia,
hemolytic anemia, anxiety, decreased libido, hypertonia, insomnia, nervousness,
paresthesia, asthma, bronchitis, dyspnea, sinusitis, urinary tract infection,
arthritis, impotence, alopecia, arthralgia, myalgia, asthenia, sweating,
gynecomastia
Eosinophilic pneumonitis, neutropenia, anaphylaxis, renal insufficiency and
renal failure have been reported with other ACE inhibitors. In addition, a
syndrome including fever, myalgia, arthralgia, interstitial nephritis,
vasculitis, rash, eosinophilia, and elevated ESR has been reported to be
associated with ACE inhibitors. |
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Overdosage/Toxicology |
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Mild hypotension has been the only toxic effect seen with acute overdose.
Bradycardia may also occur; hyperkalemia occurs even with therapeutic doses,
especially in patients with renal insufficiency and those taking NSAIDs.
Following initiation of essential overdose management, toxic symptom
treatment and supportive treatment should be initiated. Hypotension usually
responds to I.V. fluids or Trendelenburg positioning. |
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Drug
Interactions |
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Alpha1 blockers: Hypotensive effect increased.
Aspirin and NSAIDs may decrease ACE inhibitor efficacy.
Diuretics: Hypovolemia due to diuretics may precipitate acute hypotensive
events or acute renal failure.
Insulin: Risk of hypoglycemia may be increased.
Lithium: Risk of lithium toxicity may be increased; monitor lithium levels.
Potassium-sparing diuretics or potassium supplements (amiloride, potassium,
spironolactone, triamterene): Increased risk of hyperkalemia.
Trimethoprim (high dose) may increase the risk of hyperkalemia.
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Mechanism of
Action |
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Competitive inhibition of angiotensin I being converted to angiotensin II, a
potent vasoconstrictor, through the angiotensin I-converting enzyme (ACE)
activity, with resultant lower levels of angiotensin II which causes an increase
in plasma renin activity and a reduction in aldosterone
secretion |
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Pharmacodynamics/Kinetics |
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Reduction in plasma angiotensin-converting enzyme activity: Oral:
Peak effect: 1-2 hours after administration of 2-20 mg dose
Duration of action: >90% inhibition for 24 hours has been observed after
5-20 mg dose
Reduction in blood pressure:
Peak effect after single oral dose: 2-6 hours
Maximum response With continuous therapy: 2 weeks
Absorption: Rapid (37% of each oral dose); food does not alter significantly;
metabolite (benazeprilat) itself unsuitable for oral administration due to poor
absorption
Distribution: Vd: ~8.7 L
Metabolism: Rapid and extensive in the liver to its active metabolite,
benazeprilat, via enzymatic hydrolysis; undergoes significant first-pass
metabolism and is completely eliminated from plasma in 4 hours
Half-life:
Parent drug: 0.6 hour
Metabolite elimination: 22 hours (from 24 hours after dosing onward)
Metabolite: 1.5-2 hours after fasting or 2-4 hours after a meal
Time to peak: 1-1.5 hours (unchanged parent drug)
Elimination: Nonrenal clearance (ie, biliary, metabolic) appears to
contribute to the elimination of benazeprilat (11% to 12%), particularly in
patients with severe renal impairment; hepatic clearance is the main elimination
route of unchanged benazepril
Dialysis: ~6% of metabolite was removed by 4 hours of dialysis following 10
mg of benazepril administered 2 hours prior to procedure; parent compound was
not found in the dialysate |
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Usual Dosage |
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Adults: Oral: Initial: 10 mg/day in patients not receiving a diuretic; 20-40
mg/day as a single dose or 2 divided doses; base dosage adjustments on peak (2-6
hours after dosing) and trough responses.
Hemodialysis: Moderately dialyzable (20% to 50%); administer dose
postdialysis or administer 25% to 35% supplemental dose.
Peritoneal dialysis: Supplemental dose is not necessary.
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Cardiovascular
Considerations |
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ACE inhibitors decrease morbidity and mortality in patients with asymptomatic
and symptomatic left ventricular dysfunction. In this situation, they decrease
hospitalizations for, and retard progression to, congestive heart failure. ACE
inhibitors are also indicated in patients postmyocardial infarction in whom left
ventricular ejection fraction is <40%. When used in patients with heart
failure, the target dose or maximum tolerated dose, should be achieved, if
possible. Lower daily doses of ACE inhibitors have not demonstrated the same
cardioprotective effects. ACE inhibitors have renal protective effects in
patients with proteinuria and possibly cardioprotective effects in high-risk
patients. |
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Mental Health: Effects
on Mental Status |
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May cause drowsiness |
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Mental Health:
Effects on Psychiatric
Treatment |
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May decrease lithium clearance resulting in an increase in serum lithium
levels and potential lithium toxicity; monitor serum lithium
levels |
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Dental Health: Local
Anesthetic/Vasoconstrictor
Precautions |
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No information available to require special precautions |
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Dental Health:
Effects on Dental Treatment |
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No effects or complications reported |
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Patient
Information |
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Take exactly as directed; do not discontinue without consulting prescriber.
Take first dose at bedtime. Take all doses on an empty stomach (30 minutes
before or 2 hours after meals). This drug does not eliminate need for diet or
exercise regimen as recommended by prescriber. May cause dizziness, fainting,
lightheadedness (use caution when driving or engaging in tasks that require
alertness until response to drug is known); postural hypotension (use caution
when rising from lying or sitting position or climbing stairs); nausea,
vomiting, abdominal pain, dry mouth, or transient loss of appetite (small
frequent meals, frequent mouth care, sucking lozenges, or chewing gum may help)
- report if these persist. Report mouth sores; fever or chills; swelling of
extremities, face, mouth, or tongue; difficulty in breathing or unusual cough;
or other persistent adverse reactions. Pregnancy precautions: Do not get
pregnant while taking this medication; use appropriate barrier contraceptive
measures. |
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Nursing
Implications |
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Watch for hypotensive effect within 1-3 hours of first dose or new higher
dose; discontinue therapy immediately if angioedema of the face, extremities,
lips, tongue, or glottis occurs |
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Dosage Forms |
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Tablet, as hydrochloride: 5 mg, 10 mg, 20 mg, 40 mg |
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References |
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Herings RM, deBoer A, Stricker BH, et al,
"Hypoglycaemia Associated With Use of Inhibitors of Angiotensin Converting Enzyme,"
Lancet, 1995, 345(8959):1195-8.
Konstam MA, Drakup K, Baker DW, et al,
"Heart Failure: Evaluation and Care of Patients With Left Ventricular Systolic Dysfunction,"
Clinical Practice Guideline No 11, Rockville, MD: Agency for Health Care
Policy and Research, Public Health Service, U.S. Department of Health and Human
Services, 1994.
McAreavey D and Robertson JIS,
"Angiotensin Converting Enzyme Inhibitors and Moderate Hypertension,"
Drugs, 1990, 40(3):326-45.
Waeber G, Fasanella d'Amore TF, Nussberger J, et al,
"Effect on Blood Pressure and the Renin-Angiotensin System of Repeated Doses of the Converting Enzyme Inhibitor CGS 14824 A,"
Eur J Clin Pharmacol, 1987, 31(6):643-6.
Williams JF, Bristow MR, Fowler MB, et al,
"Guidelines for the Evaluation and Management of Heart Failure: Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure),"
J Am Coll Cardiol, 1995, 26:1376-8.
Woo OF, "Captopril and Related Drugs," Poisoning and Drug Overdose,
2nd ed, Olson KR, ed, East Norwalk, CT: Appleton and Lange, 1994, 117-8.
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