Angioedema
In the treatment with ACE inhibitors, cases of angioedema of the face and neck have been described, including 0.1% of patients who received quinapril. When a laryngeal whistle or angioedema occurs, face, eyes, tongue, or vocal cords, difficulties in swallowing food or breathing, the drug should be immediately discarded.The patient should be given adequate treatment and observed until the symptoms of edema disappear. Anti-histamines can be used to reduce symptoms. Angioedema with involvement of the larynx can lead to death. If edema of the tongue, vocal cords or larynx threatens with the development of airway obstruction, adequate emergency therapy, including subcutaneous injection of an adrenaline solution 1: 1000 (0.3-0.5 ml), is necessary.
In the treatment of ACE inhibitors, cases of angioedema of the intestine are also described. Patients noted abdominal pain (with / without nausea and vomiting); in some cases without a previous angioedema and a normal activity of C1-esterase. The diagnosis was established using computed tomography of the abdominal region, ultrasound examination, or at the time of surgery. Symptoms disappeared after discontinuation of ACE inhibitors. Patients who suffered angioedema, not associated with the administration of ACE inhibitors. may have a risk of developing it when treated with drugs of this group.Patients simultaneously receiving therapy with enzyme inhibitors mTOR (eg, tessirolimus) and DPP-4 (eg, vildaglipt) may be at greater risk of developing angioedema.
Ethnic differences
ACE inhibitors more often cause angioedema in patients of the Negroid race than in Caucasoid. Just as with the use of other ACE inhibitors, quinapril may be less effective for reducing blood pressure in patients of the Negroid race.
Carrying out desensitizing therapy
Patients receiving ACE inhibitors during the desensitizing therapy with Hepaticoptera venom (wasps, bees) can develop persistent anaphylactoid reactions that threaten life. The temporary cessation of the ACE inhibitor regresses the symptoms, but they can appear again when the therapy with ACE inhibitors is resumed.
Hemodialysis
Anaphylactoid reactions can also develop with the use of ACE inhibitors in patients undergoing low-density lipoprotein apheresis using dextran sulfate or patients on hemodialysis using high-flow membranes, such as polyacrylonitrile.You must use an alternative lipid-lowering therapy or use other membranes for hemodialysis.
Arterial hypotension
Akkuzid® drug can cause transient hypotension, but no more frequently than in the monotherapy components that make up the drug. Symptomatic hypotension is rarely found in the treatment of quinapril in patients with uncomplicated hypertension, but may develop as a result of ACE inhibitor therapy in patients with reduced BCC, for example, after previous treatment with diuretics, with a diet restricted salt or during hemodialysis. In case of symptomatic arterial hypotension, the patient should take a position of "lying" to hold his legs raised intravenous infusion of 0.9% sodium chloride solution. Transient arterial hypotension is not contraindication to further use of the drug Akkudid®, however in such cases it is advisable to reduce its dose.
Chronic heart failure
In patients with chronic heart failure with the presence of renal failure.and / or chronic heart failure without the presence of renal failure therapy with an inhibitor APF about arterial hypertension can lead to excessive reduction in blood pressure, which can be accompanied by oliguria, azotemia and, in rare cases, acute renal failure and even death. The treatment of such patients with Acquidol® should be started under close medical supervision and supervision during the first 2 weeks of therapy and with an increase in the dose of the drug.
Agranulocytosis
In rare cases, therapy with ACE inhibitors may be accompanied by the development of agranulocytosis and suppression of bone marrow function in patients with uncomplicated arterial hypertension, but more often in patients with impaired renal function, especially with connective tissue diseases. In these cases, the number of leukocytes in the blood should be monitored. If any symptoms appear (eg, sore throat, fever), patients should immediately consult a doctor, as they may be a manifestation of neutropenia.
Systemic lupus erythematosus
Thiazide diuretics can sometimes cause an exacerbation of the systemic lupus erythematosus.
Kidney function
The drug Akkudid® is not recommended for patients with severe renal dysfunction (CC less than 30 ml / min. Thiazide diuretics contribute to the progression of azotemia and have a cumulative effect with prolonged use in such patients. Drugs of choice in this group of patients receiving hipapril therapy are looped diuretics. For this reason, a fixed combination of hydrochlorothiazide / quinapril should not be used in patients with severe renal failure (see "Contraindications").
T1/2 Hinaprilata increases with a decrease in CK. Patients with SC less than 60 ml / min, but more than 30 ml / min quinapril should be administered at a lower initial dose. In such patients, the dose of Acquidol® should be increased taking into account the clinical state of the patient, with regular monitoring of kidney function, although in clinical studies there was no further impairment of kidney function when treated with the drug Acquidade®.
In patients with hypertension without obvious signs of an initial impairment of kidney function with the use of quinapril, especially in combination with a diuretic,An increase in the concentration of urea nitrogen in the blood and creatinine in the serum, which is usually weakly expressed, is usually transient. Similar changes are most likely in patients with initial renal dysfunction. In such cases, you may need to reduce the dose of Acquidol®. In all patients with hypertension, renal function should be monitored. Do not use the drug Akkudyod ® as an initial therapy in patients with SC less than 60 ml / min.
The effect of the renin-angiotensin-aldosterone system (RAAS)
In some patients, suppression of RAAS activity can lead to impaired renal function. In patients with severe chronic heart failure, kidney function depends on the activity of RAAS, so treatment with ACE inhibitors, including quinapril, can lead to oliguria and / or progressive azotemia, and in rare cases, to acute renal failure and / or death.
Double blockade of RAAS activity The use of antagonists of angiothezin II receptors, ACE inhibitors or aliskiren can lead to a double blockade of the activity of RAAS.This effect may be manifested by a decrease in blood pressure. hyperkalemia and changes in renal function (including acute renal failure) compared with monotherapy. Blood pressure, renal function and electrolyte content in blood plasma should be closely monitored in patients taking Acquidol® and other drugs that affect RAAS. It should avoid simultaneous use of RAAS-active agents and quinapril. The use of this combination should be narrowed down to individual cases with careful monitoring of kidney function and potassium levels in the blood plasma.
Stenosis of the renal arteries
In clinical studies in patients with hypertension with bilateral stenosis of the renal arteries or stenosis of the artery of a single kidney, in the treatment of ACE inhibitors, in some cases an increase in the concentration of urea nitrogen and creatinine in the serum was observed. These changes are almost always reversible and passed after the withdrawal of the ACE inhibitor and / or diuretic. In such cases, during the first few weeks of treatment with the drug Akkudid®, monitoring of kidney function is necessary.
Impaired liver function
The drug Akkudid® should be used with caution in patients with impaired liver function or progressive liver disease, since even small disturbances of the water-electrolyte balance can cause the development of a "hepatic" coma.
Water-electrolyte balance
FROM To identify possible violations of the water-electrolyte balance, it is necessary to regularly monitor the content of electrolytes in the blood serum. In patients receiving monotherapy with hipapril, as with other ACE inhibitors, the potassium content may increase.
Potassium of blood serum
Hyperkalemia (≥ 5.8 mmol / l) was observed in about 2% of patients taking quinapril, but in most cases this deviation was a single one and occurred during further therapy. The risk factors for the development of hyperscalcemia are: renal dysfunction, diabetes mellitus and simultaneous administration of potassium-sparing diuretics, potassium preparations, salt substitutes containing potassium, or other drugs that affect the increase in potassium in the blood serum. Simultaneous intake of potassium-sparing diuretics with the drug Acquidade®, which includes a thiazide diuretic, is not recommended.Treatment with thiazide diuretics is accompanied by hypokalemia, hyponatremia and hypochloraemic alkalosis. These disorders are sometimes manifested by the following symptoms: dryness of the oral mucosa. thirst, weakness, lethargy, drowsiness, restlessness, muscle weakness, muscle pain or spasm, lowering blood pressure. oliguria, tachycardia, nausea, confusion, convulsions and vomiting.
Hypokalemia can also enhance the toxic effect of cardiac glycosides. The risk of hypokalemia increased with cirrhosis of the liver, forced diuresis, inadequate use of drugs that improve myocardial metabolism, concomitant therapy glucocorticosteroid or adrenocorticotropic hormone (ACTH), concomitant use with drugs that increase the risk of hypokalemia with thiazide diuretics. The majority of patients can be expected balancing of opposite effects of quinapril and hydrochlorothiazide with respect to the content of potassium in the blood serum. In some cases the effect of one component Akkuzid® preparation may predominate over the other.Prior to and during treatment with the drug Akkudid®, the electrolyte content should be periodically monitored in order to detect possible disturbances in the water-electrolyte balance. Chloride deficiency associated with thiazide diuretic therapy is usually mild and only in exceptional cases requires appropriate treatment (eg, in diseases liver and / or kidney).
Hyponatremia
In hot weather, patients with peripheral edema can develop hyponatremia. When hyponatremia, adequate substitution therapy.
Hypocalcemia
Thiazide diuretics reduce excretion calcium by the kidneys.
Parathyroid glands
In rare cases, who received long-term therapy with thiazide diuretics. changes in the parathyroid glands accompanied by hypercalcemia and hypophosphatemia. More serious complications Hyperparathyrosis (nephrolithiasis, resorption bone tissue and peptic ulcer) is not are described. Before research functions parathyroid glands of thiazide diuretics needed cancel.
Magnesium
Thiazide diuretics increase the excretion of magnesium by the kidneys and can cause hypomagnesemia.
Glucose
Thiazide diuretics increase serum cholesterol concentrations, triglycerides and uric acid. These the effects are usually minor, but the development of overt gout or diabetes can be provoked in patients with a predisposition to these diseases.
Diabetes
Hyperglycaemia induced high doses of thiazide diuretics (including hydrochlorothiazide in a dose ≥100 mg / day), may interfere with the control of the glucose concentration in the blood plasma. Reducing the potassium content in blood plasma leads to increased tolerance to glucose. It is necessary to monitor the concentration of glucose in the blood plasma, if necessary, prescribe potassium preparations, in order to maintain the potassium content in the blood plasma and adjust hypoglycemic therapy. Therapy with ACE inhibitors may be accompanied by the development of hypoglycemia in patients with diabetes mellitus receiving insulinic hypoglycemic agents for oral ingestion. In the treatment of patients with diabetes, more careful monitoring and correction of the dose of hypoglycemic agents may be required.
Cough
When treated with ACE inhibitors. including quinapril, noted the development of cough. In a typical case, it is unproductive, persistent and passes after discontinuation of therapy. When differential diagnosis of cough should take into account its possible relationship with the use of inhibitors APF.
Surgical intervention
In patients undergoing surgery or general anesthesia, ACE inhibitors should be used with caution, as they block the formation of angiotensin II caused by compensatory renin secretion. This can lead to arterial hypotension, which is eliminated by increasing the BCC. In the case of surgical intervention, the patient should notify the anesthetist, that he is taking an inhibitor APF.
BCC
Patients should be warned that insufficient fluid intake, increased sweating can lead to excessive blood pressure lowering due to a decrease in BCC. Other reasons for the reduction of BCC. such as vomiting or diarrhea, can also lead to a sharp drop in blood pressure.
Acute myopia and occlusive glaucoma
Hydrochlorothiazide (derivative sulfonamide) can lead to the development of acute transient myopia and acute closed-angle glaucoma.Symptoms include an acute attack of reduced visual function or eye pain and usually occurs within the first hours or weeks after initiation of therapy. Without appropriate treatment, an angle-closure glaucoma can lead to irreversible loss of vision. The main way to treat this condition is to cancel hydrochlorothiazide therapy as soon as possible. You may need prompt medical or surgical intervention if the intraocular pressure remains uncontrolled. Risk factors for the development of acute angle-closure glaucoma may include allergic reactions to sulfopamides and penicillin in the anamnesis.
Doping control results
Hydrochlorothiazide can give a positive result in doping control.