Care should be taken in patients with reduced BCC (including, when used simultaneously with diuretics, in conditions of restriction of consumption of table salt, in hemodialysis, diarrhea, vomiting) in which a sudden and pronounced decrease in blood pressure may develop in response to the use of an ACE inhibitor. In patients with chronic heart failure of mild degree, with or without chronic renal insufficiency, symptomatic arterial hypotension is usually not observed. The development of arterial hypotension is most likely in patients with a more severe degree of chronic heart failure due to the use of high doses of diuretics, hyponatremia or functional renal failure. In these patients, treatment should be initiated under the supervision of a physician, up to the optimum dose adjustment of Berlipril® 10 and / or diuretic. Similar tactics can be applied to patients with ischemic heart disease and cerebrovascular diseases, in which excessive drop in blood pressure can lead to myocardial infarction or stroke.In the case of development of severe arterial hypotension, the patient should be placed in a horizontal position and, if necessary, intravenous infusion of physiological solution should be started. Transient arterial hypotension is not a contraindication for the continuation of enalapril treatment after BP stabilization. In the case of a re-expressed decrease in blood pressure should reduce the dose or cancel the drug. Before and during the treatment with ACE inhibitors, a dynamic control of blood pressure, certain biochemical and electrolyte blood indices (hemoglobin concentration, potassium ions, sodium ions, creatinine, urea, "liver" enzymes in blood serum) and urine for the presence of protein is necessary.
Like all vasodilators, ACE inhibitors should be administered with caution to patients with left ventricular hypertrophy and valvular obstruction and to refrain from their use in cases of cardiogenic shock and hemodynamically significant obstruction.
In cases of impaired renal function (creatinine clearance <80 ml / min), careful monitoring of serum potassium and serum creatinine concentration is necessary.In patients with renal insufficiency, it may be necessary to reduce the dose and / or frequency of the drug. In some patients with bilateral stenosis of the renal arteries or stenosis of the artery of a single kidney, there was an increase in the concentration of urea and creatinine in the serum. Changes were usually reversible and returned to normal after discontinuation of treatment.
In some patients who did not have renal disease before treatment, there was a slight and transient increase in serum urea and creatinine levels when enalapril was used concomitantly with diuretics. In such cases, a reduction in the dose and / or cancellation of enalapril and / or a diuretic may be required.
There is an increased risk of developing arterial hypotension and renal failure in patients with bilateral renal artery stenosis or stenosis of the artery of a single kidney that are on therapy with ACE inhibitors. Only modest changes in the serum creatinine concentration can indicate a decrease in renal function. In these patients, treatment should begin with small doses under close medical supervision,exact gradual selection of an individual dose and control of serum creatinine concentration.
The experience of using Berlipril® 10 in patients who have recently undergone kidney transplantation is absent. Therefore, the treatment of such patients with this drug is not recommended.
The use of Berlipril® 10 in patients with hepatic insufficiency usually does not require dose adjustment. Rarely, the administration of ACE inhibitors is associated with a syndrome that begins with the development of cholestatic jaundice until the development of fulminant liver necrosis. When symptoms of jaundice appear or the activity of liver enzymes increases in patients taking ACE inhibitors, discontinue drug therapy and conduct an appropriate examination.
There are reports of the development of life-threatening anaphylactic reactions in patients receiving ACE inhibitors during desensitisation with Hepaticoptera (Heminoptera) venom. Such reactions can be avoided, if before the beginning of desensitization temporarily stop the intake of an ACE inhibitor. The use of ACE inhibitors in patients receiving immunotherapy with bee venom should be avoided.Neutropenia, agranulocytosis, thrombocytopenia, anemia can develop on the background of therapy with ACE inhibitors. With normal kidney function and no other complications, neutropenia occurs rarely.
ACE inhibitors are prescribed only in emergency cases if the patient has systemic connective tissue diseases, during immunosuppressive therapy, in cases of simultaneous use of allopurinol or procainamide, as well as a combination of all these factors, especially against the background of existing renal failure. Some of these patients developed severe infections, which in some cases did not respond to intensive antibiotic therapy. If enalapril it is still used in such patients, periodic monitoring of the number of white blood cells in the blood formula is recommended, and patients should be instructed accordingly to immediately inform the doctor of any signs of infection.
It is reported the occurrence of cough in the treatment of ACE inhibitors. Usually the cough is of an unproductive and persistent nature and stops after the drug is discontinued.Cough due to treatment with ACE inhibitors should be taken into account in the differential diagnosis of cough.
The reports of angioneurotic edema (edema of Quincke) of the face, limbs, lips, tongue, glottis and / or larynx have been reported in patients receiving ACE inhibitors, including Berlipril® 10, at different periods of treatment. In such cases, treatment with Berlipril® 10 should be discontinued immediately, proper medical supervision should be performed until the symptoms disappear completely. Even in those cases where there is only difficulty swallowing without difficulty breathing, patients should be under medical supervision for a long time, since therapy with antihistamines and corticosteroids may not be sufficient. Angioedema of the larynx or tongue can be fatal. Swelling of the tongue, glottis or larynx can lead to airway obstruction, appropriate therapy involving subcutaneous administration of 0.1% adrenaline solution (0.3-0.5 ml) and / or measures to ensure airway conduction should be performed in the shortest possible time.
In patients of the Negroid race, the frequency of angioedema development with ACE inhibitors is higher than in representatives of other races. Like other ACE inhibitors, enalapril, appears to be less effective in lowering blood pressure in patients of the Negroid race than in others, perhaps because of the high prevalence of low renin levels in this population of patients with hypertension.
During the period of treatment it is not recommended to drink alcoholic beverages. alcohol increases the hypotensive effect of the drug.
In patients undergoing surgery or general anesthesia with the use of drugs that reduce blood pressure, enalapril can block the formation of angiotensin II under the influence of compensatory release of renin. If it is assumed that arterial hypotension develops by this mechanism, it can be corrected by an increase in BCC. Before surgery (including dental procedures), the surgeon / anesthesiologist should be warned about the use of Berlipril® 10.
In rare cases, patients taking ACE inhibitors during apheresis of low-density lipoproteins (LDL) with dextran sulfate, life-threatening anaphylactoid reactions were observed. If applicable LDLapheresis, ACE inhibitors should be temporarily replaced with drugs to treat hypertension or heart failure from other groups.
In patients on dialysis using high-capacity membranes (for example, AN69 ) on the background of the use of ACE inhibitors, anaphylactoid reactions were observed. Therefore, for such patients it is recommended either the use of dialysis membranes of a different type, or the use of antihypertensive drugs of another group.
In patients with diabetes mellitus, who take hypoglycemic agents for ingestion or insulin, it is necessary to carefully monitor the concentration of blood glucose during the first month of enalapril treatment.
In some patients taking ACE inhibitors, incl. enalapril, an increase in the concentration of potassium ions in serum is observed. The risk group for hyperkalemia includes patients suffering from renal insufficiency or diabetes mellitus, taking potassium-sparing diuretics or potassium-containing salt substitutes, and other drugs that increase the concentration of potassium ions in the blood serum (eg, heparin).If the use of the above medicines against the background of treatment with Berlipril® 10 is necessary, regular monitoring of the concentration of potassium ions in serum is recommended. Like other ACE inhibitors, enalapril may be less effective in lowering blood pressure in representatives of the Negroid race than in people of other races, possibly because of the low level of renin in patients with hypertension in this population. The sudden cessation of enalapril treatment does not lead to the development of the "withdrawal" syndrome (a sharp rise in blood pressure).