In case of hospitalization, tell your doctor that you are taking Diroton® Plus.
If you forget to take Diroton® Plus, wait and take the next dose at the usual time. Do not take two capsules to reimburse the missed dose. When using the drug Diroton® Plus, special instructions regarding individual components of the drug must be taken into account.
Indapamide-related
Impaired liver function
With the appointment of thiazide and thiazide-like diuretics, patients with impaired hepatic function may develop hepatic encephalopathy, especially if there is electrolyte imbalance. In this case, it is necessary to stop the use of diuretics.
Photosensitivity
With the use of thiazide and thiazide-like diuretics, cases of photosensitization have been noted (see "Side Effects" section). With the development of photosensitivity against the background of therapy, the withdrawal of these drugs is indicated. If necessary, continue treatment is recommended to protect the skin from sunlight or artificial UV radiation.
Water-electrolyte balance
The content of sodium in the blood plasma
The content of sodium in the blood plasma must be determined before the start of treatment. During the entire period of therapy, regular monitoring of this parameter is shown. All diuretics can cause hyponatremia, which can sometimes have very serious consequences. It is necessary to constantly monitor the sodium content in the blood plasma, since at the beginning of therapy such a decrease may not be accompanied by the appearance of pathological symptoms. Monitoring of sodium levels should be particularly careful in patients with cirrhosis and in elderly patients (see "Side Effects" and "Overdose" sections).
The content of potassium in blood plasma
Against the background of therapy with thiazide and thiazide-like diuretics, a sharp decrease in the potassium content in the blood plasma is possible, as well as the development of hypokalemia. It is necessary to minimize the risk of hypokalemia (<3.4 mmol / l) in the following patient groups: elderly patients, weakened patients, patients receiving combination therapy with other pro-grafts and drugs that can extend the interval QT, patients with cirrhosis of the liver, peripheral edema and ascites, coronary insufficiency,heart failure. In such patients, hypokalemia increases the toxic effects of cardiac glycosides and increases the risk of arrhythmias. In addition, patients with an elongated interval QT should be considered a high-risk group, regardless of whether they have the above conditions or the effects of medications. Hypokalemia, as well as bradycardia, is a condition that promotes the development of severe arrhythmias and, in particular, cardiac arrhythmias that can lead to death. Regular monitoring of the potassium content in blood plasma in these groups of patients, starting from the first week of treatment, is shown. When hypokalemia is detected, the appointment of appropriate therapy is indicated.
Calcium in the blood plasma
It has been reported that thiazide and thiazide-like diuretics reduce the excretion of calcium by the kidneys, which leads to an insignificant temporary increase in the calcium content in the blood plasma. Hypercalcemia with clinical manifestations may be the result of previously undiagnosed hyperparathyroidism. In this case, it is necessary to abolish diuretics before examining the function of parathyroid glands.
Blood plasma glucose
The control of glucose concentration in patients with diabetes mellitus is shown, especially in the presence of hypokalemia.
Uric acid
In patients with gout patients may increase the frequency of seizures or exacerbation of gout.
Diuretics and kidney function
Thiazide and thiazide-like diuretics are most effective in patients with normal or slightly decreased renal function (creatinine plasma in adults <25 mg / L or 220 μmol / L). The concentration of creatinine in the blood plasma in elderly patients is estimated depending on age, body weight and sex.
At the beginning of treatment, patients are observed to decrease the glomerular filtration rate due to hypovolemia, which may be associated with loss of water and sodium ions due to the action of diuretics. In this regard, an increase in the concentration of uric acid and creatinine in the blood plasma. In the absence of impaired renal function, such transient functional renal failure usually passes without complications, but the general condition of patients may worsen in the presence of kidney failure.
Athletes
As indapamide is included in the preparation of Diroton® Plus, a positive result of the doping test in athletes is possible.
Lactose
The drug contains lactose, so it should not be taken to patients with rare hereditary intolerance to galactose, lactase deficiency, or glucose-galactose malabsorption syndrome.
Associated with lisinopril
Symptomatic arterial hypotension
The most often significant reduction in blood pressure is associated with hypovolemia caused by the use of diuretics, a decrease in the amount of salt in the diet, dialysis, diarrhea, or vomiting (see "Interaction with Other Drugs", "Side Effects"). In patients with chronic heart failure, regardless of whether it is associated with renal insufficiency, it is possible to develop arterial hypotension. It was found that in patients with severe heart failure such a condition occurs more often due to the appointment of high doses of diuretics, hyponatremia or impaired renal function. Such patients require careful medical supervision (a careful selection of doses of lisinopril and diuretics is indicated).The same guidelines apply to patients with ischemic heart disease and cerebrovascular insufficiency, in whom a sharp decrease in blood pressure can lead to myocardial infarction or stroke.
With a significant reduction in blood pressure, the patient should take a horizontal position; possibly intravenous administration of 0.9% sodium chloride solution. Transient hypotensive reactions are not a contraindication to the use of the next dose of lisinopril.
In patients with chronic heart failure with normal or reduced BP, the use of lisinopril may lead to a reduction in blood pressure; this usually does not serve as a basis for drug discontinuation. If arterial hypotension is accompanied by clinical manifestations, consideration should be given to reducing the dose or eliminating lisinopril.
In patients with a risk of developing symptomatic arterial hypotension (with a low-salt or salt-free diet), regardless of the presence of hyponatremia, as well as in patients receiving high-dose diuretics, it is necessary to compensate for these conditions (hypovolemia or lack of sodium) before treatment.
The control of the effect of the initial dose of lisinopril on blood pressure is shown.
Acute myocardial infarction
Recommended standard treatment (thrombolytics, acetylsalicylic acid, beta-blockers).
Lizinopril can be used in combination with intravenous nitroglycerin or transdermal nitroglycerin.
In patients with acute myocardial infarction and the risk of further deterioration of hemodynamics, worsening of symptoms after the appointment of vasodilators, therapy with lisinopril should not begin. Such patients include patients with systolic blood pressure ≤100 mm Hg. Art. and patients with cardiogenic shock. In patients with systolic blood pressure ≤120 mm Hg. Art. During the first three days after myocardial infarction, a dose reduction was shown. In patients with systolic blood pressure ≤ 100 mm Hg. Art. the maintenance dose should be reduced to 5 mg (or temporarily to 2.5 mg). In patients with persistent arterial hypotension (systolic BP <90 mm Hg for 1 hour or more), the withdrawal of lisinopril is indicated.
Impaired renal function
In patients with chronic heart failure, a significant reduction in blood pressure on the background of the appointment of ACE inhibitors can lead to an aggravation of renal dysfunction. Cases of acute renal failure have been reported.
In patients with bilateral stenosis of the renal arteries or stenosis of the renal artery of a single kidney, an increase in the concentration of urea and serum creatinine was noted in patients with ACE inhibitors; usually such violations were temporary and discontinued after the abolition of therapy. They were more common in patients with renal insufficiency.
Patients with acute myocardial infarction and severe renal dysfunction (serum creatinine> 177 μmol / l and / or proteinuria> 500 mg / day) lisinopril is contraindicated. With the development of renal dysfunction during treatment (serum creatinine> 265 μmol / L or doubling as compared to the baseline), the withdrawal of lisinopril is indicated.
Allergic reactions, edema Quincke
In rare cases, against the background of the use of ACE inhibitors, including lisinopril, reported on the development of angioedema, edema, lips, tongue, epiglottis and / or larynx. In such cases, immediate withdrawal of lisinopril is required; the control of a condition of patients before the full permission of a symptomatology is shown.Usually angioedema and edema of the face and lips is temporary and does not require treatment; nevertheless, prescription of antihistamines is possible.
Angioedema may be the cause of death. Swelling of the tongue, epiglottis or larynx can lead to secondary airway obstruction. In this case, you must immediately enter 0.3-0.5 ml of a 1: 1000 solution of epinephrine subcutaneously, as well as provide airway patency. It was reported that Quincke's edema appeared more frequently in patients with ACE inhibitors of the Negroid race than in patients of other ethnic groups.
In patients with a history of Quinnke edema not associated with the administration of ACE inhibitors, the risk of angioedema development with ACE inhibitors is higher (see "Contraindications").
Anaphylactic reactions associated with desensitization of the venom of Hymenoptera insects
In very rare cases, in patients taking ACE inhibitors during the desensitization of the venom of Hymenoptera insects, the development of life-threatening anaphylactic reactions is possible, therefore it is necessary to temporarily abolish ACE inhibitors before desensitization.
Patients on hemodialysis
Anaphylactic reactions also occurred in patients who underwent hemodialysis using dialysis membranes with high permeability (for example, AN69) with the concomitant use of ACE inhibitors. Such patients show the use of other dialysis membranes or other antihypertensive drugs.
Cough
Therapy with ACE inhibitors can cause a cough, which should be considered when conducting differential diagnosis. A prolonged dry cough usually stops after the withdrawal of ACE inhibitors.
Surgical interventions / general anesthesia
The use of antihypertensive drugs with voluminous surgery or during general anesthesia can lead to inhibition of the formation of angiotensin II due to compensatory renin secretion. A significant reduction in blood pressure associated with this effect can be prevented by an increase in the volume of circulating blood.
Patients taking ACE inhibitors should inform the surgeon / anaesthesiologist before the surgery (including dental procedures).
Blood plasma potassium
There have been reports of hyperkalemia.
The risk factors for hyperkalemia include renal failure, diabetes, potassium-sparing diuretics (spironolactone, triamterene and amiloride), the use of potassium and salt substitutes based on potassium, especially in patients with impaired renal function.
If the combined use of lisinopril and these drugs is necessary, regular monitoring of the potassium content in the blood plasma is indicated.
Double blockade of RAAS
It is proved that simultaneous administration of ACE inhibitors. blockers of angiotensin II receptors or aliskiren increases the risk of arterial hypotension, hyperkalemia and renal dysfunction (including acute renal failure). Thus, it is not recommended to prescribe ACE inhibitors, angiotensin II receptor blockers or aliskiren for a double blockade of the RAAS.
If there are absolute indications for a double blockade of RAAS, then it should be performed under the close supervision of a specialist with frequent monitoring of blood pressure, kidney function and electrolyte content.
ACE inhibitors and angiotensin receptor blockers II should not be used simultaneously in patients with diabetic nephropathy.