Symptomatic arterial hypotension
Most often, a marked decrease in blood pressure occurs with a decrease in bcc caused by diuretic therapy, a decrease in the amount of salt in the diet, dialysis, diarrhea, or vomiting.
With cirrhosis of the liver accompanied by edema and ascites, arterial hypotension, CHF, there may be a significant activation of RAAS, especially with pronounced hypovolemia and a decrease in the electrolyte content in the blood plasma (against a background of a salt-free diet or a long-term intake of diuretics).
The use of an ACE inhibitor causes blockade of RAAS, in this regard, a sharp decrease in blood pressure and / or an increase in the concentration of creatinine in the blood plasma,indicating the development of acute renal failure, which is more often possible with the initial use of Zoniksem® ND or during the first two weeks of therapy.
Thus, in patients with a decrease in fluid volume against diuretic therapy, dialysis, diarrhea, and vomiting, treatment should be started under the strict supervision of a physician, with care to conduct a dose of the drug.
Renal impairment
Thiazide diuretics should not be used in patients with impaired renal function; they are ineffective with QC 30 ml / min or less (ie, with moderate or severe renal impairment).
The drug can not be used in patients with renal insufficiency (CC less than 80 ml / min) until the doses of each of the components individually corresponding to the doses in the combined preparation are selected.
If patients with hypertension without obvious signs of existing kidney diseases have an increase in the concentration of urea and creatinine in the blood serum on the background of the drug, further use should be stopped. Renewal of therapy is possible either by lower doses or by monotherapy of the active components of the drug.
In patients with bilateral stenosis of the renal arteries or stenosis of the artery of a single kidney taking ACE inhibitors, an increase in the concentration of urea and serum creatinine, usually reversible after the abolition of therapy, is possible.
Dysfunction of the liver
Thiazide diuretics must be used with caution in patients with impaired liver function or with progressive liver damage, since in such patients even minimal changes in electrolyte balance can trigger the development of the hepatic coma. The use of ACE inhibitors in patients with liver disease can lead to the development of fulminant liver necrosis.
Patients with diabetes mellitus and other endocrine pathologies
When the drug is administered to patients with diabetes mellitus receiving hypoglycemic agents for ingestion or insulin, during the first month of therapy it is necessary to regularly monitor the concentration of glucose in the blood. Thiazide diuretics can reduce the excretion of calcium by the kidneys and cause a temporary moderate increase in serum calcium. Expressed hypercalcemia may be a manifestation of undiagnosed hyperparathyroidism.Before the study of the function of parathyroid glands, thiazide diuretics should be discontinued.
Against the background of therapy with thiazide diuretics, the concentration of cholesterol and triglycerides can increase.
In some patients, therapy with thiazide diuretics can exacerbate hyperuricemia and / or aggravate the course of gout. But, lisinopril strengthens
excretion of uric acid by the kidneys, thereby counteracting the hyperuricemic effect of hydrochlorothiazide.
During the treatment period, regular monitoring of calcium, potassium, glucose, urea, lipids and creatinine in the blood plasma is necessary.
Hypersensitivity / angioedema (angioedema)
With the use of ACE inhibitors, including lisinopril, in rare cases development of angioedema, lip, tongue, pharynx and / or larynx can be observed. If these symptoms appear, the drug should be discontinued immediately, the patient should be observed until the signs of edema disappear completely.
If angioedema affects only the face and lips, then its manifestations usually go away alone or antihistamines may be used to treat its symptoms.Angioedema, accompanied by swelling of the tongue or larynx, can lead to airway obstruction and death.
When such symptoms occur, immediately enter subcutaneously epinephrine (adrenaline) (at 1: 1000 dilution (0.3 or 0.5 mL) and / or provide airway patency.
Patients with a history of Quincke edema who are not associated with the administration of ACE inhibitors may be at increased risk of developing it with the use of drugs of this group.
In rare cases, against the background of therapy with ACE inhibitors, angioedema develops in the intestine. In this case, patients have abdominal pain as an isolated symptom or in combination with nausea and vomiting, in some cases without a previous angioedema and at a normal level of C-1 - esterase. The diagnosis is established by means of computed tomography of the abdominal cavity, ultrasound examination or at the time of surgical intervention. Symptoms disappear after the cessation of the use of ACE inhibitors. In patients with abdominal pain receiving ACE inhibitors, the differential diagnosis should take into account the possibility of developing angioedema of the intestine.
Anaphylactoid reactions during desensitization procedures
There are separate reports on the development of long-term, life-threatening anaphylactoid reactions in patients receiving ACE inhibitors during desensitizing therapy with the poison of Hymenoptera insects (bees, wasps).
ACE inhibitors should be used with caution in patients prone to allergic reactions undergoing desensitization procedures. The appointment of an ACE inhibitor should be avoided for patients receiving immunotherapy with venom of Hymenoptera. Nevertheless, the development of anaphylactoid reactions can be avoided by the temporary withdrawal of the ACE inhibitor at least 24 hours before the desensitization procedure begins.
Anaphylactoid reactions during apheresis of low density lipoprotein (LDL)
In rare cases, patients receiving ACE inhibitors may develop life-threatening anaphylactoid reactions in LDL-apheresis using dextran sulfate. To prevent the anaphylactoid reaction, ACE inhibitor therapy should be discontinued before each procedure for LDL apheresis using high-flow membranes.
Hemodialysis
In patients receiving ACE inhibitors, hemodialysis using high-flow membranes (for example, AN69®) Anaphylactoid reactions were noted. Therefore, it is desirable to use a different type of membrane or to use an antihypertensive drug of another pharmacotherapeutic group.
Cough
Against the background of therapy with ACE inhibitors, a cough appears. By its nature, it is stubborn, unproductive, which passes after the drug is discontinued. Cough caused by ACE inhibitors should be considered in the differential diagnosis of cough.
Surgical procedures / General anesthesia
The use of ACE inhibitors in patients undergoing surgery with general anesthesia can lead to a marked decrease in blood pressure, especially with the use of general anesthetic agents with antihypertensive effects.
It is recommended to stop the use of ACE inhibitors, including lisinopril, 12 hours prior to surgery, alerting the surgeon / anesthesiologist about the use of ACE inhibitors.
Hyperkalemia
Perhaps the development of hyperkalemia.Risk factors for the development of hyperkalemia: renal failure, diabetes mellitus, the use of potassium drugs or drugs that cause an increase in the concentration of potassium in the blood (including heparin), especially in patients with impaired renal function.
In patients at risk of developing symptomatic arterial hypotension, loss of fluid and salts before the start of therapy should be compensated.
Elderly patients
Before starting the drug should be evaluated kidney function and the content of potassium in the blood plasma. The initial dose is selected depending on the degree of BP reduction, especially with a decrease in BCC and CHF (IV functional class by classification NYHA). Such measures allow to avoid a sharp decrease in blood pressure.