Enzyme (ACE) inhibitor

Quinapril hydrochloride

Each 5mg tablet contains quinapril hydrochloride 5.416 mg (equivalent to 5 mg quinapril base) - Reddish brown oval tablets scored on both sides and '5' embossed on both sides. Each 10mg tablet contains quinapril hydrochloride 10.832 mg (equivalent to 10 mg quinapril base) - Reddish brown triangular tablets scored on both sides and '10' embossed on one side. Each 20mg tablet contains quinapril hydrochloride 21.664 mg (equivalent to 20 mg quinapril base) - Reddish brown round tablets scored on both sides and '20' embossed on one side. Each 40mg tablet contains quinapril hydrochloride 43.328 mg (equivalent to 40 mg quinapril base) - Reddish brown, oval, biconvex film-coated tablet with debossing '40' on one side and 'PD 535' on the other side.

Accupro Tablets 5mg, 10mg, 20mg & 40mg

Hypertension - For the treatment of all grades of essential hypertension. Accupro is effective as monotherapy or concomitantly with diuretics in patients with hypertension.

Congestive Heart Failure - For the treatment of congestive heart failure when given concomitantly with a diuretic and/or cardiac glycoside. Treatment of congestive heart failure with Accupro should always be initiated under close medical supervision.

Hypertension

Monotherapy: The recommended initial dosage is 10 mg once daily in uncomplicated hypertension. Depending upon clinical response, patient's dosage may be titrated (by doubling the dose allowing adequate time for dosage adjustment) to a maintenance dosage of 20 to 40 mg/day given as a single dose or divided into 2 doses. Long-term control is maintained in most patients with a single daily dosage regimen. Patients have been treated with dosages up to 80 mg/day. Take either with or without food. The dose should always be taken at about the same time of day to help increase compliance.

Concomitant Diuretics: In order to determine if excess hypotension will occur, an initial dosage of 2.5 mg of Accupro is recommended in patients who are being treated with a diuretic. After this the dosage of Accupro should be titrated (as described above) to the optimal response. (see section 4.5 Interaction with other medicaments and other forms of interaction).

Congestive Heart Failure

In order to closely monitor patients for symptomatic hypotension, a single 2.5 mg initial dosage is recommended. After this, patients should be titrated to an effective dose: (up to 40 mg/day) given in 1 or 2 doses with concomitant diuretic and/or cardiac glycoside therapy. Patients are usually maintained effectively on doses of 10-20 mg/day given with concomitant therapy. Take either with or without food. The dose should always be taken at about the same time of day to help increase compliance.

Severe Heart Failure

In the treatment of severe or unstable congestive heart failure, Accupro should always be initiated in hospital under close medical supervision.

Other patients who may also be considered to be at higher risk and should have treatment initiated in hospital include: patients who are on high dose loop diuretics (e.g.> 80 mg furosemide) or on multiple diuretic therapy, have hypovolaemia, hyponatraemia (serum sodium < 130 mgEq/l) or systolic blood pressure < 90 mm Hg, are on high dose vasodilator therapy, have a serum creatinine> 150 µmol/l or are aged 70 years or over.

There is limited clinical trial experience of the use of quinapril in hypertensive children aged 5 years and above. There are no data regarding children below 5 years of age. Therefore its use in children and adolescents is not recommended.

In elderly patients and in patients with a creatinine clearance of less than 40 ml/min, an initial dosage in essential hypertension of 2.5 mg is recommended followed by titration to the optimal response.

• Accupro is contraindicated in patients with hypersensitivity to any of the ingredients.
• Accupro is contraindicated throughout pregnancy.
• Accupro is contraindicated in nursing mothers.
• Accupro is contraindicated in patients with a history of angioedema related to previous treatment with ACE inhibitors.
• Accupro is contraindicated in patients with hereditary/idiopathic angioneurotic oedema.

Accupro should not be used in patients with aortic stenosis or outflow obstruction.

Patients haemodialysed using high-flux polyacrylonitrile ('AN69') membranes are highly likely to experience anaphylactoid reactions if they are treated with ACE inhibitors. This combination should therefore be avoided, either by use of alternative antihypertensive drugs or alternative membranes for haemodialysis. Similar reactions have been observed during low density lipoprotein apheresis with dextran-sulphate. This method should therefore not be used in patients treated with ACE inhibitors.

Anaphylactoid reactions: Patients receiving ACE inhibitors during desensitising treatment with hymenoptera venom have experienced life threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE inhibitor therapy prior to each desensitisation.

In patients with renal insufficiency, monitoring of renal function during therapy should be performed as deemed appropriate, although in the majority renal function will not alter or may improve.

As a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function may be anticipated in susceptible individuals. In patients with severe heart failure whose renal function may depend on the activity of the renin-angiotensin-aldosterone system, treatment with ACE inhibitors including quinapril, may be associated with oliguria and/or progressive azotemia and rarely acute renal failure and/or death.

The half-life of quinaprilat is prolonged as creatinine clearance falls. Patients with a creatinine clearance of <40 ml/min require a lower initial dosage of quinapril. These patients' dosage should be titrated upwards based upon therapeutic response, and renal function should be closely monitored although initial studies do not indicate that quinapril produces further deterioration in renal function.

In clinical studies in hypertensive patients with unilateral or bilateral renal artery stenosis, increases in blood urea nitrogen and serum creatinine have been observed in some patients following ACE inhibitor therapy. These increases were almost always reversible upon discontinuation of the ACE inhibitor and/or diuretic therapy. In such patients, renal function should be monitored during the first few weeks of therapy.

Some patients with hypertension or heart failure with no apparent pre-existing renal vascular disease have developed increases >1.25 times the upper limit of normal) in blood urea and serum creatinine, usually minor and transient, especially when quinapril has been given concomitantly with a diuretic and has been observed in 4% and 3% respectively of patients on monotherapy. This is more likely to occur in patients with pre-existing renal impairment. Dosage reduction and/or discontinuation of a diuretic and/or quinapril may be required.

Angioedema: Angioedema has been reported in patients treated with angiotensin-converting enzyme inhibitors. If laryngeal stridor or angioedema of the face, tongue, or glottis occur, treatment should be discontinued immediately, the patient treated appropriately in accordance with accepted medical care, and carefully observed until the swelling disappears. In instances where swelling is confined to the face and lips, the condition generally resolves without treatment; antihistamines may be useful in relieving symptoms. Angioedema associated with laryngeal involvement may be fatal. Where there is involvement of the tongue, glottis, or larynx likely to cause airway obstruction, appropriate therapy e.g., subcutaneous adrenaline solution 1:1000 (0.3 to 0.5 ml) should be promptly administered.

Black patients receiving ACE inhibitor therapy generally have a higher incidence of angioedema than non-black patients.

Intestinal angioedema: Intestinal angioedema has been reported in patients treated with ACE inhibitors. These patients presented with abdominal pain (with or without nausea or vomiting); in some cases there was no prior history of facial angioedema and C-1 esterase levels were normal. The angioedema was diagnosed by procedures including abdominal CT scan or ultrasound, or at surgery, and symptoms resolved after stopping the ACE inhibitor. Intestinal angioedema should be included in the differential diagnosis of patients on ACE inhibitors presenting with abdominal pain.

Hypotension: Symptomatic hypotension was rarely seen in hypertensive patients treated with Accupro but it is a possible consequence of ACE inhibition therapy particularly in salt/volume depleted patients such as those previously treated with diuretics, who have a dietary salt reduction, or who are on dialysis. If symptomatic hypotension occurs, the patient should be placed in the supine position and, if necessary, receive an intravenous infusion of normal saline. A transient hypotensive response is not a contraindication to further doses; however, lower doses of quinapril or any concomitant diuretic therapy should be considered if this event occurs.

Neutropenia/agranulocytosis: ACE inhibitors have been rarely associated with agranulocytosis and bone marrow depression in patients with uncomplicated hypertension but more frequently in patients with renal impairment, especially if they also have collagen vascular disease. As with other ACE inhibitors, monitoring of white blood cell counts in patients with collagen vascular disease and/or renal diseases should be considered.

Tetracycline and other drugs that interact with magnesium: Because of the presence of magnesium carbonate in the formulation, Accupro has been shown in healthy volunteers to reduce the absorption of tetracycline in concomitant administration by 28-37%. It is recommended that concomitant administration with tetracycline be avoided.

Concomitant diuretic therapy: Patients treated with diuretics may occasionally experience an excessive reduction of blood pressure after initiation of therapy with Accupro. This hypotensive effect may be effectively minimised by either discontinuing the diuretic or increasing the salt intake prior to the initial dose of Accupro. If discontinuation of the diuretic is not possible, medical supervision should be provided for up to two hours following administration of the initial dose.

Agents increasing serum potassium: Quinapril is an angiotensin-converting enzyme inhibitor capable of lowering aldosterone levels, which in turn can result in elevation in serum potassium. Concomitant treatments with potassium sparing diuretics, potassium supplements or potassium salts should be used with caution and with appropriate monitoring of serum potassium. As with other ACE inhibitors, patients on quinapril alone may have increased serum potassium levels. When administered concomitantly, quinapril may reduce the hypokalaemia induced by thiazide diuretics.

Surgery/anaesthesia: Although no data are available to indicate there is an interaction between Accupro and anaesthetic agents that produces hypotension, caution should be exercised when patients undergo major surgery or anaesthesia since angiotensin converting enzyme inhibitors have been shown to block angiotensin II formation secondary to compensatory renin release. This may lead to hypotension which can be corrected by volume expansion.

Lithium: Increased serum lithium levels and symptoms of lithium toxicity have been reported in patients receiving concomitant lithium and ACE inhibitor therapy due to the sodium-losing effect of these agents. These drugs should be co-administered with caution and frequent monitoring of serum lithium levels is recommended. If a diuretic is also used, it may increase the risk of lithium toxicity.

Non-steroidal anti-inflammatory drugs: In some patients, the administration of a non-steroidal anti-inflammatory agent may reduce the antihypertensive effect of ACE inhibitors. Furthermore, it has been described that NSAIDs and ACE inhibitors exert an additive effect on the increase in serum potassium, whereas renal function may decrease. These effects are in principle reversible and occur especially in patients with compromised renal function.

Allopurinol, cytostatic and immunosuppressive agents, systemic corticosteroids or procainamide: Concomitant administration with ACE inhibitors may lead to an increased risk for leucopenia.

Alcohol, barbiturates or narcotics: Potentiation of orthostatic hypotension may occur.

Other hypertensive drugs: There may be an additive effect or potentiation.

Antacids: May decrease the bioavailability of Accupro.

Antidiabetic drugs (oral hypoglycaemic agents and insulin): Dosage adjustments of the antidiabetic drug may be required.

The most frequent clinical adverse reactions in hypertension and congestive heart failure are headache, dizziness, rhinitis, coughing, upper respiratory tract infection, fatigue, nausea and vomiting. Other less frequent side effects are dyspepsia, myalgia, chest pain, abdominal pain, diarrhoea, back pain, sinusitis, insomnia, paraesthesia, nervousness, asthenia, pharyngitis, hypotension, palpitations, flatulence, depression, pruritus, rash, impotence, oedema, arthralgia, amblyopia.

Renal dysfunction, angioedema, hypotension, hyperkalaemia, neutropenia, agranulocytosis - see warnings and precautions.

The following side effects have been observed associated with ACE inhibitor therapy:

Cardiac Disorders: Tachycardia, myocardial infarction

Nervous System Disorders: Cerebral haemorrage, disorders of balance, syncope, taste disturbances, transient ischaemic attacks

Respiratory, Thoracic and Mediastinal Disorders: Bronchitis, bronchospasm, dyspnoea

In individual cases angioneurotic oedema involving the upper airways has caused fatal airway obstruction.

Gastrointestinal Disorders: Constipation, dry mouth, glossitis, ileus, intestinal angioedema. Pancreatitis has been reported rarely in patients treated with ACE inhibitors; in some cases this has proved fatal.

Hepatobiliary Disorders: Cholestatic icterus, hepatitis

Skin and Subcutaneous Tissue Disorders: Alopecia, erythema multiforme, epidermic necrolysis, psoriasis-like efflorescences, Steven Johnson syndrome, urticaria. May be accompanied by fever, eosinophilia and/or increased ANA-titers.

Psychiatric Disorders: Confusion

Eye Disorders: Blurred vision

Ear and Labyrinth Disorders: Tinnitus

Investigations: Increases in blood urea and plasma creatinine may occur. Decreases in haematocrit,

platelets and white cell count as well as elevation of liver enzymes and serum bilirubin. In patients

with a congential deficiency concerning G-6-PDH individual cases of haemolytic anaemia have

been reported.

Pfizer

(POM)

22 June 2009