Amlodipine with Lisinopril
Amlodipine+Lisinopril is indicated in the treatment of mild to moderate hypertension. It is also indicated in hypertension not responding to monotherapy with ACE inhibitors or calcium antagonists. It may also be substituted for the titrated doses of the individual components.
Dosage and Administration
The usual initial dosage is one tablet (amlodpine 5mg+Lisinopril 5mg) daily. If blood pressure control is
inadequate after a week or two, the dose may be increased to two tablets daily.
Hypersensitivity to either component, history of angioedema related to previous treatment with an ACE inhibitor and in patients with hereditary or idiopathic angioedema
Warnings and Precautions
Elderly patients have decreased clearance of amlodipine with a resulting increase of AUC of approximately 40-60% and a lower initial dose may be required.
Pharmacokinetic studies indicate that maximum blood levels and area under plasma concentration curve (AUC) are doubled in elderly patients treated with lisinopril. Lisinopril is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection. Evaluation of patients with hypertension should always include assessment of renal function.
Aggravation of Angina
Congestive Heart Failure
Diuretics: Patients on diuretics may occasionally experience an excessive reduction of blood pressure after initiation of therapy with this combination. The possibility of hypotensive effects can be minimized by either discontinuing the combination or increasing the salt intake prior to initiation of treatment.
Agents Increasing Serum Potassium: Lisinopril attenuates potassium loss caused by thiazide-type diuretics. If concomitant use of these agents is indicated, they should be used with caution, and with frequent monitoring of serum potassium.
Lithium: Increased serum lithium levels and symptoms of lithium toxicity have been reported in patients receiving ACE inhibitors during therapy with lithium.
The combination and lithium should be co-administered with caution, and frequent monitoring of serum lithium levels is recommended.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): In some patients with compromised renal function who are being treated with NSAIDs, the coadministration of lisinopril may result in a further deterioration of renal function.
These effects are usually reversible. NSAIDs blunt the antihypertensive effect of ACE inhibitors, including lisinopril, and this should be given consideration in patients taking NSAIDs concomitantly with the combination. Indomethacin may reduce the antihypertensive efficacy of lisinopril.
The combination of amlodipine and lisinopril is well tolerated. Angioneurotic edema has been reported with ACE inhibitors. In such cases, the combination should be discontinued immediately. Other side effects include nausea, headache, dizziness, cough, diarrhea, fatigue, rash, edema, flushing, palpitations, and asthenia.
The most likely manifestation of overdosage of lisinopril would be hypotension, for which the usual treatment would be intravenous infusion of normal saline solution. Lisinopril can be removed by hemodialysis.
If massive overdose of amlodipine should occur, active cardiac and respiratory monitoring should be instituted. Frequent blood pressure measurements are essential. Should hypotension occur, cardiovascular support including elevation of the extremities and the judicious administration of fluids should be initiated. If hypotension remains unresponsive to these conservative measures, administration of vasopressors (such as phenylephrine) should be considered with attention to circulating volume and urine output. Intravenous calcium gluconate may help to reverse the effects of calcium entry blockade. As amlodipne is highly protein bound, hemodialysis is not likely to be of benefit.