A-Z Drug Facts > Lisinopril/Hydrochlorothiazide

Lisinopril / Hydrochlorothiazide

Pronunciation: (lye-SIN-oh-pril/HYE-droe-KLOR-oh-THYE-a-zide)
Class: Antihypertensive combination

Trade Names:
Prinzide 10/12.5 mg
- Tablets lisinopril 10 mg/hydrochlorothiazide 12.5 mg

Trade Names:
Prinzide 20/12.5 mg
- Tablets lisinopril 20 mg/hydrochlorothiazide 12.5 mg

Trade Names:
Prinzide 20/25 mg
- Tablets lisinopril 20 mg/hydrochlorothiazide 25 mg

Trade Names:
Zestoretic 10/12.5 mg
- Tablets lisinopril 10 mg/hydrochlorothiazide 12.5 mg

Trade Names:
Zestoretic 20/12.5 mg
- Tablets lisinopril 20 mg/hydrochlorothiazide 12.5 mg

Trade Names:
Zestoretic 20/25 mg
- Tablets lisinopril 20 mg/hydrochlorothiazide 25 mg

Pharmacology

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Lisinopril

Competitively inhibits angiotensin-converting enzyme (ACE), preventing the conversion of angiotensin I to angiotensin II, reversing the potassium loss associated with the diuretic.

Hydrochlorothiazide

Increases chloride, sodium, and water excretion by interfering with transport of sodium ions across renal tubular epithelium.

Indications and Usage

Treatment of hypertension.

Contraindications

History of angioedema related to previous treatment with an ACE inhibitor; hereditary or idiopathic angioedema; anuria; hypersensitivity to sulfonamide-derived drugs, hypersensitivity to any component of the product.

Dosage and Administration

Adults

PO Usual daily dose is lisinopril 10 to 80 mg/hydrochlorothiazide 6.25 to 50 mg. Max daily dose, lisinopril 80 mg/hydrochlorothiazide 50 mg. Allow 2 to 3 wk to elapse before adjusting the hydrochlorothiazide dose.

Conversion From Monotherapy With Lisinopril or Hydrochlorothiazide
Adults

PO Start with lisinopril 10 mg/hydrochlorothiazide 12.5 mg or lisinopril 20 mg/hydrochlorothiazide 12.5 mg, depending on current monotherapy dose. Titrate doses of either or both components depending on blood pressure response.

Replacement Therapy
Adults

PO The combination may be substituted for the titrated individual components.

Renal Function Impairment

Not recommended when CrCl is less than 30 mL/min.

General Advice

• Administer prescribed dose once daily in the morning, with or without food. Administer with food if GI upset occurs.

Storage/Stability

Store tablets at controlled room temperature (59° to 86°F). Keep container tightly closed. Protect from excessive light and moisture.

Drug Interactions

Hydrochlorothiazide Alcohol, barbiturates, narcotics

Increased risk of orthostatic hypotension.

Antidiabetic agents (oral agents and insulin)

Dosage adjustment of antidiabetic agent may be necessary.

Antihypertensive agents

Additive or potentiation of effects.

Cholestyramine, colestipol resins

Impaired absorption of hydrochlorothiazide.

Corticosteroids, ACTH

Increased electrolyte depletion, increasing the risk of hypokalemia.

Diazoxide

Hyperglycemia may occur.

Digoxin

May predispose to digitalis-induced arrhythmias.

Dofetilide

Hypokalemia may occur, increasing the risk of torsades de pointes.

Lithium

Renal Cl of lithium may be reduced, increasing the risk of lithium toxicity.

Nondepolarizing skeletal muscle relaxants (eg, tubocurarine)

Increased effect of the muscle relaxant.

NSAIDs

The diuretic, natriuretic, and antihypertensive effects of loop, potassium-sparing, and thiazide diuretics may be reduced.

Pressor amines (eg, norepinephrine)

Decreased responsiveness to the pressor amine.

Lisinopril Agents increasing serum potassium (eg, potassium-sparing diuretics [eg, spironolactone], potassium supplements, potassium-containing salt substitutes)

May lead to increases in serum potassium.

Digoxin

Plasma levels of digoxin may be increased or decreased.

Diuretic therapy

Excessive reduction in BP after starting lisinopril therapy.

Gold

Nitroid reactions (facial flushing, hypotension, nausea, vomiting) have occurred in patients receiving injectable gold (sodium aurothiomalate) therapy.

Lithium

Because of possible increased sodium elimination, the risk of lithium toxicity is increased.

NSAIDs

Worsening of renal function in patients with compromised renal function; antihypertensive effects of lisinopril may be diminished.

Salicylates

The hypotensive and vasodilator effects of lisinopril may be reduced.

Sulfonylureas

Risk of hypoglycemia may be increased.

Laboratory Test Interactions

Hydrochlorothiazide

May decrease serum protein-bound iodine levels without signs of thyroid disturbances. May cause diagnostic interference of serum electrolyte levels, blood and urine glucose levels, serum bilirubin levels, and serum uric acid levels.

Lisinopril

False elevation of liver enzymes, serum bilirubin, uric acid, or blood glucose may occur.

Adverse Reactions

Adverse reactions have been limited to those that have been previously reported with lisinopril or hydrochlorothiazide. The most frequently occurring adverse reactions reported with the combination include the following:

Cardiovascular

Orthostatic effects (3%); hypotension (1%).

CNS

Dizziness (8%); headache (5%); fatigue (4%); asthenia, paresthesia (2%).

Dermatologic

Rash (1%).

GI

Diarrhea (3%); nausea (2%); dyspepsia, vomiting (1%).

Genitourinary

Impotence (1%).

Respiratory

Cough (4%); upper respiratory infection (2%).

Miscellaneous

Muscle cramps (2%).

Precautions

Warnings When used in pregnancy during the second and third trimesters, ACE inhibitors can cause injury and even death to the developing fetus. When pregnancy is detected, discontinue therapy as soon as possible.

Monitor Periodically monitor electrolytes, including potassium, BUN, and serum creatinine, especially when therapy is initiated or dosage adjusted. Periodically monitor WBC in patients with collagen vascular disease and renal disease.

Pregnancy

Category D (second and third trimesters); Category C (first trimester).

Lactation

Undetermined.

Children

Safety and efficacy not established.

Hypersensitivity

Angioedema, including swelling of the face, extremities, lips, tongue, glottis, and/or larynx, has been reported rarely. Angioedema associated with laryngeal edema may be fatal; promptly discontinue drug.

Renal Function

Use with caution. Not recommended in severe renal impairment.

Hepatic Function

Use with caution. Minor alterations of fluid and electrolyte balance may precipitate hepatic coma.

Anaphylactoid reactions

ACE inhibitors affect the metabolism of eicosanoids and polypeptides, including endogenous bradykinin. Patients may be subject to a variety of adverse reactions, some of them serious.

Aortic stenosis/hypertrophic cardiomyopathy

Use with caution.

Cough

Persistent nonproductive cough has been reported; almost always resolves after discontinuation of therapy.

Fluid/Electrolyte imbalance

Observe all patients receiving thiazide therapy for clinical signs of fluid or electrolyte imbalance, mainly hyperkalemia and hypokalemia, hypercalcemia, hyponatremia, and hypomagnesemia.

Glucose tolerance

Dosage adjustment of insulin or oral hypoglycemic agents may be required. Hyperglycemia may occur with thiazide diuretics.

Head/Neck angioedema

Angioedema of the face, extremities, lips, tongue, glottis, and/or larynx has been reported rarely.

Hepatoxicity

Cholestatic jaundice, hepatitis, and fulminant hepatic necrosis, sometimes fatal, has been reported.

Hyperuricemia

Hyperuricemia may occur or frank gout may be precipitated in certain patients receiving thiazide therapy.

Hypotension

Excessive hypotension may occur, especially in severely salt- or volume-depleted patients or those with severe CHF.

Intestinal angioedema

Has been reported; patients may present with abdominal pain (with or without nausea or vomiting).

Lipids

Increases in cholesterol and triglyceride levels may be associated with thiazide diuretic therapy.

Neutropenia/Agranulocytosis

May occur more frequently in patients with renal function impairment, especially if they also have collagen vascular disease.

Renal effects

Increases in BUN and serum creatinine have occurred, especially in patients with preexisting renal vascular disease or renal artery stenosis. Usually reversible upon discontinuation.

Overdosage

Symptoms

Dehydration, electrolyte imbalance, hypotension.

Patient Information

• Advise female patients to avoid becoming pregnant while taking this medication.
• Advise patient to take prescribed dose once daily, without regard to meals, but to take with food if GI upset occurs.
• Advise patient to try to take each dose at about the same time each day.
• Inform patient that drug controls, but does not cure, hypertension and to continue taking drug as prescribed even when BP is not elevated.
• Instruct patient to continue taking other BP medications as prescribed by health care provider.
• Instruct patient in BP and pulse measurement skills.
• Advise patient to monitor and record BP and pulse at home and to inform health care provider if abnormal measurements are noted. Also advise patient to take record of BP and pulse to each follow-up visit.
• Caution patient to avoid sudden position changes to prevent orthostatic hypotension.
• Instruct patient to lie or sit down if experiencing dizziness or light-headedness when standing.
• Caution patient that inadequate fluid intake, excessive perspiration, diarrhea, or vomiting can lead to excessive fall in BP, resulting in light-headedness or fainting.
• Instruct diabetic patient to monitor blood glucose more frequently when drug is started or dose is changed and to inform health care provider of significant changes in readings.
• Caution patient to avoid unnecessary exposure to UV light (eg, sunlight, tanning booths), to use sunscreen, and to wear protective clothing when exposed to UV light to avoid photosensitivity reaction.
• Emphasize to hypertensive patient importance of other modalities on BP: weight control, regular exercise, smoking cessation, moderate intake of alcohol and salt.
• Instruct patient to stop taking drug and immediately report any of these symptoms to health care provider: fainting; swelling of the face, lips, eyelids, or tongue; difficulty breathing; any indication of infection (eg, sore throat, fever).
• Instruct patient to inform health care provider if a persistent cough develops while taking this medication.
• Caution patient not to take any prescription or OTC medications, potassium-containing salt substitutes, potassium supplements, herbal preparations, or dietary supplements unless advised by health care provider.

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