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Moexipril Hydrochloride

Class: Angiotensin-Converting Enzyme Inhibitors
VA Class: CV800
Chemical Name: (3S-(2(R*(R*)),3R*))-2-(2-((1 -(Ethoxycarbonyl)-3-phenylpropyl)amino)-1-oxopropyl)-1,2,3,4-tetrahydro-6,7-dimethoxy-3-isoquinolinecarboxylic acid monohydrochloride
Molecular Formula: C27H34N2O7•ClH
CAS Number: 82586-52-5

Medically reviewed on Mar 19, 2018

Warning

  • May cause fetal and neonatal morbidity and mortality if used during pregnancy.1 83 110 111 (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

  • If pregnancy is detected, discontinue as soon as possible.1 111

Introduction

Nonsulfhydryl ACE inhibitor.1

Uses for Moexipril Hydrochloride

Hypertension

Management of hypertension (alone or in combination with other classes of antihypertensive agents).1 2 5 25 83 500

ACE inhibitors are recommended as one of several preferred drugs for the initial management of hypertension; other options include angiotensin II receptor antagonists, calcium-channel blockers, and thiazide diuretics.501 502 503 504 While there may be individual differences with respect to specific outcomes, these antihypertensive drug classes all produce comparable effects on overall mortality and cardiovascular, cerebrovascular, and renal outcomes.500 501 502 504 Individualize choice of therapy; consider patient characteristics (e.g., age, ethnicity/race, comorbidities, cardiovascular risk) as well as drug-related factors (e.g., ease of administration, availability, adverse effects, cost).500 501 502 503 504 515

ACE inhibitors may be preferred in hypertensive patients with heart failure, ischemic heart disease, diabetes mellitus, chronic kidney disease, or cerebrovascular disease or post-MI.500 501 502 504 520 523 524 525 526 527 534 535 536 543

Black hypertensive patients generally tend to respond better to monotherapy with calcium-channel blockers or thiazide diuretics than to ACE inhibitors.25 83 92 93 108 109 500 501 504 However, diminished response to an ACE inhibitor is largely eliminated when administered concomitantly with a calcium-channel blocker or thiazide diuretic.25 83 500 504

The optimum BP threshold for initiating antihypertensive drug therapy is controversial.501 504 505 506 507 508 515 523 530 Further study needed to determine optimum BP thresholds/goals; individualize treatment decisions.501 503 507 515 526 530

JNC 7 recommends initiation of drug therapy in all patients with uncomplicated hypertension and BP ≥140/90 mm Hg;500 JNC 8 panel recommends SBP threshold of 150 mm Hg for patients ≥60 years of age.501 Although many experts agree that SBP goal of <150 mm Hg may be appropriate for patients ≥80 years of age,502 504 505 530 application of this goal to those ≥60 years of age is controversial, especially for those at higher cardiovascular risk.501 502 505 506 508 511 515

In the past, initial antihypertensive drug therapy was recommended for patients with diabetes mellitus or chronic kidney disease who had BP ≥130/80 mm Hg;500 503 current hypertension management guidelines generally recommend a BP threshold of 140/90 mm Hg for these individuals (same as for the general population of patients without these conditions), although a goal of <130/80 mm Hg may still be considered.501 502 503 504 520 530 535 536 541

Heart Failure

Management of heart failure, usually in conjunction with other agents such as cardiac glycosides, diuretics, and β-adrenergic blocking agents (β-blockers).10 11 12 14 96 524 800

Some evidence indicates that therapy with an ACE inhibitor (enalapril) may be less effective than angiotensin receptor-neprilysin inhibitor (ARNI) therapy (e.g., sacubitril/valsartan) in reducing cardiovascular death and heart failure-related hospitalization.702 800

ACCF, AHA, and the Heart Failure Society of America (HFSA) recommend that patients with chronic symptomatic heart failure and reduced left ventricular ejection fraction (LVEF) (NYHA class II or III) who are able to tolerate an ACE inhibitor or angiotensin II receptor antagonist be switched to therapy containing an ARNI to further reduce morbidity and mortality.800

Diabetic Nephropathy

A recommended agent in the management of patients with diabetes mellitus and persistent albuminuria who have modestly elevated (30–300 mg/24 hours) or higher (>300 mg/24 hours) levels of urinary albumin excretion; slows rate of progression of renal disease in such patients.103 104 105 106 107 520 535 536

Moexipril Hydrochloride Dosage and Administration

General

BP Monitoring and Treatment Goals

  • Carefully monitor BP during initial titration or subsequent upward adjustment in dosage.500 501

  • When available, use evidence-based dosing information (i.e., dosages shown in randomized controlled trials to reduce complications of hypertension) to determine target dosages; target dosages usually can be achieved within 2–4 weeks but may take up to several months.501

  • If adequate BP response not achieved with a single antihypertensive agent, add a second drug with demonstrated benefit; if goal BP still not achieved with optimal dosages of 2 antihypertensive agents, add a third drug.501 May maximize dosage of the first drug before adding a second drug, or add a second drug before maximizing dosage of the initial drug.501

  • Consider initiating antihypertensive therapy with a combination of drugs if patient's BP exceeds goal BP by >20/10 mm Hg.500 501 503 504

  • Goal is to achieve and maintain optimal control of BP; individualize specific target BP based on consideration of multiple factors, including patient age and comorbidities, and currently available evidence from clinical studies.500 501 (See Hypertension under Uses.)

Administration

Oral Administration

Administer orally once or twice daily 1 hour before meals.1 3 83

Dosage

Available as moexipril hydrochloride; dosage expressed in terms of the salt.1 83

Adults

Hypertension
Moexipril Therapy
Oral

Initially, 7.5 mg once daily in patients not receiving a diuretic.1 5

In patients currently receiving diuretic therapy, discontinue diuretic, if possible, 2–3 days before initiating moexipril or cautiously increase salt intake.1 8 9 10 11 12 13 14 37 46 May resume diuretic therapy if BP not controlled adequately with moexipril alone.1 28 29 30 39 If diuretic cannot be discontinued, give lower initial moexipril dose (3.75 mg) under close medical supervision until BP has stabilized.8 10 11 12 13 14 83 84

Usual dosage: 7.5–30 mg daily, given in 1 dose or 2 divided doses.1 83 500

If effectiveness diminishes toward end of dosing interval in patients treated once daily, consider increasing dosage or administering drug in 2 divided doses.1

If intolerable adverse effects occur, consider dosage reduction; if adverse effects worsen or fail to resolve, may need to discontinue and switch to another antihypertensive drug class.501

Moexipril/Hydrochlorothiazide Fixed-combination Therapy
Oral

Manufacturer states fixed-combination preparation should not be used for initial antihypertensive therapy.83

If BP is not adequately controlled by monotherapy with moexipril, can switch to the fixed-combination preparation containing moexipril hydrochloride 7.5 mg and hydrochlorothiazide 12.5 mg, moexipril hydrochloride 15 mg and hydrochlorothiazide 12.5 mg, or moexipril hydrochloride 15 mg and hydrochlorothiazide 25 mg.83 Adjust dosage of either or both drugs according to patient’s response.83

Prescribing Limits

Adults

Hypertension
Oral

Usually, maximum 30 mg daily.1 Dosages >60 mg daily have not been extensively evaluated in hypertensive patients.1 5

Special Populations

Renal Impairment

Hypertension
Oral

Initially, 3.75 mg once daily in patients with severe renal impairment (Clcr ≤40 mL/minute); titrate until BP is controlled or to maximum of 15 mg daily.1

Moexipril/hydrochlorothiazide fixed combination is not recommended in patients with severe renal impairment.83

Volume- and/or Salt-depleted Patients

Correct volume and/or salt depletion prior to initiation of therapy or initiate therapy under close medical supervision using lower initial dosage.1

Cautions for Moexipril Hydrochloride

Contraindications

  • Known hypersensitivity to moexipril, any ingredient in the formulation, or any other ACE inhibitor.1 83

  • History of angioedema with prior ACE inhibitor treatment.1 83

  • Concomitant therapy with aliskiren in patients with diabetes mellitus.1 83

Warnings/Precautions

Warnings

Fetal/Neonatal Morbidity and Mortality

Possible fetal and neonatal morbidity and mortality when used during pregnancy.1 111 (See Boxed Warning.) Such potential risks occur throughout pregnancy, especially during the second and third trimesters.111

Also may increase the risk of major congenital malformations when administered during the first trimester of pregnancy.110 111

Discontinue ACE inhibitors (e.g., moexipril) as soon as possible when pregnancy is detected, unless continued use is considered lifesaving.1 110 111 Nearly all women can be transferred successfully to alternative therapy for the remainder of their pregnancy.75

Hypotension

Possible symptomatic hypotension, particularly in volume- and/or salt-depleted patients (e.g., those with restricted salt intake, treated with diuretics, undergoing dialysis, with nausea or vomiting).1

Risk of marked hypotension, sometimes associated with oliguria and azotemia, and rarely acute renal failure and death in patients with heart failure with or without associated renal insufficiency.1 Severe hypotension may result in MI or stroke in patients with ischemic heart disease, aortic stenosis, or cerebrovascular disease.1 12 34 35 36

Hypotension may occur in patients undergoing surgery or during anesthesia with agents that produce hypotension; recommended treatment is fluid volume expansion.1

To minimize potential for hypotension, consider recent antihypertensive therapy, extent of BP elevation, sodium intake, fluid status, and other clinical conditions.1 May minimize potential for hypotension by withholding diuretic therapy and/or increasing sodium intake for 2–3 days prior to initiation of moexipril.1

Transient hypotension is not a contraindication to additional doses; may reinstate therapy cautiously after BP is stabilized (e.g., with volume expansion).1

Initiate therapy in patients with heart failure (with or without associated renal insufficiency) under close medical supervision; monitor closely for first 2 weeks following initiation of moexipril or any increase in moexipril or diuretic dosage.1

Neutropenia/Agranulocytosis

Neutropenia and agranulocytosis reported with ACE inhibitors.1 83 Risk of neutropenia appears to depend principally on degree of renal impairment and presence of collagen vascular disease (e.g., systemic lupus erythematosus, scleroderma); risk with moexipril is unknown.1 83

Consider monitoring leukocytes in patients with collagen vascular disease, especially if renal impairment exists.1 83

Hepatic Effects

Clinical syndrome that usually is manifested initially by cholestatic jaundice and may progress to fulminant hepatic necrosis (occasionally fatal) reported rarely with ACE inhibitors.1

If jaundice or marked elevation of liver enzymes occurs, discontinue drug and monitor patient.1

Sensitivity Reactions

Anaphylactoid reactions and/or angioedema possible; if associated with laryngeal edema, may be fatal.1 83 Immediate medical intervention (e.g., epinephrine) required for involvement of tongue, glottis, or larynx.1 83 Intestinal angioedema possible; consider in differential diagnosis of patients who develop abdominal pain.1 83

Anaphylactoid reactions reported in patients receiving ACE inhibitors while undergoing LDL apheresis with dextran sulfate absorption1 51 52 83 or following initiation of hemodialysis that utilized high-flux membrane.1 47 48 49 83

Life-threatening anaphylactoid reactions reported in at least 2 patients receiving ACE inhibitors while undergoing desensitization treatment with hymenoptera venom.1 83

Contraindicated in patients with a history of angioedema associated with ACE inhibitors.1 83

General Precautions

Renal Effects

Inhibition of renin-angiotensin-aldosterone (RAA) system may cause renal impairment, and, rarely, acute renal failure and/or death in susceptible patients (e.g., hypertensive patients with severe heart failure).1 83

Deterioration in renal function possible in hypertensive patients with unilateral or bilateral renal artery stenosis; generally reversible following discontinuance of ACE inhibitors and/or diuretic.1 83

Closely monitor renal function for first few weeks following initiation of therapy and periodically thereafter in such patients.1 83 Some patients may require dosage reduction or discontinuance of ACE inhibitor or diuretic.1 83

Effects on Potassium

Possible hyperkalemia, especially in patients with renal impairment or diabetes mellitus and those receiving drugs that can increase serum potassium concentration (e.g., potassium-sparing diuretics, potassium supplements, potassium-containing salt substitutes).1 (See Specific Drugs under Interactions.)

Monitor serum potassium concentration carefully in these patients.1

Cough

Persistent and nonproductive cough; resolves after drug discontinuance.1

Surgery/Anesthesia

Hypotension may occur during surgery or anesthesia with agents that produce hypotension; moexipril may block the effects on compensatory renin release in such patients.1 83 May correct such hypotension by volume expansion.1 83

Use of Fixed Combinations

When moexipril is used in fixed combination with hydrochlorothiazide, consider the cautions, precautions, and contraindications associated with hydrochlorothiazide.83

Specific Populations

Pregnancy

Category D.1 83

Can cause fetal and neonatal morbidity and mortality when administered to a pregnant woman.1 83 (See Fetal/Neonatal Morbidity and Mortality under Cautions and see Boxed Warning.)

Lactation

Not known whether moexipril is distributed into milk.1 Caution advised if used in nursing women.1

Pediatric Use

If oliguria or hypotension occurs in neonates with a history of in utero exposure to moexipril, support BP and renal function; exchange transfusions or dialysis may be required.1 83 (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

Safety and efficacy not established.1

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.1 Select dosage with caution because of age-related decreases in hepatic, renal, and/or cardiac function and potential for concomitant disease and drug therapy.1

Renal Impairment

Systemic exposure to moexipril and moexiprilat may be increased.1 Initial dosage adjustment recommended in patients with severe renal impairment.1 (See Renal Impairment under Dosage and Administration.)

Moexipril/hydrochlorothiazide fixed combination is not recommended in patients with severe renal impairment.83

Black Patients

BP reduction may be smaller in black patients compared with patients of other races.25 83 92 93 108 109 (See Hypertension under Uses.)

Higher incidence of angioedema reported with ACE inhibitors in black patients compared with other races.1 500

Common Adverse Effects

Cough, dizziness, diarrhea, flu syndrome, fatigue, pharyngitis, flushing, rash, myalgia.1

Interactions for Moexipril Hydrochloride

Specific Drugs

Drug

Interaction

Comments

ACE inhibitors

Increased risk of renal impairment, hyperkalemia, and hypotension1 83

Generally, avoid concomitant use; monitor BP, renal function, and electrolytes if used concomitantly1 83

Aliskiren

Increased risk of renal impairment, hyperkalemia, and hypotension1 83

Generally, avoid concomitant use; monitor BP, renal function, and electrolytes if used concomitantly1 83

Angiotensin II receptor antagonists

Increased risk of renal impairment, hyperkalemia, and hypotension1 83

Generally, avoid concomitant use; monitor BP, renal function, and electrolytes if used concomitantly1 83

Anticoagulants, oral

Clinically important interaction not observed1

Cimetidine

Clinically important interaction not observed1

Digoxin

Clinically important interaction not observed1

Diuretics

Increased hypotensive effect1

If possible, discontinue diuretic before initiating moexipril1 (see Dosage under Dosage and Administration)

Diuretic, potassium-sparing (amiloride, spironolactone, triamterene)

Enhanced hyperkalemic effect1

Use with caution; monitor serum potassium concentrations frequently1

Gold

Nitroid reactions reported rarely in patients receiving concomitant therapy with sodium aurothiomalate and an ACE inhibitor1 83

Lithium

Increased serum lithium concentrations; possible toxicity1

Use with caution; monitor serum lithium concentration frequently1

NSAIAs (including COX-2 inhibitors)

May result in deterioration of renal function, including possible renal failure, in geriatric patients, volume-depleted patients, or patients with compromised renal function;1 83 effects usually reversible1 83

Monitor renal function periodically 1 83

Potassium supplements or potassium-containing salt substitutes.

Enhanced hyperkalemic effect1

Use with caution; monitor serum potassium concentrations frequently1

Moexipril Hydrochloride Pharmacokinetics

Absorption

Bioavailability

About 13% of oral dose is absorbed.1 Peak plasma concentration of moexiprilat is achieved within about 1.5 hours.1

Onset

Following a single oral dose, antihypertensive effects are observed within about 1 hour with peak BP reduction at 3–6 hours.1

During chronic therapy, maximum antihypertensive effect with any dose is achieved after 4 weeks.1

Duration

Antihypertensive effect of a single dose persists for about 24 hours.1

Food

Food reduces peak plasma concentration of moexipril; administer 1 hour before meals.1

Special Populations

In patients with cirrhosis, peak plasma concentration and AUC of moexipril following a single oral dose were increased, while peak plasma concentration of moexiprilat was decreased and AUC of moexiprilat was increased.1

In patients with renal impairment, increased moexipril and moexiprilat concentrations.1

Distribution

Extent

Not known whether distributed into milk.1

Plasma Protein Binding

Moexiprilat: 50%.1

Elimination

Metabolism

Metabolized in the liver, principally to an active metabolite, moexiprilat.1

Elimination Route

Following oral administration, eliminated in feces (53%), principally as moexiprilat, and to a lesser extent in urine (13%).1

Following IV administration, eliminated principally in urine, as moexiprilat (40%) and moexipril (26%), and to lesser extent in feces (about 20%, mainly as moexiprilat).1

Half-life

Moexiprilat: 12 hours.1

Special Populations

In patients with renal impairment (Clcr 10–40 mL/minute), threefold to fourfold increase in moexiprilat half-life.1

Stability

Storage

Oral

Tablets

Tight containers at 15–30°C.1

Actions

  • Prodrug; not pharmacologically active until hydrolyzed in the liver to moexiprilat.1

  • Suppresses the renin-angiotensin-aldosterone system.1

Advice to Patients

  • Risk of angioedema, anaphylactoid reactions, or other sensitivity reactions.1 Importance of reporting sensitivity reactions (e.g., edema of face, eyes, lips, tongue, or extremities; hoarseness; swallowing or breathing with difficulty) immediately to clinician and of discontinuing the drug.1

  • Risk of hypotension.1 Importance of informing clinicians promptly if lightheadedness or fainting occurs.1 Importance of adequate fluid intake; risk of volume depletion with excessive perspiration, dehydration, vomiting, or diarrhea.1

  • Importance of reporting signs of infection (e.g., sore throat, fever).1

  • Risk of hyperkalemia.1 83 Importance of avoiding use of potassium supplements or salt substitutes containing potassium without consulting a clinician.1 83

  • Importance of taking moexipril 1 hour before meals.1

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.1

  • Importance of women informing their clinician if they are or plan to become pregnant or plan to breast-feed.1 Risks of use during pregnancy; importance of discussing other options for hypertension treatment if pregnancy occurs.1 110 111

  • Importance of advising patients of other important precautionary information.1 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Moexipril Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, film-coated

7.5 mg*

Moexipril Hydrochloride Tablets

15 mg*

Moexipril Hydrochloride Tablets

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Moexipril Hydrochloride Combinations

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, film-coated

7.5 mg with Hydrochlorothiazide 12.5 mg*

Moexipril Hydrochloride and Hydrochlorothiazide Tablets

15 mg with Hydrochlorothiazide 12.5 mg*

Moexipril Hydrochloride and Hydrochlorothiazide Tablets

15 mg with Hydrochlorothiazide 25 mg*

Moexipril Hydrochloride and Hydrochlorothiazide Tablets

AHFS DI Essentials. © Copyright 2018, Selected Revisions March 19, 2018. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

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