Quinapril Information
Quinapril ()
Quinapril () Description
Quinapril () tablets (Quinapril () hydrochloride) is the hydrochloride salt of Quinapril () , the ethyl ester of a non-sulfhydryl, angiotensin-converting enzyme (ACE) inhibitor, Quinapril () at.
Quinapril () hydrochloride is chemically described as [3S-[2[R*(R*)], 3R*]]-2-[2-[[1- (ethoxycarbonyl)-3-phenylpropyl]amino]-1-oxopropyl]-1,2,3,4-tetrahydro-3- isoquinolinecarboxylic acid, monohydrochloride. Its empirical formula is CHNO •HCl and its structural formula is:
Quinapril () hydrochloride is a white to off-white amorphous powder that is freely soluble in aqueous solvents.
Quinapril () tablets contain 5 mg, 10 mg, 20 mg, or 40 mg of Quinapril () for oral administration. Each film-coated tablet also contains crospovidone, iron oxide yellow, lecithin, magnesium carbonate, magnesium stearate, microcrystalline cellulose, polyvinyl alcohol, povidone, talc, titanium dioxide and xanthan gum.
Quinapril () Clinical Pharmacology
Quinapril () is deesterified to the principal metabolite, Quinapril () at, which is an inhibitor of ACE activity in human subjects and animals. ACE is a peptidyl dipeptidase that catalyzes the conversion of angiotensin I to the vasoconstrictor, angiotensin II. The effect of Quinapril () in hypertension appears to result primarily from the inhibition of circulating and tissue ACE activity, thereby reducing angiotensin II formation. Quinapril () inhibits the elevation in blood pressure caused by intravenously administered angiotensin I, but has no effect on the pressor response to angiotensin II, norepinephrine or epinephrine. Angiotensin II also stimulates the secretion of aldosterone from the adrenal cortex, thereby facilitating renal sodium and fluid reabsorption. Reduced aldosterone secretion by Quinapril () may result in a small increase in serum potassium. In controlled hypertension trials, treatment with Quinapril () alone resulted in mean increases in potassium of 0.07 mmol/L (see ). Removal of angiotensin II negative feedback on renin secretion leads to increased plasma renin activity (PRA).
While the principal mechanism of antihypertensive effect is thought to be through the rennin-angiotensin-aldosterone system, Quinapril () exerts antihypertensive actions even in patients with low renin hypertension. Quinapril () was an effective antihypertensive in all races studied, although it was somewhat less effective in blacks (usually a predominantly low renin group) than in nonblacks. ACE is identical to kininase II, an enzyme that degrades bradykinin, a potent peptide vasodilator; whether increased levels of bradykinin play a role in the therapeutic effect of Quinapril () remains to be elucidated.
Following oral administration, peak plasma Quinapril () concentrations are observed within one hour. Based on recovery of Quinapril () and its metabolites in urine, the extent of absorption is at least 60%. The rate and extent of Quinapril () absorption are diminished moderately (approximately 25-30%) when Quinapril () tablets are administered during a high-fat meal. Following absorption, Quinapril () is deesterified to its major active metabolite, Quinapril () at (about 38% of oral dose), and to other minor inactive metabolites. Following multiple oral dosing of Quinapril () , there is an effective accumulation half-life of Quinapril () at of approximately 3 hours, and peak plasma Quinapril () at concentrations are observed approximately 2 hours post-dose. Quinapril () at is eliminated primarily by renal excretion, up to 96% of an IV dose, and has an elimination half-life in plasma of approximately 2 hours and a prolonged terminal phase with a half-life of 25 hours. The pharmacokinetics of Quinapril () and Quinapril () at are linear over a single-dose range of 5-80 mg doses and 40-160 mg in multiple daily doses. Approximately 97% of either Quinapril () or Quinapril () at circulating in plasma is bound to proteins.
In patients with renal insufficiency, the elimination half-life of Quinapril () at increases as creatinine clearance decreases. There is a linear correlation between plasma Quinapril () at clearance and creatinine clearance. In patients with end-stage renal disease, chronic hemodialysis or continuous ambulatory peritoneal dialysis has little effect on the elimination of Quinapril () and Quinapril () at. Elimination of Quinapril () at may be reduced in elderly patients (≥65 years); this reduction is attributable to decrease in renal function (see ). Quinapril () at concentrations are reduced in patients with alcoholic cirrhosis due to impaired deesterification of Quinapril () . Studies in rats indicate that Quinapril () and its metabolites do not cross the blood-brain barrier.
Single doses of 20 mg of Quinapril () provide over 80% inhibition of plasma ACE for 24 hours. Inhibition of the pressor response to angiotensin I is shorter-lived, with a 20 mg dose giving 75% inhibition for about 4 hours, 50% inhibition for about 8 hours, and 20% inhibition at 24 hours. With chronic dosing, however, there is substantial inhibition of angiotensin II levels at 24 hours by doses of 20-80 mg.
Administration of 10 to 80 mg of Quinapril () to patients with mild to severe hypertension results in a reduction of sitting and standing blood pressure to about the same extent with minimal effect on heart rate. Symptomatic postural hypotension is infrequent although it can occur in patients who are salt-and/or volume-depleted (see ). Antihypertensive activity commences within 1 hour with peak effects usually achieved by 2 to 4 hours after dosing. During chronic therapy, most of the blood pressure lowering effect of a given dose is obtained in 1-2 weeks. In multiple-dose studies, 10-80 mg per day in single or divided doses lowered systolic and diastolic blood pressure throughout the dosing interval, with a trough effect of about 5-11/3-7 mm Hg. The trough effect represents about 50% of the peak effect. While the dose-response relationship is relatively flat, doses of 40-80 mg were somewhat more effective at trough than 10-20 mg, and twice daily dosing tended to give a somewhat lower trough blood pressure than once daily dosing with the same total dose. The antihypertensive effect of Quinapril () continues during long-term therapy, with no evidence of loss of effectiveness.
Hemodynamic assessments in patients with hypertension indicate that blood pressure reduction produced by Quinapril () is accompanied by a reduction in total peripheral resistance and renal vascular resistance with little or no change in heart rate, cardiac index, renal blood flow, glomerular filtration rate, or filtration fraction.
Use of Quinapril () with a thiazide diuretic gives a blood-pressure lowering effect greater than that seen with either agent alone.
In patients with hypertension, Quinapril () 10-40 mg was similar in effectiveness to captopril, enalapril, propranolol, and thiazide diuretics.
Therapeutic effects appear to be the same for elderly (≥65 years of age) and younger adult patients given the same daily dosages, with no increase in adverse events in elderly patients.
Quinapril () Indications And Usage
Quinapril () tablets are indicated for the treatment of hypertension. It may be used alone or in combination with thiazide diuretics.
In using Quinapril () tablets, consideration should be given to the fact that another angiotensin-converting enzyme inhibitor, captopril, has caused agranulocytosis, particularly in patients with renal impairment or collagen vascular disease. Available data are insufficient to show that Quinapril () tablets does not have a similar risk (see ).
Quinapril () Contraindications
Quinapril () is contraindicated in patients who are hypersensitive to this product and in patients with a history of angioedema related to previous treatment with an ACE inhibitor.
Quinapril () Warnings
Angioedema of the face, extremities, lips, tongue, glottis, and larynx has been reported in patients treated with ACE inhibitors and has been seen in 0.1% of patients receiving Quinapril () .
In two similarly sized U.S. postmarketing trials that, combined, enrolled over 3,000 black patients and over 19,000 non-blacks, angioedema was reported in 0.30% and 0.55% of blacks (in study 1 and 2 respectively) and 0.39% and 0.17% of non-blacks.
Angioedema associated with laryngeal edema can be fatal. If laryngeal stridor or angioedema of the face, tongue, or glottis occurs, treatment with Quinapril () should be discontinued immediately, the patient treated 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. (see ).
Excessive hypotension is rare in patients with uncomplicated hypertension treated with Quinapril () alone. Patients with heart failure given Quinapril () commonly have some reduction in blood pressure, but discontinuation of therapy because of continuing symptomatic hypotension usually is not necessary when dosing instructions are followed. Caution should be observed when initiating therapy in patients with heart failure (see ). In controlled studies, syncope was observed in 0.4% of patients (N=3203); this incidence was similar to that observed for captopril (1%) and enalapril (0.8%).
Patients at risk of excessive hypotension, sometimes associated with oliguria and/or progressive azotemia, and rarely with acute renal failure and/or death, include patients with the following conditions or characteristics: hyponatremia, high dose diuretic therapy, recent intensive diuresis or increase in diuretic dose, renal dialysis, or severe volume and/or salt depletion of any etiology. It may be advisable to eliminate the diuretic (except in patients with heart failure), reduce the diuretic dose or cautiously increase salt intake (except in patients with heart failure) before initiating therapy with Quinapril () in patients at risk for excessive hypotension who are able to tolerate such adjustments.
In patients at risk of excessive hypotension, therapy with Quinapril () should be started under close medical supervision. Such patients should be followed closely for the first two weeks of treatment and whenever the dose of Quinapril () and/or diuretic is increased. Similar considerations may apply to patients with ischemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in a myocardial infarction or a cerebrovascular accident.
If excessive 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 of Quinapril () , which usually can be given without difficulty once the blood pressure has stabilized. If symptomatic hypotension develops, a dose reduction or discontinuation of Quinapril () or concomitant diuretic may be necessary.
ACE inhibitors can cause fetal and neonatal morbidity and death when administered to pregnant women. Several dozen cases have been reported in the world literature. When pregnancy is detected, ACE inhibitors should be discontinued as soon as possible.
The use of ACE inhibitors during the second and third trimesters of pregnancy has been associated with fetal and neonatal injury, including hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, and death. Oligohydramnios has also been reported, presumably resulting from decreased fetal renal function; oligohydramnios in this setting has been associated with fetal limb contractures, craniofacial deformation, and hypoplastic lung development. Prematurity, intrauterine growth retardation, and patent ductus arteriosus have also been reported, although it is not clear whether these occurrences were due to the ACE inhibitor exposure.
These adverse effects do not appear to have resulted from intrauterine ACE inhibitor exposure that has been limited to the first trimester. Mothers whose embryos and fetuses are exposed to ACE inhibitors only during the first trimester should be so informed. Nonetheless, when patients become pregnant, physicians should make every effort to discontinue the use of Quinapril () as soon as possible.
Rarely (probably less often than once in every thousand pregnancies), no alternative to ACE inhibitors will be found. In these rare cases, the mothers should be apprised of the potential hazards to their fetuses, and serial ultrasound examinations should be performed to assess the intraamniotic environment.
If oligohydramnios is observed, Quinapril () should be discontinued unless it is considered lifesaving for the mother. Contraction stress testing (CST), a non-stress test (NST), or biophysical profiling (BPP) may be appropriate, depending upon the week of pregnancy. Patients and physicians should be aware, however, that oligohydramnios may not appear until after the fetus has sustained irreversible injury.
Infants with histories of exposure to ACE inhibitors should be closely observed for hypotension, oliguria, and hyperkalemia. If oliguria occurs, attention should be directed toward support of blood pressure and renal perfusion. Exchange transfusion or dialysis may be required as a means of reversing hypotension and/or substituting for disordered renal function. Removal of Quinapril () , which crosses the placenta, from the neonatal circulation is not significantly accelerated by these means.
No teratogenic effects of Quinapril () were seen in studies of pregnant rats and rabbits. On a mg/kg basis, the doses used were up to 180 times (in rats) and one time (in rabbits) the maximum recommended human dose.
Quinapril () Precautions
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.
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 preexisting renal vascular disease have developed increases in blood urea and serum creatinine, usually minor and transient, especially when Quinapril () has been given concomitantly with a diuretic. This is more likely to occur in patients with preexisting renal impairment. Dosage reduction and/or discontinuation of any diuretic and/or Quinapril () may be required.
In clinical trials, hyperkalemia (serum potassium ≥5.8 mmol/L) occurred in approximately 2% of patients receiving Quinapril () . In most cases, elevated serum potassium levels were isolated values which resolved despite continued therapy. Less than 0.1% of patients discontinued therapy due to hyperkalemia. Risk factors for the development of hyperkalemia include renal insufficiency, diabetes mellitus, and the concomitant use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salt substitutes, which should be used cautiously, if at all, with Quinapril () (see ).
Presumably due to the inhibition of the degradation of endogenous bradykinin, persistent non-productive cough has been reported with all ACE inhibitors, always resolving after discontinuation of therapy. ACE inhibitor-induced cough should be considered in the differential diagnosis of cough.
In patients undergoing major surgery or during anesthesia with agents that produce hypotension, Quinapril () will block angiotensin II formation secondary to compensatory renin release. If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.
Female patients of childbearing age should be told about the consequences of second- and third-trimester exposure to ACE inhibitors, and they should also be told that these consequences do not appear to have resulted from intrauterine ACE-inhibitor exposure that has been limited to the first trimester. These patients should be asked to report pregnancies to their physicians as soon as possible.
Angioedema, including laryngeal edema can occur with treatment with ACE inhibitors, especially following the first dose. Patients should be so advised and told to report immediately any signs or symptoms suggesting angioedema (swelling of face, extremities, eyes, lips, tongue, difficulty in swallowing or breathing) and to stop taking the drug until they have consulted with their physician (see ).
Patients should be cautioned that lightheadedness can occur, especially during the first few days of Quinapril () therapy, and that it should be reported to a physician. If actual syncope occurs, patients should be told to not take the drug until they have consulted with their physician (see ).
All patients should be cautioned that inadequate fluid intake or excessive perspiration, diarrhea, or vomiting can lead to an excessive fall in blood pressure because of reduction in fluid volume, with the same consequences of lightheadedness and possible syncope.
Patients planning to undergo any surgery and/or anesthesia should be told to inform their physician that they are taking an ACE inhibitor.
Patients should be told not to use potassium supplements or salt substitutes containing potassium without consulting their physician (see ).
Patients should be told to report promptly any indication of infection (eg, sore throat, fever) which could be a sign of neutropenia.
NOTE: As with many other drugs, certain advice to patients being treated with Quinapril () is warranted. This information is intended to aid in the safe and effective use of this medication. It is not a disclosure of all possible adverse or intended effects.
As with other ACE inhibitors, patients on diuretics, especially those on recently instituted diuretic therapy, may occasionally experience an excessive reduction of blood pressure after initiation of therapy with Quinapril () . The possibility of hypotensive effects with Quinapril () may be minimized by either discontinuing the diuretic or cautiously increasing salt intake prior to initiation of treatment with Quinapril () . If it is not possible to discontinue the diuretic, the starting dose of Quinapril () should be reduced (see ).
Quinapril () can attenuate potassium loss caused by thiazide diuretics and increase serum potassium when used alone. If concomitant therapy of Quinapril () with potassium-sparing diuretics (eg, spironolactone, triamterene, or amiloride), potassium supplements, or potassium-containing salt substitutes is indicated, they should be used with caution along with appropriate monitoring of serum potassium (see ).
Simultaneous administration of tetracycline with Quinapril () reduced the absorption of tetracycline by approximately 28% to 37%, possibly due to the high magnesium content in Quinapril () tablets. This interaction should be considered if coprescribing Quinapril () and tetracycline or other drugs that interact with magnesium.
Increased serum lithium levels and symptoms of lithium toxicity have been reported in patients receiving concomitant lithium and ACE inhibitor therapy. These drugs should be coadministered 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.
Nitritoid reactions (symptoms include facial flushing, nausea, vomiting, and hypotension) have been reported rarely in patients on therapy with injectable gold (sodium aurothiomalate) and concomitant ACE inhibitor therapy.
Drug interaction studies of Quinapril () with other agents showed:
Pregnancy Categories C (first trimester) and D (second and third trimesters):
WARNINGS, Fetal/Neonatal Morbidity and Mortality
Clinical studies of Quinapril () did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.
In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy.
This drug 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, and it may be useful to monitor renal function.
Elderly patients exhibited increased area under the plasma concentration time curve and peak levels for Quinapril () at compared to values observed in younger patients; this appeared to relate to decreased renal function rather than to age itself.
Quinapril () Adverse Reactions
Quinapril () has been evaluated for safety in 4960 subjects and patients. Of these, 3203 patients, including 655 elderly patients, participated in controlled clinical trials. Quinapril () has been evaluated for long-term safety in over 1400 patients treated for 1 year or more.
Adverse experiences were usually mild and transient.
In placebo-controlled trials, discontinuation of therapy because of adverse events was required in 4.7% of patients with hypertension.
Adverse experiences probably or possibly related to therapy or of unknown relationship to therapy occurring in 1% or more of the 1563 patients in placebo-controlled hypertension trials who were treated with Quinapril () hydrochloride are shown below.
Clinical adverse experiences probably, possibly, or definitely related, or of uncertain relationship to therapy occurring in 0.5% to 1.0% (except as noted) of the patients with hypertension treated with Quinapril () hydrochloride (with or without concomitant diuretic) in controlled or uncontrolled trials (N=4847) and less frequent, clinically significant events seen in clinical trials or post-marketing experience (the rarer events are in italics) include (listed by body system):
Back pain, malaise, viral infections,
Palpitation, vasodilation, tachycardia,
Hemolytic anemia
Flatulence, dry mouth or throat, constipation,
Somnolence, vertigo, syncope, nervousness, depression, insomnia, paresthesia
Alopecia, increased sweating, pemphigus, pruritus,
Urinary tract infection, impotence,
Eosinophilic pneumonitis
Amblyopia, edema, arthralgia, pharyngitis,
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Increases (>1.25 times the upper limit of normal) in serum creatinine and blood urea nitrogen were observed in 2% and 2%, respectively, of all patients treated with Quinapril () alone. Increases are more likely to occur in patients receiving concomitant diuretic therapy than in those on Quinapril () alone. These increases often remit on continued therapy.
Quinapril () Overdosage
Doses of 1440 to 4280 mg/kg of Quinapril () cause significant lethality in mice and rats.
No specific information is available on the treatment of overdosage with Quinapril () . The most likely clinical manifestation would be symptoms attributable to severe hypotension.
Laboratory determinations of serum levels of Quinapril () and its metabolites are not widely available, and such determinations have, in any event, no established role in the management of Quinapril () overdose.
No data are available to suggest physiological maneuvers (eg, maneuvers to change pH of the urine) that might accelerate elimination of Quinapril () and its metabolites.
Hemodialysis and peritoneal dialysis have little effect on the elimination of Quinapril () and Quinapril () at. Angiotensin II could presumably serve as a specific antagonist-antidote in the setting of Quinapril () overdose, but angiotensin II is essentially unavailable outside of scattered research facilities. Because the hypotensive effect of Quinapril () is achieved through vasodilation and effective hypovolemia, it is reasonable to treat Quinapril () overdose by infusion of normal saline solution.
Quinapril () How Supplied
Quinapril () tablets are supplied as follows:
NDC 21695-393-30 bottles of 30 tablets
NDC 21695-394-30 bottles of 30 tablets
Dispense in well-closed containers as defined in the USP.
Manufactured for: Baltimore, Maryland 21202United States
Manufactured by: Goa 403 722INDIA
Revised: September 2010 ID#:222888
Repackaged by:
Thousand Oaks, CA 91320
Quinapril () Package/label Principal Display Panel
Quinapril () Package/label Principal Display Panel
