quinapril (Rx)

Brand and Other Names:Accupril
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

tablet

  • 5mg
  • 10mg
  • 20mg
  • 40mg

Hypertension

Initial: 10-20 mg PO qDay; may administer 5 mg in patients receiving diuretic therapy if the diuretic is continued

Maintenance: 20-80 mg PO qDay or divided q12hr

Congestive Heart Failure

Initial: 5 mg PO q12hr

Maintenance: 20-40 mg PO qDay or divided q12hr

Diabetic Nephropathy (Off-Label)

Slows rate of progression of renal disease in patients with HTN, DM, and microalbuminuria

Initial: 10-20 mg PO qDay

Maintenance: 20-80 mg PO qDay or divided q12hr

Dosage Modification

Renal impairment with hypertension

  • CrCl >60 mL/min: 10 mg/day
  • CrCl 30-60 mL/min: 5 mg/day
  • CrCl 10-30 mL/min: 2.5 mg/day
  • CrCl <10 mL/min: Insufficient data

Renal impairment with CHF

  • CrCl >30 mL/min: 5 mg/day
  • CrCl 10-30 mL/min: 2.5 mg/day
  • CrCl <10 mL/min: Insufficient data

Dosage Forms & Strengths

tablet

  • 5mg
  • 10mg
  • 20mg
  • 40mg

Hypertension (Off-label)

5-10 mg PO qDay initially

2.5-5 mg/day initially; increase dose by increments of 2.5-5 mg at 1-2 week intervals; adjust for renal impairment

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Interactions

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and quinapril

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            Adverse Effects

            1-10%

            Dizziness (7.7%)

            Coughing (4.3%)

            Fatigue (2.6%)

            Nausea and/or vomiting (2.4%)

            Hypotension (2.9%)

            Dyspnea (1.9%)

            Diarrhea (1.7%)

            Headache (1.7%)

            Myalgia (1.5%)

            Rash (1.4%)

            Back pain (1.2%)

            <1%

            Angioedema

            General: Back pain, malaise, viral infections, anaphylactoid reaction

            Cardiovascular: Palpitation, vasodilation, tachycardia, heart failure, hyperkalemia, myocardial infarction, cerebrovascular accident, hypertensive crisis, angina pectoris, orthostatic hypotension, cardiac rhythm disturbances, cardiogenic shock

            Hematology: Hemolytic anemia

            Gastrointestinal: Flatulence, dry mouth or throat, constipation, gastrointestinal hemorrhage, pancreatitis, abnormal liver function tests, dyspepsia

            Metabolism and nutrition disorders: Hyponatremia

            Nervous/psychiatric: Somnolence, vertigo, syncope, nervousness, depression, insomnia, paresthesia

            Integumentary: Alopecia, increased sweating, pemphigus, pruritus, exfoliative dermatitis, photosensitivity reaction, dermatopolymyositis

            Urogenital: Urinary tract infection, impotence, acute renal failure, worsening renal failure

            Respiratory: Eosinophilic pneumonitis

            Other: Amblyopia, edema, arthralgia, pharyngitis, agranulocytosis, hepatitis, thrombocytopenia

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            Warnings

            Black Box Warnings

            Discontinue as soon as possible when pregnancy is detected; affects renin-angiotensin system causing oligohydramnios, which may result in fetal injury and/or death

            Contraindications

            Hypersensitivity

            History of hereditary or angioedema associated with previous ACE inhibitor treatment

            Coadministration of neprilysin inhibitors (eg, sacubitril) with ACE inhibitors may increase angioedema risk; do not administer ACE inhibitors within 36 hr of switching to or from sacubitril/valsartan

            Do not coadminister with aliskiren in patients with diabetes mellitus

            Cautions

            Discontinue STAT if pregnant (see Contraindications and Black Box Warnings)

            Less effective in blacks

            ACE inhibitors associated with a syndrome that starts with cholestatic jaundice and progresses to fulminant hepatic necrosis and (sometimes) death; mechanism of this syndrome is not understood; patients receiving ACE inhibitors who develop jaundice or marked elevations of hepatic enzymes should discontinue ACE inhibitor and receive appropriate medical follow-up

            Use caution in severe aortic stenosis

            Hyperkalemia may occur; risk factors may include renal insufficiency, diabetes mellitus, and concomitant use of other drugs that raise serum potassium levels; monitor serum potassium in such patients

            Dual blockade of the renin-angiotensin system with ARBs, ACE inhibitors, or aliskiren associated with increased risk for hypotension, hyperkalemia, and renal function changes (including acute renal failure) compared to monotherapy

            Anaphylactoid reactions reported in patients dialyzed with high-flux membranes and treated concomitantly with an ACE inhibitor; anaphylactoid reactions also reported in patients undergoing low-density lipoprotein apheresis with dextran sulfate absorption

            Decreased absorption (25-30%) with high-fat meal

            ACE inhibition also causes increased bradykinin levels which putatively mediates angioedema

            Angioedema of the face, extremities, lips, tongue, glottis, and larynx reported in patients treated with angiotensin-converting enzyme inhibitors; in instances where swelling is confined to face and lips, condition generally resolves without treatment; antihistamines may be useful in relieving symptoms; when there is involvement of tongue, glottis, or larynx, likely to cause airway obstruction, administer emergency therapy including, but not limited to, subcutaneous epinephrine solution 1:1000 (0.3 to 0.5 mL)

            Patients receiving coadministration of ACE inhibitor and mTOR (mammalian target of rapamycin) inhibitor (e.g. temsirolimus, sirolimus, everolimus) therapy or a neprilysin inhibitor may be at increased risk for angioedema

            Intestinal angioedema has been reported in patients treated with ACE inhibitors

            Presumably due to inhibition of degradation of endogenous bradykinin, persistent non-productive cough reported with all ACE inhibitors, always resolving after discontinuation of therapy; ACE inhibitor-induced cough should be considered in differential diagnosis of cough

            Agranulocytosis, neutropenia, or leukopenia with myeloid hypoplasia reported with other ACE inhibitor in patients with uncomplicated hypertension, but frequently in patients with renal impairment, especially if they have a collagen vascular disease, such as, systemic lupus erythematosus or scleroderma; consider periodic monitoring of white blood cell counts in patients with collage vascular disease and/or renal disease

            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

            Renal impairment

            • As a consequence of inhibiting 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 activity of renin-angiotensin-­aldosterone system, treatment with ACE inhibitors, 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 ACE inhibitor and/or diuretic therapy; monitor renal function during first few weeks of therapy in such patients
            • 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 drug given concomitantly with a diuretic; likely to occur in patients with preexisting renal impairment; reduction in dose and/or discontinuation of any diuretic and/or quinapril may be required

            Hypotension

            • Excessive hypotension is rare in patients with uncomplicated hypertension treated with drug alone; patients with heart failure given drug 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
            • Observe caution when initiating therapy in patients with heart failure; in controlled studies, syncope was observed in 0.4% of patients (N=3203)
            • 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 heart failure, 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 diuretic dose or cautiously increase salt intake (except in patients with heart failure) before initiating therapy in patients at risk for excessive hypotension who are able to tolerate such adjustments
            • In patients at risk of excessive hypotension, therapy should be started under close medical supervision; such patients should be followed closely for first two weeks of treatment and whenever dose of drug and/or diuretic is increased; similar considerations may apply to patients with ischemic heart or cerebrovascular disease in whom excessive fall in blood pressure could result in a myocardial infarction or a cerebrovascular accident
            • If excessive hypotension occurs, patient should be placed in supine position and, if necessary, receive an intravenous infusion of normal saline; a transient hypotensive response is not a contraindication to further doses of drgu, which usually can be given without difficulty once blood pressure has stabilized; if symptomatic hypotension develops, a dose reduction or discontinuation of drug or concomitant diuretic may be necessary
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            Pregnancy & Lactation

            Pregnancy Category: C (1st trimester); D (2nd & 3rd trimester)

            Discontinue as soon as pregnancy detected; during the second and third trimesters of pregnancy, drugs that act directly on the renin-angiotensin have been associated with fetal injury that includes hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, and death

            Lactation: excreted in breast milk; use caution

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Angiotensin converting enzyme (ACE) inhibitors dilate arteries and veins by competively inhibiting the conversion of angiotensin I to angiotensin II (a potent endogenous vasoconstrictor) and by inhibiting bradykinin metabolism; these actions result in preload and afterload reductions on the heart

            ACE inhibitors also promote sodium and water excretion by inhibiting angiotensin-II induced aldosterone secretion; elevation in potassium may also be observed

            ACE inhibitors also elicit renoprotective effects through vasodilation of renal arterioles

            ACE inhibitors reduce cardiac and vascular remodeling associated with chronic hypertension, heart failure, and myocardial infarction

            Pharmacokinetics

            Half-life: 0.8 hr (quinapril); 3 hr (quinaprilat)

            Onset: 1 hr

            Duration: 24 hr

            Peak plasma time: 1 hr (quinapril); 2 hr (quinaprilat)

            Bioavailability: ≥60%

            Protein bound: 97%

            Metabolite: quinaprilat (active)

            Metabolism: Liver

            Excretion: Urine (50-60% primarily as quinaprilat)

            Dialyzable: Minimally

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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.