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ZESTRIL is indicated for the treatment of hypertension, to lower blood pressure. Lowering blood pressure lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions. These benefits have been seen in controlled trials of antihypertensive drugs from a wide variety of pharmacologic classes including lisinopril.
Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program's Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC).
Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits. The largest and most consistent cardiovascular outcome benefit has been a reduction in the risk of stroke, but reductions in myocardial infarction and cardiovascular mortality also have been seen regularly.
Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit. Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal.
Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (eg, on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy.
ZESTRIL may be administered alone or with other antihypertensive agents.
ZESTRIL is indicated as adjunctive therapy in the management of heart failure in patients who are not responding adequately to diuretics and digitalis.
Acute Myocardial Infarction
ZESTRIL is indicated for the treatment of hemodynamically stable patients within 24 hours of acute myocardial infarction, to improve survival. Patients should receive, as appropriate, the standard recommended treatments such as thrombolytics, aspirin and beta—blockers.
In using ZESTRIL, 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, and that available data are insufficient to show that ZESTRIL does not have a similar risk (See WARNINGS).
In considering the use of ZESTRIL, it should be noted that in controlled clinical trials ACE inhibitors have an effect on blood pressure that is less in Black patients than in non-Blacks. In addition, ACE inhibitors have been associated with a higher rate of angioedema in Black than in non-Black patients (See WARNINGS, Anaphylactoid and Possibly Related Reactions).
DOSAGE AND ADMINISTRATION
In patients with uncomplicated essential hypertension not on diuretic therapy, the recommended initial dose is 10 mg once a day. Dosage should be adjusted according to blood pressure response. The usual dosage range is 20 to 40 mg per day administered in a single daily dose. The antihypertensive effect may diminish toward the end of the dosing interval regardless of the administered dose, but most commonly with a dose of 10 mg daily. This can be evaluated by measuring blood pressure just prior to dosing to determine whether satisfactory control is being maintained for 24 hours. If it is not, an increase in dose should be considered. Doses up to 80 mg have been used but do not appear to give greater effect. If blood pressure is not controlled with ZESTRIL alone, a low dose of a diuretic may be added. Hydrochlorothiazide, 12.5 mg has been shown to provide an additive effect. After the addition of a diuretic, it may be possible to reduce the dose of ZESTRIL.
Diuretic Treated Patients
In hypertensive patients who are currently being treated with a diuretic, symptomatic hypotension may occur occasionally following the initial dose of ZESTRIL. The diuretic should be discontinued, if possible, for two to three days before beginning therapy with ZESTRIL to reduce the likelihood of hypotension (See WARNINGS). The dosage of ZESTRIL should be adjusted according to blood pressure response. If the patient's blood pressure is not controlled with ZESTRIL alone, diuretic therapy may be resumed as described above.
If the diuretic cannot be discontinued, an initial dose of 5 mg should be used under medical supervision for at least two hours and until blood pressure has stabilized for at least an additional hour (See WARNINGS AND PRECAUTIONS, DRUG INTERACTIONS).
Dosage Adjustment in Renal Impairment
The usual dose of ZESTRIL (10 mg) is recommended for patients with creatinine clearance > 30 mL/min (serum creatinine of up to approximately 3 mg/dL). For patients with creatinine clearance ≥ 10 mL/min ≤ 30 mL/min (serum creatinine ≥ 3 mg/dL), the first dose is 5 mg once daily. For patients with creatinine clearance < 10 mL/min (usually on hemodialysis) the recommended initial dose is 2.5 mg. The dosage may be titrated upward until blood pressure is controlled or to a maximum of 40 mg daily.
|Renal Status||Creatinine Clearance mL/min||Initial Dose mg/day|
|Normal Renal Function to Mild Impairment||> 30||10|
|Moderate to Severe Impairment||≥ 10 ≤ 30||5|
|1 See WARNINGS, Anaphylactoid Reactions
During Membrane Exposure
2Dosage or dosing interval should be adjusted depending on the blood pressure response.
ZESTRIL is indicated as adjunctive therapy with diuretics and (usually) digitalis. The recommended starting dose is 5 mg once a day. When initiating treatment with lisinopril in patients with heart failure, the initial dose should be administered under medical observation, especially in those patients with low blood pressure (systolic blood pressure below 100 mmHg). The mean peak blood pressure lowering occurs six to eight hours after dosing. Observation should continue until blood pressure is stable. The concomitant diuretic dose should be reduced, if possible, to help minimize hypovolemia which may contribute to hypotension (See WARNINGS AND PRECAUTIONS, DRUG INTERACTIONS). The appearance of hypotension after the initial dose of ZESTRIL does not preclude subsequent careful dose titration with the drug, following effective management of the hypotension.
The usual effective dosage range is 5 to 40 mg per day administered as a single daily dose. The dose of ZESTRIL can be increased by increments of no greater than 10 mg, at intervals of no less than 2 weeks to the highest tolerated dose, up to a maximum of 40 mg daily. Dose adjustment should be based on the clinical response of individual patients.
Dosage Adjustment in Patients with Heart Failure and Renal Impairment or Hyponatremia
In patients with heart failure who have hyponatremia (serum sodium < 130 mEq/L) or moderate to severe renal impairment (creatinine clearance ≤ 30 mL/min or serum creatinine > 3 mg/dL), therapy with ZESTRIL should be initiated at a dose of 2.5 mg once a day under close medical supervision (See WARNINGS AND PRECAUTIONS, DRUG INTERACTIONS).
Acute Myocardial Infarction
In hemodynamically stable patients within 24 hours of the onset of symptoms of acute myocardial infarction, the first dose of ZESTRIL is 5 mg given orally, followed by 5 mg after 24 hours, 10 mg after 48 hours and then 10 mg of ZESTRIL once daily. Dosing should continue for six weeks. Patients should receive, as appropriate, the standard recommended treatments such as thrombolytics, aspirin, and beta-blockers.
Patients with a low systolic blood pressure ( ≤ 120 mmHg) when treatment is started or during the first 3 days after the infarct should be given a lower 2.5 mg oral dose of ZESTRIL (See WARNINGS). If hypotension occurs (systolic blood pressure ≤ 100 mmHg) a daily maintenance dose of 5 mg may be given with temporary reductions to 2.5 mg if needed. If prolonged hypotension occurs (systolic blood pressure < 90 mmHg for more than 1 hour) ZESTRIL should be withdrawn. For patients who develop symptoms of heart failure, see DOSAGE AND ADMINISTRATION, Heart Failure.
Dosage Adjustment in Patients With Myocardial Infarction with Renal Impairment
In acute myocardial infarction, treatment with ZESTRIL should be initiated with caution in patients with evidence of renal dysfunction, defined as serum creatinine concentration exceeding 2 mg/dL. No evaluation of dosing adjustments in myocardial infarction patients with severe renal impairment has been performed.
Use in Elderly
In general, the clinical response was similar in younger and older patients given similar doses of ZESTRIL. Pharmacokinetic studies, however indicate that maximum blood levels and area under the plasma concentration time curve (AUC) are doubled in older patients, so that dosage adjustments should be made with particular caution.
Pediatric Hypertensive Patients ≥ 6 years of age
The usual recommended starting dose is 0.07 mg/kg once daily (up to 5 mg total). Dosage should be adjusted according to blood pressure response. Doses above 0.61 mg/kg (or in excess of 40 mg) have not been studied in pediatric patients (See CLINICAL PHARMACOLOGY, Pharmacokinetics and Metabolism and Pharmacodynamics and Clinical Effects).
ZESTRIL is not recommended in pediatric patients < 6 years or in pediatric patients with glomerular filtration rate < 30 mL/min/1.73m² (See CLINICAL PHARMACOLOGY, Pharmacokinetics and Metabolism and Pharmacodynamics and Clinical Effects and PRECAUTIONS).
Preparation of Suspension (for 200 mL of a 1.0 mg/mL suspension)
Add 10 mL of Purified Water USP to a polyethylene terephthalate (PET) bottle containing ten 20–mg tablets of ZESTRIL and shake for at least one minute. Add 30 mL of Bicitrả3 diluent and 160 mL of Ora—Sweet SF™4 to the concentrate in the PET bottle and gently shake for several seconds to disperse the ingredients. The suspension should be stored at or below 25°C (77°F) and can be stored for up to four weeks. Shake the suspension before each use.
2.5 mg Tablets (NDC 0310-0135) white, round, biconvex, uncoated tablets identified as “ZESTRIL 2 1/2” on one side and “135” on the other side are supplied in bottles of 100 tablets.
5 mg Tablets (NDC 0310-0130) pink, capsule-shaped, biconvex, bisected, uncoated tablets, identified “ZESTRIL” on one side and “130” on the other side are supplied in bottles of 100 tablets.
10 mg Tablets (NDC 0310-0131) pink, round, biconvex, uncoated tablets identified “ZESTRIL 10” debossed on one side, and “131“ debossed on the other side are supplied in bottles of 100 tablets.
20 mg Tablets (NDC 0310-0132) red, round, biconvex, uncoated tablets identified “ZESTRIL 20” debossed on one side, and “132“ debossed on the other side are supplied in bottles of 100 tablets.
30 mg Tablets (NDC 0310-0133) red, round, biconvex, uncoated tablets identified “ZESTRIL 30” debossed on one side, and “133” debossed on the other side are supplied in bottles of 100 tablets.
40 mg Tablets (NDC 0310-0134) yellow, round, biconvex, uncoated tablets identified “ZESTRIL 40” debossed on one side, and “134” debossed on the other side are supplied in bottles of 100 tablets.
Store at controlled room temperature, 20-25°C (68-77°F) [see USP]. Protect from moisture, freezing and excessive heat. Dispense in a tight container.
Distributed by: AstraZeneca Pharmaceuticals LP Wilmington, DE 19850 Revision: 11/2013
Last reviewed on RxList: 12/12/2013
This monograph has been modified to include the generic and brand name in many instances.
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