Angiotension converting enzyme (ACE) inhibitors (captopril, cilazapril, enalapril, fosinopril, imidapril, lisinopril, moexipril perindopril, quinapril, ramipril, trandolapril) have many uses, including hypertension, heart failure and post-myocardial infarction. It is best to check the individual product's SPC to ensure it is being used for a licensed indication and at the correct dose.

Dosage regimen

* ACE inhibitors should be initiated at low doses and slowly titrated upwards until the optimal tolerated/target dose is achieved. They are normally taken once daily.

Patient's knowledge of the medicine's use

* ACE inhibitors are used for range of cardiovascular conditions, may of which are "silent". To improve compliance, explain to the patient why it is important to continue taking the medicine regularly.

Is the medicine working?

* Has the patient been taking the correct dosage of their medication?

* Has the patients symptoms/condition deteriorated? If so, refer back to the prescriber.

* Is the patient taking any OTC/herbal remedies, which may interact with their medication?

Side effects

* ACE inhibitors can cause profound first dose hypotension (in patients taking high doses of diuretics), renal impairment and a persistent dry cough.

* ACE inhibitors are potassium-sparing, with hyperkalaemia more common in those with renal impairment. ACE inhibitors should never be used with potassium-sparing diuretics.

Monitoring

* Electrolytes and renal function should be checked before an ACE inhibitor is started

* ACE inhibitors require biochemical monitoring after every dose change and then every six months.

Lifestyle

* Patients with cardiovascular conditions often benefit from regular aerobic and/or resistive exercise and quitting smoking and may be eligible for a "one-off" pneumococcal vaccination and a yearly flu vaccination.

* Patients on ACE inhibitors should be advised to avoid salt substitutes as these are likely to be potassium-based and may contribute to hyperkalaemia.

Kevin Alexander, community pharmacist, Hafod Pharmacy, Swansea / AF

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