Ramipril

Dose:1.25-2.5mg daily up to 10mg daily (dose increased at 2–4-week intervals

Renal:

• Crcl 30-60ml/min max daily dose 5mg
• Below 30ml/min  max daily dose 1.25mg

Lisinopril:

Dose: 10mg daily and usual maintenance 20mg daily. Max 80mg per day

Renal:

• CrCl: 30-80ml/mindaily dose 5-10mg
• CrCl: Less than 30ml/min dose 2.5-5mg daily

1. Monitoring: Renal Function
2. Blood Urea Nitrogen (BUN) and Creatinine: These parameters are also indicators of kidney function and should be monitored regularly, particularly in patients with existing kidney issues.
3. Blood Glucose: Patients with diabetes taking ACE inhibitors may need careful monitoring of their blood glucose levels, as these medications can affect blood sugar levels.

1. Potassium: ACE inhibitors can increase the levels of potassium in the blood, a condition known as hyperkalemia. High potassium levels can be dangerous, leading to irregular heart rhythms and, in severe cases, life-threatening cardiac events.
2. Sodium: While ACE inhibitors themselves do not typically cause hyponatremia (low sodium levels), the medications can exacerbate hyponatremia in people who are already at risk, such as those taking diuretics (water pills) or with certain medical conditions.
3. Chloride and Bicarbonate: ACE inhibitors can sometimes lead to mild metabolic acidosis, a condition where the blood becomes slightly acidic due to a decrease in bicarbonate levels or an increase in chloride levels.
4. Calcium: ACE inhibitors do not significantly affect calcium levels in most people. However, individuals with existing calcium imbalances or those taking other medications that influence calcium levels may experience changes when using ACE inhibitors.

• Hypotension, persistent dry cough, hyperkalaemia (due to low aldosterone levels promotes potassium levels)
• Worsen renal failure and rarely cause angioedema
• NSAIDs with ACE particularly increase the chances of nephrotoxicity
• Warning in breastfeeding
• dry cough, dizziness, headache, fatigue, hypotension (low blood pressure), and kidney problems. They may also cause a rare but serious side effect known as angioedema, which is swelling of the face, lips, tongue, throat, or extremities.

ARBs Losartan:

Adult 18–75 years

• Initially 50 mg once daily for several weeks, then increased if necessary to 100 mg once daily.

For Adult 76 years and over

• Initially 25 mg once daily for several weeks, then increased if necessary to 100 mg oce daily.

1. Blood Pressure Monitoring: Regular blood pressure checks are crucial to assess the medication’s effectiveness in controlling hypertension.
2. Kidney Function Tests: ARBs can affect kidney function, so periodic monitoring of kidney function is important. This may include checking serum creatinine levels and estimating the glomerular filtration rate (eGFR). Changes in kidney function may require adjustments in medication dosage.
3. Electrolyte Levels: ARBs can sometimes lead to imbalances in electrolytes, particularly potassium. Monitoring serum potassium levels can help prevent hyperkalemia (high potassium levels), which can be a potential side effect of ARBs.

• Hyperkalemia (High Potassium Levels): ARBs can reduce the excretion of potassium by the kidneys. In some cases, this reduced excretion can lead to an accumulation of potassium in the bloodstream, resulting in hyperkalemia.
• High potassium levels can be dangerous and may cause symptoms such as muscle weakness, irregular heartbeat, and, in severe cases, cardiac arrest.

Adverse effects: Common side effects of ARBs include dizziness, headache, fatigue, and hypotension (low blood pressure). Like ACE inhibitors, ARBs may cause hyperkalemia (high potassium levels) in some patients. They may also have rare adverse effects such as angioedema and kidney problems.

When to avoid: ARBs should be avoided in patients with a known hypersensitivity to ARBs or a history of angioedema caused by these medications. They are not recommended during pregnancy, especially in the second and third trimesters, as they can harm the developing fetus.

There are two different types of CCB’s that work differently

Rate-Limiting CCBs (Negative Chronotropes):

• Slow down heart rate and reduce AV node conduction (negative chronotrpe)
• Used for arrhythmias and angina.
• Examples: Verapamil and diltiazem.
• Classified as non-dihydropyridine CCBs.

Non-Rate-Limiting CCBs (Neutral Chronotropes):

• Do not significantly affect heart rate or AV node (neutral chorotrope) 
• Cause vasodilation, lowering blood pressure.
• Used for hypertension and cardiovascular conditions.
• Examples: Amlodipine, nifedipine, and felodipine.
• Classified as dihydropyridine CCBs.

Amlodipine (CCB):

• Initial Dose: 5mg daily
• Usual Maintenance Dose: 5-10mg daily
• Maximum Daily Dose: 10mg

Felodipine: 

• Initial Dose: 2.5mg daily
• Usual Maintenance Dose: 2.5-10mg daily
• Maximum Daily Dose: 10mg

Nifedipine (CCB):

• Initial Dose ( Immediate-release): 10-20mg three times daily
• Usual Maintenance Dose (Immediate-release): 30-90mg daily
• Maximum Daily Dose (Immediate-release): 120mg
  
  
• Initial Dose ( Extended-release): 30-60mg once daily
• Usual Maintenance Dose (Extended-release): 30-120mg once daily
• Maximum Daily Dose (Extended-release): 120mg

• Monitor for blood pressure 
• Overdose: Features of calcium-channel blocker poisoning include nausea, vomiting, dizziness, agitation, confusion, and coma in severe poisoning.
• Metabolic acidosis and hyperglycaemia may occur in overdose
• In overdose, the dihydropyridine calcium-channel blockers cause severe hypotension secondary to profound peripheral vasodilatation. 

• Non-rate-limiting CCBs, such as amlodipine and nifedipine, are generally not associated with significant electrolyte imbalances like potassium disturbances, as their primary mode of action is vasodilation.

• Dizziness or lightheadedness
• Gingivial hyperplasia
• Flushing or headache
• Swelling of the ankles or feet
• Constipation
• Nausea
• Fatigue

• Simvastatin (max 20mg of simvastatin with amlodipine)
• St Johns Wort is an an inducer of cytochrome P450 3A4 (CYP3A4) therefore increasing the metabolism of CCB
• Carbamazepine – may reduce exposure to amlodipine may reduce exposure to amlodipine

Bendroflumethiazide (Thiazide-like Diuretic):

• Initial Dose: 2.5mg once daily
• Usual Maintenance Dose: 2.5-5mg once daily
• Maximum Daily Dose: 5mg

Indapamide (Thiazide-like Diuretic):

• Initial Dose: 1.25 mg once daily
• Usual Maintenance Dose: 1.25-2.5 mg once daily
• Maximum Daily Dose: 5 mg

Renal: 

• Monitoring kidney function is important, as thiazide-like diuretics can affect renal function. Tests may include measuring serum creatinine levels and estimating the glomerular filtration rate (eGFR).
• Changes in kidney function may require adjustments in medication dosage or closer monitoring.

Glucose Levels:

• Thiazide-like diuretics can affect glucose metabolism and may lead to hyperglycemia (high blood sugar) in some individuals.
• Monitoring blood glucose levels may be necessary, especially in patients with diabetes or those at risk of developing diabetes.

Electrolytes

• Thiazide-like diuretics can lead to electrolyte imbalances, such as low potassium (hypokalemia) or sodium disturbances. Periodic monitoring of serum electrolyte levels is important.

• Aminoglycosides increased risk of ototoxicity
• NSAIDS increases risk of hepatotoxicity

• Hyperglycaemia
• Postural hypotension

Avoid in:

• Addisons
• Hypercalcaemia
• Hyponatraemia
• Refractory hypokalaemia
• Symptomatic hyperuricaemia

Caution:

• Diabetic gout

• Initial Dose: 25 to 50 milligrams (mg) once daily.
• Usual Maintenance Dose: 25 to 100 mg once daily.
• Maximum Daily Dose: 200 mg (in divided doses).

Taken with food

• Not licensed in hypertension 

1. Blood Pressure Monitoring: Regular blood pressure checks are crucial to assess the medication’s effectiveness in controlling hypertension.
2. Kidney Function Tests: ARBs can affect kidney function, so periodic monitoring of kidney function is important. This may include checking serum creatinine levels and estimating the glomerular filtration rate (eGFR). Changes in kidney function may require adjustments in medication dosage.

• Hyperkalemia – potassium levels must be below 4.5mmol/L

• Hyperchiosis
• Gynecomastia
• Alopecia
• Hyperkalaemia

Avoid in

• Addisons diease
• Anuria;
• Hyperkalemia – potassium levels must be below 4.5mmol/L