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Cholesterol Drug Precautions
and Nutrient Depletion
Source: Excerpts from Drug-Induced Nutrient Depletion Handbook 1999-2000
By Ross Pelton, RPh, PhD, CCN. James B. LaValle, Rph, DHM, NMD, CCN.
Ernest B. Hawkins, RPh, MS. Daniel L. Krinsky, RPh, MS.

Available in paperback for $34.95
Sources:    Research References/Bibliography
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Cerivastatin


Nutrients Depleted: Coenzyme Q10

U.S. Brand Names: Baycol™

Use: Adjunct to dietary therapy for the reduction of elevated total and LDL cholesterol levels in patients with primary hypercholesterolemia and mixed dyslipidermia when the response to dietary restriction of saturated fat and cholesterol and other nonpharmacological measures alone has been inadequate.

Pregnancy Risk Factor and Implications: X; enters breast milk/contraindicated.

Contraindications: Hypersensitivity or severe adverse reactions to cerivastatin or other statins; active hepatic disease, pregnancy.

Warnings/Precautions: Use with caution in patients with history of liver disease, those who are breast-feeding, and those predisposed to renal failure.

Adverse Reactions:
1% to 10% experience:
  • Cardiovascular: Chest pain, peripheral edema (2%)
  • Central nervous system: Headache, dizziness, insomnia, asthenia (2%)
  • Gastrointestinal: Pain (3%), diarrhea (4%), dyspepsia (6%), nausea (3%), constipation (2%)
  • Neuromuscular & skeletal: Myalgia (3%), arthralgia (7%), leg pain (2%)
    Less than 1% experience: LFTs, myopathy, possible rhabdomyolysis with renal failure, sinusitis, rhinitis, cough


  • Atorvastatin


    Nutrients Depleted: Coenzyme Q10

    U.S. Brand Names: Lipitor®

    Use: Adjunct to diet for the reduction of elevated total and LDL-cholesterol levels in patients with hypercholesterolemia (type IIa, IIb, and IIc); used in hypercholesterolemic patients without clinically evident heart disease to reduce the risk of myocardial infarction, to reduce the risk for revascularization, and reduce the risk of death due to cardiovascular causes.

    Pregnancy Risk Factor and Implications: X; enters breast milk/contraindicated.

    Contraindications: Hypersensitivity to atorvastatin or its components; patients with active liver disease; pregnancy or lactation.

    Warnings/Precautions: Discontinue therapy if symptoms of myopathy or renal failure due to rhabdomyolysis develop. Use with caution in patients with history of liver disease or who consume excessive amounts of alcohol. It is recommended that liver function tests (LFTs) be performed prior to and at 12 weeks following both the initiation of therapy and any elevate of dose, and periodically (eg, semiannually) thereafter.

    Adverse Reactions:
    More than 1% experience:
  • Central nervous system: Headache
  • Gastrointestinal: Diarrhea, flatulence, abdominal pain (2% to 3%)
  • Neuromuscular & skeletal: Myalgia (1% to 5%)

    Less than 1% experience: Giddiness, euphoria, mild confusion, impaired short-term memory, mild LFT increases, pharyngitis, rhinitis

    Overdose/Toxicology: Few symptoms are anticipated. Treatment is supportive.

  • Beta-Blockers


    Nutrients Depleted: Coenzyme Q10

    Generic Names: Acebutolol; Atenolol; Betaxolol; Bisoprolol; Carteolol; Carvedilol; Esmolol; Labetalol; Metoprolol; Nadolol; Pindolol; Propranolol; Sotalol; Timolol.

    U.S. Brand Names: Betapace®; Betimol®; Ophthalmic; Betoptic®; Ophthalmic; Betoptic®; S Ophthalmic;; Blocadren®; Oral; Lopressor®; Normodyne®; Ocupress®; Ophthalmic; Sectral®; Tenormin®; Timoptic® OcuDose®; Timoptic® Ophthalmic; Timoptic-XE® Ophthalmic; Toprol XL®; Trandate®; Zebeta®.

    Use: Treatment of hypertension, angina, IHSS, and arrhythmias. Treatment and prevention of myocardial infarction, and migraine. Use may be specific to individual agent. Selected agents are used in the management of congestive heart failure and superventricular arrhythmias. Additional unlabeled uses include management of esophageal varices, essential tremor, performance anxiety, hyperthyroidism, panic disorder, akathisia, and alcohol withdrawal.

    Pregnancy Risk Factor and Implications: C; Acebutolol, atenolol, betaxolol (oral), disoprolol, labetalol, metoprolol, nadolol, pindolol, propranolol, sotalol, timolol: Enters breast milk/use caution.

    Contraindications: Hypersensitivity to beta-blockers, uncompensated congestive heart failure, bradycardia, or heart block, cardiogenic shock, pulmonary edema, severe hyper-reactive airway disease, Raynaud's disease.

    Warnings/Precautions: Use with caution in patients with peripheral vascular disease, diabetes mellitus, asthma, chronic obstructive pulmonary disease, bradycardia, and hypotension.

    Adverse Reactions: Individual agents may vary in their potential to cause specific adverse effects. The listing below provides only a general indication of the spectrum and frequency of adverse reactions to beta-adrenergic blocking potential may cause increased hypotensive responses.

    Greater than 10% experience:
    Cardiovascular: Bradycardia
    Central nervous system: Mental depression
    Endocrine & metabolic: Decreased sexual ability

    1% to 10% experience:
    Cardiovascular: Congestive heart failure, reduced peripheral circulation
    Central nervous system: Confusion, hallucinations, dizziness, insomnia, fatigue
    Dermatologic: Rash
    Gastrointestinal: Diarrhea, nausea, vomiting, stomach discomfort
    Neuromuscular & skeletal: Weakness
    Respiratory: Wheezing

    Less than 1% experience: Chest pain, hypotension, impaired myocardial contractility, worsening of A-V conduction disturbances, nightmares, vivid dreams, lethargy, red, scaling, or crusted skin; hypoglycemia, hyperglycemia, GI distress, leukopenia, thrombocytopenia, agranulocytosis, bronchospasm, cold extremities.

    Overdose/Toxicology: Symptoms of intoxication include cardiac disturbances, CNS toxicity, bronchospasm, hypoglycemia, and hyperkalemia. The most common cardiac symptoms include hypotension and brady-cardia. Atrioventricular block, intraventricular conduction disturbances, Cardiogenic shock, and asystole may occur with severe overdose, especially with membrane-depressant drugs (eg, propranolol). CNS effects include convulsions and coma. Respiratory arrest (commonly seen with propranolol and other membrane-depressant and lipid-soluble drugs). Treat symptomatically. Cardiac and hemodynamic monitoring may be necessary.

    Bumetanide


    Nutrients Depleted: Calcium, Magnesium, Potassium, Vitamin B1, Vitamin B6, Vitamin C.

    U.S. Brand Names: Bumex®

    Use: Management of edema secondary to congestive heart failure or hepatic or renal disease including nephrotic syndrome; may be used alone or in combination with antihypertensives in the treatment of hypertesion; can be used in furosemide-allergic patients; (1 mg = 40 mg furosemide).

    Pregnancy Risk Factor and Implications: D; Excretion in breast milk unknown/use caution.

    Contraindications: Hypersensitivity to bumetanide or any component; in anuria or increasing azotemia.

    Warnings/Precautions: Profound diuresis with fluid and electrolye loss is possible; close medical supervision and dose evaluation is required; use caution when dosing in patients with hepatic failure.

    Adverse Reactions:
    Greater than 10% experience:
    Endocrine & metabolic: Hyperuricemia, hypochloremia, hypokalemia
    Renal: Azotemia.

    1% to 10% experience:
    Central nervous system: Dizziness, encephalopathy, headache
    Endocrine & metabolic: Hyponatremia
    Neuromuscular & skeletal: Muscle cramps, weakness

    Less than 1% experience: Hypotension, rash, pruritus, hyperglycemia, hyperuricemia, cramps, nausea, vomiting, alteration of liver function test results, hearing loss, increased serum creatinine.


    Overdose/Toxicology: Symptoms of overdose include electrolyte depletion and volume depletion. Treatment is symptomatic and supportive.

    Captopril


    Nutrients Depleted: Zinc

    U.S. Brand Names: Capoten®

    Use: Management of hypertension and treatment of congestive heart failure; left ventricular dysfunction after myocardial infarction (MI), diabetic nephropathy.

    Unlabeled use: Hypertensive crisis, rheumatoid arthritis, diagnosis of anatomic renal artery stenosis, hypertension secondary to scleroderma renal crisis, diagnosis of aldosteronism, idiopathic edema, Bartter's syndrome, increase circulation in Raynaud's phenomenon.

    Pregnancy Risk Factor and Implications: C (1st trimester); D (2nd and 3rd trimesters); Enters breast milk/compatible

    Contraindications: Hypersensitivity to captopril, other ACE inhibitors, or any component.

    Warnings/Precautions: Use with caution and decrease dosage in patients with renal impairment (especially renal artery stenosis), severe congestive heart failure, or with coadministered diuretic therapy; experience in children is limited. Severe hypotension may occur in patients who are sodium and/or volume depleted, initiate lower doses and monitor closely when starting therapy in these patients; ACE inhibitors may be preferred agents in elderly patients with congestive heart failure and diabetes mellitus (diabetic proteinuria is reduced, minimal CNS effects, and enhanced insulin sensitivity); however due to decreased renal function, tolerance must be carefully monitored.

    Adverse Reactions:
    Greater than 1% experience:
    Cardiovascular: Tachycardia, chest pain, palpitations
    Central nervous system: Insomnia, headache, dizziness, fatigue malaise
    Dermatologic: Rash (4% to 7%), pruritus, alopecia
    Gastrointestinal: Abdominal pain, vomiting, nausea, diarrhea, anorexia, constipation, abnormal taste (2% to 4%), xerostomia
    Neuromuscular & skeletal: Paresthesias
    Renal: Oliguria
    Respiratory: Transient cough (0.5% to 2%)

    Less than 1% experience: Hypotension, angioedema, hyperkalemia, neutropenia, agranulocytosis, proteinuria, increased BUN/serum creatinine.

    Overdose/Toxicology: Mild hypotension has been the primary toxic effect seen with acute overdose. Bradycardia may also occur. Hyperkalemia occurs even with therapeutic doses, especially in patients with renal insufficiency and those taking BSAIDs. Treatment is symptom directed and supportive.

    Chlorothiazide


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Zinc.

    U.S. Brand Names: Diurigen®, Diuril®

    Use: Management of mild to moderate hypertension, or edema associated with congestive heart failure, pregnancy, or nephrotic syndrome in patients unable to take oral hydrochlorothiazide, when a thiazide is the diuretic of choice.

    Pregnancy Risk Factor and Implications: B; Enters breast milk/use caution.

    Contraindications: Hypersensitivity to chlorothiazide or any component; cross-sensitivity with other thiazides or sulfonamides; do not use in anuric patients.

    Warnings/Precautions: Injection must not be administered S.C. or I.M.; may cause hyperbilirubinemia, hypokalemia, alkalosis, hyperglycemia, hyperuricemia; chlorothiazide is minimally effective in patients with a Cl(cr).
    Greater than 40 mL/minute; this may limit the usefulness of chlorothiazide in the elderly; use the I.V. form only when oral therapy is prohibitive or in and emergency, do not use in children if possible; avoid coadministration with blood.


    Adverse Reactions:
    1% to 10% experience: Endocrine & metabolic: Hypokalemia, hyponatremia

    Less than 1% experience: Arrhythmia, weak pulse, orthostatic hypotension, dizziness, vertigo, headache, fever, rash, photosensitivity, hypochloremic alkalosis, hyperglycemia, hyperlipidemia, hyperuricemia, rarely blood dyscrasias, leukopenia, agranulocytosis, aplastic anemia, paresthesias, prerenal azotemia.


    Overdose/Toxicology: Symptoms of overdose include hypermotility, diuresis, lethargy, confusion, muscle weakness, and coma. Treatment is supportive.

    Chlorthalidone


    Nutrients Depleted: Zinc

    U.S. Brand Names: Hygroton®; Thalitone®

    Canadian Brand Names: Apo®-Chlorthalidone; Novo-Thalidone; Uridon®

    Use: Management of mild to moderate hypertension, used aloneor in combination with other agents; treatment of edema associated with congestive heart failure, nephrotic syndrome, or pregnancy. Recent studies have found chlorthalidone effective in the treatment of isolated systolic hypertension in the elderly.

    Pregnancy Risk Factor and Implications: B; Enters breast milk/use caution.

    Contraindications: Hypersensitivity to chlorthalidone or any component cross-sensitivity with other thiazides or sulfonamides; do not use in anuric patients.

    Warnings/Precautions: Use with caution in patients with hypokalemia renal disease, hepatic disease, gout, lupus erythematosus, diabetes mellitus; use with caution in severe renal diseases.

    Adverse Reactions:
    1% to 10% experience: Hypokalemia

    Less than 1% experience: Hypotension, photosensitivity, fluid and electrolyte imbalances (hypocalcemia, hypomagnesemia, hyponatremia), hyperglycemia, rarely blood dyscrasias, prerenal azotemia.


    Overdose/Toxicology: Symptoms of overdose include hypermotility, diuresis, lethargy, confusion, muscle weakness, and coma. Treatment is supportive.

    Clonidine


    Nutrients Depleted: Coenzyme Q10

    U.S. Brand Names: Catapres® Oral; Catapres-TTS® Transdermal; Duraclon® Injection.

    Use: Management of mild to moderate hypertension; either used alone or in combination with other antihypertensives; not recommended for first-line therapy for hypertension; as a second-line agent for decreasing heroin or nicotine withdrawal symptoms in patients with severe symptoms; indicated by the epidural route, in combination with opiates, for treatment of severe pain in refractory cancer patients (most effective in patients with neuropathic pain); other uses may include prophylaxis of migraines, glaucoma, and diabetes-associated diarrhea.

    Pregnancy Risk Factor and Implications: C; Enters breast milk/not recommended.

    Contraindications: Hypersensitivity to clonidine hydrochloride or any component.

    Warnings/Precautions: Use with caution in cerebrovascular disease, coronary insufficiency, renal impairment, sinus node dysfunction; do not abruptly discontinue as rapid increase in blood pressure and symptoms of sympathetic overactivity (ie, increased heart rate, tremor, agitation, anxiety, inxomnia, sweating, palpitations) may occur; if need to discontinue, taper dose gradually over 1 week or more (2-4 days with epidural product); adjust dosage in patients with renal dysfunction (especially the elderly); not recommended for obstetrical, postpartum or perioperative pain management or in hypotension and bradycardia; clonidine injection should be administered via a continuous epidural infusion device.

    Adverse Reactions:
    Greater than 10% experience: Cardiovascular: Orthostatic hypotension (especially with epidural route), rebound hypertension, bradycardia.
    Central nervous system: Drowsiness, dizziness, confusion, anxiety.
    Gastrointestinal: Xerostomia, constipation, nausea.

    1% to 10% experience:
    Central nervous system: Mental depression, headache, fatigue, hyperaesthesia, pain.
    Dermatologic: Rash, skin ulcer.
    Respiratory: Dyspnea, hypoventilation.
    Cardiovascular: Chest pain.
    Endocrine & metabolic: Decreased sexual activity, loss of libido.
    Gastrointestinal: vomiting, constipation.
    Genitourinary: Nocturia, impotence.
    Hepatic: Abnormal liver function test.
    Neuromuscular & skeletal: Weakness.
    Otic: Tinnitus.

    Less 1% experience: Palpitations, tachycardia, Raynaud's phenomenon, congestive heart failure, insomnia, vivid dreams, delirium, fever, pruritus, urticaria, alopecia, gynecomastia, weight gain, urinary retention, dysuria, infection possible, burning eyes, blurred vision.


    Overdose/Toxicology: Symptoms of overdose include bradycardia, CNS depression, hypothermia, diarrhea, respiratory depression, and apnea. Treatment is supportive and symptomatic. Naloxone may be utilized in treating CNS depression and /or apnea and should be given I.V.,-.4-2 mg, with repeated doses as needed up to a total of 10 mg, or as an infusion.

    Enalapril


    Nutrients Depleted: Zinc

    U.S. Brand Names: Vasotec®; Vasotec® I.V.

    Use: Management of mild to severe hypertension and congestive heart failure; believed to prolong susvival in heart failure.

    Unlabeled Use: Hypertensive crisis, diabetic nephropathy, rheumatoid arthritis, diagnosis of anatomic renal artery stenosis, hypertension secondary to scleroderma renal crisis, diagnosis of aldosteronism, idiopathic edema, Bartter's syndrome, pastmyocardial infarction for prevention of ventricular failure.

    Pregnancy Risk Factor and Implications: C(1st trimester); D)2nd and 3rd trimester); Enters breast milk/compatible.

    Contraindications: Hypersensitivity to enalapril, enalaprilat, other ACE inhibitors, or any component.

    Warnings/Precautions: Use with caution and modify dosage in patients with renal impairment (especially renal artery stenosis), severe congestive heart failure, or with coadministered diuretic therapy, valvular stenosis, hyperkalemia(greater than 5.7 mEq/L); experience in children is limited. Severe hypotension may occur in patients who are sodium and/or volume depleted; initiate lower doses and monitor closely when starting therapy in these patients.

    Adverse Reactions:
    1% to 10% experience:
    Cardiovascular: Chest pain (2%), syncope(2%), hypotension (6.7%).
    Central nervous system: Headache (2% to 5%), dizziness (4% to 8%), fatigue (2% to 3%).
    Dermatologic: Rash (1.5%).
    Gastrointestinal: Abnormal taste, abdominal pain, vomiting, nausea, diarrhea, anorexia, constipation. Neuromuscular & skeletal: Weakness.
    Respiratory (1% to 2%): Bronchitis, cough, dyspnea.

    Less than 1% experience: Angina pectoris, pulmonary edema, palpitations, arrest, CVA, myocardial infarction, orthostatic hypotension, rhythm, insomnia, ataxia, drowsiness, confusion, depression, nervousness, vertigo, alopecia, erythema mutiforme, pruritus, Stevens-Johnson syndrome, urticaria, angioedema, pemphigus, hypoglycemia, hyperkaemia, gynecomastia, stomatitis, xerostomia, dyspepsia, glossitis, pacreatitis, ileus, urinary tract infection, importence, agranulocytosis, neutropenia, anemia, hemolysis with G-6-PD, jaundice, hepatitis, paresthesia, blurred vision, conjunctivitis, tinnitus, oliguria, renal dysfunction, asthma, bronchospasm, URI, diaphoresis.


    Overdose/Toxicology: Mild hypotension has been the primary toxic effect seen with acute overdose. Bradycardia may also occur. Hyperkalemia occurs even with therapeutic doses, especially in patients with renal insufficiency and those taking NSAIDs. Following initiation of essential overdose management, toxic symptom treatment and supportive treatment should be initiated.

    Fosinopril (foe SIN oh pril)


    Nutrients Depleted: Zinc.

    U.S. Brand Names: Monopril®

    Use: Treatment of hypertension, either alone or in combination with other antihypertensive agents; congestive heart failure; believed to prolong survival in heart failure.

    Pregnancy Risk Factor and Implications: C (1st trimester; D (2nd and 3rd trimester).

    Contraindications: Renal impairment, collagen vascular disease, hypersensitivity to fosinopril, any component, or other angiotensin-converting enzyme inhibitors.

    Warnings/Precautions: Use with caution and modify dosage in patients with renal impairment (decrease dosage) (especially renal artery stenosis), severe congestive heart failure or with coadministered diuretic therapy; experience in children is limited. Severe hypotension may occur in patients who are sodium and/or volume depleted; initiate lower doses and monitor closely when starting therapy in these patients.

    Adverse Reactions:
    1% to 10% experience:
    Cardiovascular: Orthostatic hypotension (especially after initial dose)
    Central nervous system: Headache (3%), dizziness (1% to 2%), fatigue (1% to 2%).
    Gastrointestinal: Diarrhea/nausea/vomiting (1% to 2%).
    Respiratory: Cough (2%).

    Less than 1% experience: Syncope, hypotension, hypertensive crisis, claudication, edema, vertigo, insomnia, memory disturbance, drowsiness, angioedema, rash, hypoglycemia, hyperkalemia, abnormal taste, dysphagia, abdominal distention, dyspepsia, impotence, neutropenia, agranulocytosis, anemia, muscle cramps, tremor, deterioration in renal function, cold/flu symptoms.


    Overdose/Toxicology: Mild hypotension has been the primary toxic effect seen with acute overdose. Bradycardia may also occur; hyperkalemia occurs even with therapeutic doses, especially in patients with renal insufficiency and those taking NSAIDs. Treatment is symptom directed and supportive.

    Furosemide


    Nutrients Depleted: Calcium, Magnesium, Potassium, Vitamin B1, Vitamin B6, Vitamin C, Zinc.

    U.S. Brand Names: Lasix®

    Use: Management of edema associated with congestive heart failure and hepatic or renal disease; used alone or in combination with antihypertensives in treatment of hypertension.

    Pregnancy Risk Factor and Implications: C; Enters breast milk/use caution.

    Contraindications: Hypersensitivity to furosemide, any component, or other sulfonamides; use with sparfloxacin; anuric patients.

    Warnings/Precautions: Loop diuretics are potent diuretics; close medical supervision and dose evaluation is required to prevent fluid and electrolyte imbalance; use caution with other nephrotoxic or ototoxic drugs.

    Adverse Reactions:
    Greater than 10% experience:
    Cardiovascular: Orthostatic hypotension.
    Central nervous system: Dizziness.

    1% to 10% experience:
    Central nervous system: Headache.
    Dermatologic: Photosensitivity.
    Endocrine & metabolic: Electrolyte imbalance (hypokalemia, hyponatremia, hypochloremia, hypercalciuria, hyperuricemia), alkalosis, dehydration.
    Gastrointestinal: Diarrhea, loss of appetite, stomach cramps or pain.
    Oscular: Blurred vision.

    Less 1% experience: Rash, pancreatitis, nausea, hepatic dysfunction, agranulocytosis, leukopenia, anemia, thrombocytopenia, redness at injection site, gout, xanthopsia, ototoxicity, nephrocalcinosis, interstitial nephritis, prerenal azotemia.


    Overdose/Toxicology: Symptoms of overdose include electrolyte depletion, volume depletion, hypotension, dehydration, and circulatory collapse. Treatment is supportive.

    Hydralazine


    Nutrients Depleted: Coenzyme Q10, Vitamin B6

    U.S. Brand Names: Apresoline®

    Use: Management of moderate to severe hypertension, congestive heart failure, hypertension secondary to pre-eclampsia/eclampsia; also used to treat primary pulmonary hypertension.

    Pregnancy Risk Factor and Implications: C; Enters breast milk/compatible.

    Contraindications: Hypersensitivity to hydralazine or any component, dissecting aortic aneurysm, mitral valve rheumatic heart disease.

    Dietary Considerations: Food enhances bioavailability of hydralazine.

    Warnings/Precautions: Discontinue hydralazine in patients who develop SLE-like syndrome or positive ANA. Use with caution in patients with severe renal disease or cerebral vascular accidents or with known or suspected coronary artery disease; monitor blood pressure closely with I.V. use; some formulations may contain tartrazines or sulfites. Slow acetylators, patients with decreased renal function, and patients receiving greater than 200 mg/day (chronically are at higher risk for SLE. Titrate dosage to patient's response. Usually administered with diuretic and a beta-blocker to counteract side effects of sodium and water retention and reflex tachycardia.

    Adverse Reactions:
    Greater than 10% experience: Cardiovascular: Palpitations, flushing, tachycardia, angina pectoris
    Central nervous system: Headache
    Gastrointestinal: Nausea, vomiting, diarrhea, anorexia

    1% to 10% experience: Cardiovascular: Hypotension, redness or flushing of face.
    Gastrointestinal: Constipation
    Ocular: Lacrimation
    Respiratory: Dyspnea, nasal congestion

    Less than 1% experience: Malaise, fever, dizziness, rash, edema, arthralgias, weakness, peripheral neuritis, positive ANA, positive LE cells.

    NOTE: Because of blunted beta-receptor response, the elderly are less likely to experience reflex tachycardia; this puts them at greater risk for orthostatic hypotension.


    Overdose/Toxicology: Symptoms of overdose include hypotension, tachycardia, and shock. Treatment is supportive and symptomatic.

    Hydralazine & Hydrochlorothiazide


    Nutrients Depleted: Coenzyme Q10, Vitamin B6

    U.S. Brand Names: Apresazide®

    Use: Management of moderate to severe hypertension and treatment of congestive heart failure.

    Pregnancy Risk Factor and Implications: C

    Contraindications: Hypersensitivity to hydralazine, hydrochlorothiazide, or any component.

    Warnings/Precautions: This fixed combination is not indicated for initial therapy of hypertension; therapy requires titration to the individual patient, if dosage so determined represents this fixed combination, its use may be more convenient.

    Hydralazine, Hydrochlorothiazide, and Reserpine


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Vitamin B6, Zinc.

    U.S. Brand Names: Esidrix®; Ezide®; HydroDIURIL®; Hydro-Par®; Micro-zide™; Oretic®.

    Use: Management of mild to moderate hypertension; treatment of edema in congestive heart failure and nephrotic syndrome.

    Pregnancy Risk Factor and Implications: B; Enters breast milk/use caution.

    Contraindications: Anuria, renal decompensation, hypersensitivity to hydrochlorothiazide or any component, cross-sensitivity with other thiazides and sulfonamide derivatives.

    Warnings/Precautions: Use with caution in renal disease, hepatic disease, gout, lupus erythematosus, diabetes mellitus; some products may contain tartrazine. Hydrochlorothiazide is not effective in patients with a CIcr 25-50 mL/minute, therefore, it may not be a useful agent in many elderly patients.

    Adverse Reactions:
    1% to 10% experience: Endocrine & metabolic: Hypokalemia

    Less 1% experience: Hypotension, photosensitivity, fluid and electrolyte imbalances, hyperglycemia, rarely blood dyscrasias, prerenal azotemia.

    Overdose/Toxicology: Symptoms of overdose include hypermotility, diuresis, lethargy, confusion, and muscle weakness. Treatment is supportive.

    Hydrochlorothiazide


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Vitamin B6, & Zinc.

    U.S. Brand Names: Esidrix®; Ezide®; HydroDIURIL®; Hydro-Par®; Microzide™; Oretic®

    Use: Management of mild to moderate hypertension; treatment of edema in congestive heart failure and nephrotic syndrome.

    Pregnancy Risk Factor and Implications: B; enters breast milk/use caution.

    Contraindications: Anuria, renal decompensation, hypersensitivity to hydrochlorothiazide or any component, cross-sensitivity with other thiazides and sulfonamide derivatives.

    Warnings/Precautions: Use with caution in renal disease, hepatic disease, gout, lupus erythematosus, diabetes mellitus; some products may contain tartrazine. Hydrochlorothiazide is not effective in patients with a CIcr 25-50 mL/minute, therefore, it may not be a useful agent in many elderly patients.

    Adverse Reactions:

    1% to 10% experience:
    Endocrine & metabolic: Hypokalemia

    Less than 1% experience: Hypotension, photosensitivity, fluid and electrolyte imbalances, hyperglycemia, rarely blood dyscrasias, prerenal azotemia.

    Overdose/Toxicology: Symptoms of overdose include hypermotility, diuresis, lethargy, confusion, and muscle weakness, Treatment is supportive.

    Hydrochlorothiazide and Triamterene


    Nutrients Depleted: Calcium, Folic Acid, Vitamin B6.

    U.S. Brand Names: Dyazide®; Maxzide®.

    Use: Management of mild to moderate hypertension; treatment of edema in congestive heart failure and nephrotic syndrome.

    Pregnancy Risk Factor and Implications: B; Excretion in breast milk unknown/use caution.

    Contraindications: Anuria, hyperkalemia, renal or hepatic failure, hypersensitivity to hydrochlorothiazide, triamterene or any component; concurrent use of potassium supplements.

    Warnings/Precautions: This fixed combination is not indicated for initial therapy of hypertension; therapy requires titration to the individual patient, if dosage so determined represents this fixed combination, its use may be more convenient; safety and efficacy in children have not been established; avoid interchanging brands of drug.

    Serum potassium concentration do not necessarily indicate the true body potassium concentration. A rise in plasma pH or an increase in the circulating levels of insulin or epinephrine may cause a decrease in plasma potassium concentration and an increase in the intracellular potassium concentration. The efficacy of hydrochlorothiazide is limited in patients with Clcr Less than 30 mL/minute.

    Adverse Reactions:
    1% to 10% experience: Gastrointestinal: Loss of appetite, nausea, vomiting, stomach cramps, diarrhea, upset stomach.

    Less than 1% experience: Dizziness, fatigue, purpura, electrolyte disturbances, burning of tongue, aplastic anemia, agranulocytosis, hemolytic anemia, leukopenia, thrombocytopenia, megaloblastic anemia, muscle cramps, xanthopsia, transient blurred vision, allergic pneumonitis, pulmonary edema, respiratory distress, bright orange tongue, cracked corners of mouth.

    Overdose/Toxicology: Triamterene: Symptoms of overdose include drowsiness, confusion, clinical signs of dehydration, electrolyte imbalance, and hypotension; ingestion of large amounts of potassium-sparing diuretics, may result in life-threatening hyperkalemia. This can be treated with I.V. glucose with concurrent regular insulin, I.V. sodium bicarbonate and, if needed, Kayexalate® oral or rectal solutions in sorbitol may also be used. Hydrochlorothiazide: Symptoms of overdose include hypermotility, diuresis, lethargy, confusion, muscle weakness; following GI decontamination, therapy is supportive with I.V. fluids, electrolytes, and I.V. pressors if needed.

    Hydroflumethiazide


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Zinc.

    U.S. Brand Names: Diucardin®; Saluron®.

    Use: Management of mild to moderate hypertension; treatment of edema in congestive heart failure and nephrotic syndrome.

    Pregnancy Risk Factor and Implications: C; Excretion in breast milk unknown/use caution.

    Contraindications: Anuria, renal decompensation, hypersensitivity to hydrochlorothiazide or any component, cross-sensitivity with other thiazides and sulfonamide derivatives.

    Warnings/Precautions: Use with caution in renal disease, hepatic disease, gout, lupus erythematosus, diabetes mellitus; some products may contain tartrazine.

    Adverse Reactions:
    1% to 10% experience: Endocrine & metabolic: Hypokalemia.

    Less than 1% experience: Hypotension, drowsiness, photosensitivity, rash, fluid and electrolyte imbalances (hypocalcemia, hypomagnesemia, hyponatremia), hyperglycemia, anorexia, polyuria, aplastic anemia, hemolytic anemia, leukopenia, agranulocytosis, thrombocytopenia, rarely blood dyscrasias, hepatitis, paresthesia, prerenal azotemia, uremia.


    Overdose/Toxicology: Symptoms of overdose include hypermotility, diuresis, and lethargy. Treatment is supportive.

    Indapamide


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Zinc.

    U.S. Brand Names: Lozol®

    Use: Management of mild to moderate hypertension; treatment of edema in congestive heart failure and nephrotic syndrome.

    Pregnancy Risk Factor and Implications: D; Excretion in breast milk unknown.

    Contraindications: Anuria, hypersensitivity to indapamide or any component, cross-sensitivity with other thiazides and sulfonamide derivatives.

    Warnings/Precautions: Use with caution in patients with renal or hepatic disease, gout, lupus erythematosus, or diabetes mellitus.

    Adverse Reactions:
    1% to 10% experience: Endocrine & metabolic: Hypokalemia.

    Less than 1% experience: Arrhythmia, weak pulse, hypotension, mood changes, photosensitivity, fluid and electrlyte imbalances (hypocalcemia, hypomagnesemia, hyponatremia), hyperglycemia, xerostomia, rarely blood dyscrasias, numbness or paresthesia in hands, feet or lips, muscle cramps or pain, unusual weakness, prerenal azotemia, shortness or breath, increased thirst.


    Overdose/Toxicology: Symptoms of overdose include lethargy, diuresis, hypermotility, confusion, and muscle weakness. Treatment is supportive.

    Methyclothiazide


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Zinc.

    U.S. Brand Names: Aquatensen®; Enduron®

    Use: Management of mild to moderate hypertension; treatment of edema in congestive heart failure and nephrotic syndrome.

    Pregnancy Risk Factor and Implications: D; Excretion in breast milk unknown/use caution.

    Contraindications: Hypersensitivity to methyclothiazide, other thiazides or sulfonamides, or any component, anuria.

    Warnings/Precautions: Use with caution in renal disease, hepatic disease, gout, lupus erythematosus, diabetes mellitus; some products may contain tartrazine.

    Adverse Reactions:
    1% to 10% experience: Endocrine & metabolic: Hypokalemia

    Less than 1% experience: Hypotension, drowsiness, photosensitivity, rash, fluid and electrolyte imbalances (hypocalcemia, hypomagnesemia, hyponatremia), hyperglycemia, nausea, vomiting, anorexia, polyuria, rarely blood dyscrasias, aplastic anemia, hemolytic anemia, leukopenia, agranulocytosis, thrombocytopenia, hepatitis, paresthesia, prerenal azotemia, uremia.


    Overdose/Toxicology: Symptoms of overdose include hypermotility, diuresis, and lethargy. Treatment is supportive.

    Methyldopa


    Nutrients Depleted: Coenzyme Q10

    U.S. Brand Names: Aldomet®

    Pregnancy Risk Factor and Implications: B (oral); C (I.V.); Enters breast milk/compatible.

    Contraindications: Hypersensitivity to methyldopa or any component; (oral suspension contains benzoic acid and sodium bisulfite; injection contains sodium bisulfite); liver disease, pheochromocytoma, coadministration with MAO inhibitors.

    Warnings/Precautions: May rarely produce hemolytic anemia and liver disorders; positive Coombs' test occurs in 10% to 20% of patients (perform periodic CBDs); sedation usually transient may occur during initial therapy or whenever the dose is increased. Use with caution in patients with previous liver disease or dysfunction, the active metabolites of methyldopa accumulate in uremia. Patients with impaired renal function may respond to smaller doses. Elderly patients may experience syncope (avoid by giving smaller doses). Tolerance may occur usually between the second and third month of therapy. Adding a diuretic or increasing the dosage of methyldopa frequently restores blood pressure control. Because of its CNS effects, methyldopa is not considered a drug of first choice in the elderly.

    Adverse Reactions:
    Cardiovascular: Peripheral edema, orthostatic hypotension, bradycardia (sinus).
    Central nervous system: Drug fever, mental depression, anxiety, nightmares, drowsiness, headache, fever, chills, sedation, vertigo, depression, memory lapse.
    Dermatologic: Rash
    Endocrine & metabolic: Sodium retention, sexual dysfunction, gynecomastia, hyperprolactinemia.
    Gastrointestinal: Xerostomia, colitis, pancreatitis, diarrhea, nausea, vomiting, "black" tongue.
    Genitourinary: Decreased libido.
    Hematologic: Thrombocytopenia, hemolytic anemia, positive Coombs' test, leukopenia, transient leukopenia or granulocytopenia.
    Hepatic: Cholestasis or hepatitis and heptocellular injury, increased liver enzymes, jaundice, cirrhosis.
    Neuromuscular & skeletal: Paresthesias, weakness.
    Respiratory: Dyspnea.
    Miscellaneous: SLE-like syndrome
    .

    Overdose/Toxicology: Symptoms of overdose include hypotension, sedation, bradycardia, dizziness, constipation or diarrhea, flatus, nausea, and vomiting. Treatment is supportive and symptomatic. Can be removed by hemodialysis.

    Metolazone


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Zinc.

    Use: Management of mild to moderate hypertension; treatiment of edema in congestive heart failure and nephrotic syndrome, impaired renal function.

    Pregnancy Risk Factor and Implications: D; Enters breast milk/use caution.

    Contraindications: Hypersensitivity to metolazone or any component other thiazides, and sulfonamide derivatives; patients with hepatic coma, anuria.

    Warnings/Precautions: Use with caution in renal disease, hepatic disease, gout, lupus erythematosus, diabetes mellitus; some products may dontain tartrazine. Mykrox is not bioequivalient to Zaroxolyn® and should not be interchanged for one another.

    Adverse Reactions:
    1% to 10% experience: Cardiovascular: Chest pain (3% with fast-acting product) Central nervous system: Dizziness (10%), headache (9%) Endocrine & metabolic: Hypokalemia Neuromuscular & skeletal: Muscle cramps/spasms (6%)

    Less than 1% experience: Hypotension, drowsiness, photosensitivity, rash, fluid and electrolyte imbalances (hypocalcemia, hypomagnesemia, hyponatremia), hyperglycemia, nausea, vomiting, anorexia, polyuria, rarely blood dyscraseas, aplastic anemia, hemolytic anemia, leukopenia, agranulocytosis, thrombocytopenia, hepatitis, paresthesia, prerenal azotemia, uremia.


    Overdose/Toxicology: Sympptoms of overdose include orthostatic hypotension, dizziness, drowsiness, syncope, hemoconcentration and hemodynamic changes due to plasma volume depletion. Treatment is symptomatic and supportive.

    Moexipril


    Nutrients Depleted: Zinc

    U.S. Brand Names: Univasc®

    Use: Treatment of hypertension, alone or in combination with thiazide diuretics in a once daily dosing regimen.

    Pregnancy Risk Factor and Implications: C (1st trimester); D (2nd and 3rd trimester.

    Contraindications: Hypersensitivity to moexipril, meoxiprilat, or component; hypersensitivity or allergic reactions or angioedema related to an ACE inhibitor.

    Warnings/Precautions: Do not administer in pregnancy; use with caution and modify dosage in patients with renal impairment especially renal artery stenosis, severe congestive heart failure, or with coadministered diuretic therapy; experience in children is limited. Severe hypotension may occur in patients who are sodium and/or volume depleted; initiate lower doses and monitor closely when starting therapy in these patients; ACE inhibitors may be preferred agents in elderly patients with congestive heart failure and diabetes mellitus (diabetic proteinuria is reduced, minimal CNS effects, and enhanced insulin sesitivity), however due to decreased renal function, tolerance must be carefully monitored; if possible, discontinue the diuretic 2-3 days prior to initiating moexipril in patients receiving them to reduce the risk of symptomatic hypotension.

    Adverse Reactions:
    1% to 10% experience: Central nervous system: Headache, dizziness, fatigue.
    Dermatologic: Rash, pruritus, alopecia, flushing, rash
    Endocrine & metabolic: Hyperkalemia
    Gastrointestinal: Diarrhea
    Genitourinary: Polyuria
    Renal: Oliguria, reversible increases in creatinine or BUN. Respiratory: Nonproductive cough (6%), pharyngitis, upper respiratory infections, rhinitis.
    Miscellaneous: Flu-like symptoms.

    Less than 1% experience: Symptomatic hypotension, chest pain, angina, peripheral edema, myocardial infarction, palpitations, arrhythmias, sleep disturbances, anxiety, mood changes, angioedema, photosensitivity, pemphigus, hypercholesterolemia, abdominal pain, taste disturbance, constipation, vomiting, xerotomia, changes in appetite, pancreatitis, abnormal taste, neutropenia, elevated LFTs, myalgia, arthralgia, proteinuria, bronchospasm, dyspnea.


    Overdose/Toxicology: Mild hypotension has been the primary toxic effect seen with acute overdose. Bradycardia may also occur. Hyperkalemia occurs even with therapeutic doses, especially in patients with renal insufficiency and those taking NSAIDs. Treatment is symptom directed and supportive.

    Perindopril Erbumine


    Nutrients Depleted: Zinc

    U.S. Brand Names: Aceon®

    Use: Treatment of stage I or II hypertension and congestive heart failure.

    Pregnancy Risk Factor and Implications: D (especially during 2nd and 3rd trimester).

    Contraindications: Hypersensitivity to perindopril perindoprilat, other ACE inhibitors, or any component; pregnancy; history of angioedema with other ACE inhibitors.

    Warnings/Precautions: Use with caution and modify dosage in patients with reanl impairment (especially renal artery stenosis), sever congestive heart failure, or with coadministered diuretic therapy, valvular stenosis, hyperkalemia (>5.7 mEq/L); experience in children is limited. Severe hypotension may occur in patients who are sodium and/or volume depleted; initiate lower doses and monitor closely when starting therapy in these patients.

    Adverse Reactions:
    1% to 10% experience: Central nervous system: Headache, dizziness, mood and sleep dosorders, fatigue.
    Dermatologic: Rash, pruritus
    Gastrointestinal: Nausea, epigastric pain, diarrhea, vomiting
    Neuromuscular & skeletal: Muscle cramps
    Respiratory: Cough (incidence is greater in women, 3:1)

    Less than 1% experience: Hypotension, angioedema, psoriasis, hyperkalemia, taste disturbances, impotence, agranulocytosis for all ACE inhibitors (especially in patients with renal impairment or collagen vascular disease), possibly neutropenia, dry eyes, blurred vision, optic phosphenes, decreases in creatinine clearance in some elderly hypertensive patients or those with chronic renal failure, worsening of renal function in patients with bilateral renal artery stenosis, or furosemide therapy; proteinuria.


    Overdose/Toxicology: Mild hypotension has been the primary toxic effect seen with acute overdose. Bradycardia may also occur. Hyperkalemia occurs even with therapeutic doses, especially in patients with renal insufficiency and those taking NSAIDs. Treatment is symptom directed and supportive.

    Polythiazide


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Zinc.

    U.S. Brand Names: Renese®

    Use: Adjunctive therapy in treatment of edema and hypertension.

    Pregnancy Risk Factor and Implications: D

    Contraindications: Anuria; hypersensitivity to polythiazide or any other sulfonamide derivatives.

    Warnings/Precautions: Use with caution in renal disease, hepatic disease, gout, lupus erythematosus, diabetes mellitus; some products may contain tartrazine.

    Adverse Reactions:
    1% to 10% experience: Hypokalemia

    Less than 1% experience: Hypotension, drowsiness, photosensitivity, rash, fluid and electrolyte imbalances (hypocalcemia, hypomagnesemia, hyponatremia), hyperglycemia, nausea, vomiting, anorexia, polyuria, rarely blood dyscrasias, hepatitis, prerenal azotemia, uremia.


    Overdose/Toxicology: Symptoms of overdose include hypermotility, diuresis, lethargy, confusion, muscle weakness. Following GI decontamination, therapy is supportive with I.V. fluids, electrolytes, and I.V. pressors if needed.

    Potassium Chloride (Time Release)


    Nutrients Depleted: Vitamin B12

    U.S. Brand Names: Cena-K®; Gen-K®; K+ 10®; Kaochlor®; Daochlor® SF; Kaon-Cl®; Kaon Cl-10®; Kay Ciel®; K+ Care®; K-Dur® 10; K-Dur® 20; K-Lease®; K-Lor™; Klor-Con®; Klor-Con® 8; Klor-Con® 10; Klor-Con/25®; Klorvess®; Klotrix®; K-Lyte/Cl®; K-Norm®; K-Tab®; Micro-K® 10; Micro-K® Extencaps®; Micro-K® LS®; Potasalan®; Rum-K®; Slow-K®; Ten-K®.

    Use: Treatment or prevention of hypokalemia.

    Pregnancy Risk Factor and Implications: A; Enters breast milk/compatible.

    Contraindications: Severe renal impairment, untreated Addison's disease, heat cramps, hyperkalemia, severe tissue trauma; solid oral dosage forms are constraindicated in patients in whom there is a structural, pathological, and/or phrmacologic cause for delay or arrest in passage through the GI tract; an oral liquid potassium preparation should be used in patients with esophageal compression or delayed gastric emptying time.

    Warnings/Precautions: Use with caution in patients with cardiac disease, severe renal impairment, hyperkalemia.

    Adverse Reactions:
    More than 10% experience: Gastrointestinal: Diarrhea, nausea, stomach pain, flatulence, vomiting (oral).

    1% to 10% experience: Cardiovascular: Bradycardia
    Endocrine & metabolic: Hyperkalemia
    Local: Local tissue necrosis with extravasation, pain at the site of injection.
    Neuromuscular & skeletal: Hyperkalemia
    Respiratory: Dyspnea

    Less than 1% experience: Chest pain, arrhythmias, heart block, hypotension, mental confusion, alkalosis, abdominal pain, throat pain, phlebitis, paresthesias, paralysis.


    Overdose/Toxicology: Symptoms of overdose include muscle weakness, paralysis, peaked T waves flattened P waves, prolongation of QRS complex, and ventricular arrhythmias. Removal of potassium can be accomplished by various means: removal through the GI tract with Kayexalate® administration; by way of the kidney through diuresis, mineralocorticoid administration, or increased sodium intake; by hemodialysis or peritoneal dialysis; by shifting potassium back into the cells by insulin and glucose infusion; or by administration of sodium bicarbonate. Calcium chloride reverses cardiac effects.

    Quinapril


    Nutrients Depleted: Zinc

    U.S. Brand Names: Accupril®

    Use: Management of hypertension and treatment of congestive heart failure; increase circulation in Raynaud's phenomenon; idiopathic edema; believed to improve survival in heart failure.

    Pregnancy Risk Factor and Implications: C (1st trimester); D (2nd and 3rd trimester); Excretion in breast milk unknown.

    Contraindications: Hypersensitivity to quinapril or history of angioedema induced by other ACE inhibitors.

    Warnings/Precautions: Use with caution in patients with renal insufficiency, autoimmune disease, renal artery stenosis; excessive hypotension may be more likely in volum-depleted patients, the elderly, and following the first dose (first dose phenomenon); quinapril should be discontinued of laryngeal stridor or angioedema of the face, tongue, or glottis is observed.

    Adverse Reactions:
    1% to 10% experience: Cardiovascular: Hypotension
    Central nervous system: Dizziness (3.9%), headache (5.6%), fatigue (2.6%).
    Gastrointestinal: Vomiting/nausea(1.4%)
    Renal: Increased BUN/serum creatinine (transient)
    Respiratory: Upper respiratory symptoms, cough(2%)

    Less than 1% experience: Chest discomfort, flushing, myocardial infarction, angina pectoris, orthostatic hypotension, rhythm disturbances, tachycardia, peripheral edema, vasculitis, palpitation, syncope, fever, malaise, depression, somnolence, insomnia, urticaria, pruritus, angioedema, gout, pancreatitis, abdominal pain, anorexia, constipation, flatulence, xerostomia, neutropenia, bone marrow suppression, hepatitis, arthralgia, shoulder pain, bluued vision, bronchitis, sinusitis, pharyngeal pain, diaphoresis.


    Overdose/Toxicology: Mild hypotension has been the primary toxic effect seen with acute overdose. Bradycardia may also occur. Hyperkalemia occurs even with therapeutic doses, especially in patients with renal insufficiency and those taking NSAIDs. Treatment is symptom directed and supportive.

    Quinethazone


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Zinc.

    U.S. Brand Names: Hydromox®

    Use: Adjunctive therapy in treatment of edema and hypertension.

    Pregnancy Risk Factor and Implications: D

    Contraindications: Anuria; hypersensitivity to sulfonamide-derived drugs.

    Warnings/Precautions: Use with caution in renal disease, hepatic disease, gout, lupus erythematosus, diabetes mellitus; some products may contain tartrazine.

    Adverse Reactions: 1% to 10% experience: Endocrine & metabolic: Hypokalemia

    Less than 1% experience: Hypotension, drowsiness, photosensitivity, rash, fluid and electrolyte imbalances (hypocalcemia, hypomagnesemia, hyponatremia, hyperglycemia, hyperuricemia) with slow-acting product, nausea, vomiting, anorexia, polyuria, aplastic anemia, hemolytic anemia, leukopenia, agranulocytosis, thrombocytopenia, hepatitis, prerenal azotemia, uremia.


    Overdose/Toxicology: Symptoms of overdose include hypermotility, diuresis, lethargy, confusion, muscle weakness. Following GI decontamination, therapy is supportive with I.V. fluids, electrolytes, and I.V. pressors if needed.

    Ramipril


    Nutrients Depleted: Zinc

    U.S. Brand Names: Altace™

    Use: Treatment of hypertension, alone or in combination with thiazide diuretics; treatment of congestive heart failure within the first few days after myocardial infarction (Note: This indication is based on a study involving 2006 patients; a decrease by 26% in all-cause mortality was observed when ramipril was administered 3-10 days after a myocardial infarction).

    Pregnancy Risk Factor and Implications: C (1st trimester); D (2nd and 3rd trimester); Enters breast milk/not recommended.

    Contraindications: Hypersensitivity to ramipril or ramiprilat, or history of angioedema with any other angiotensin-converting enzyme inhibitors.

    Warnings/Precautions: Use with caution and modify dosage in patients with renal impairment (especially renal artery stenosis), severe congestive heart failure; severe hypotension may occur in the elderly and patients who are sodium and/or volume depleted, initiate lower doses and monitor closely when starting therapy in these patients; should be discontinued if laryngeal stridor or angioedema of the face tongue, or glottis is observed.

    Adverse Reactions:
    More than 10% experience: Respiratory: Cough (12%)

    Less than 1% experience: Hypotension, syncope, arrhythmia, angina, palpitations, myocardial infarction, headache, dizziness, fatigue, insomnia, drowsiness, depression, malaise, nervousness, vertigo, amnesia, convulsions, rash, pruritus, alopecia, photosensitivity, angioedema rash, dermatitis, hyperkalemia (small increase in patients with renal dysfunction), abdominal pain (rarely occurs but may with enzyme changes which suggest pancreatitis), vomiting, nausea, diarrhea, dysgeusia, anorexia, constipation, dyspepsia, xerostomia, dysphagia, increased salivation, weight gain, impotence, neutropenia, eosinophilia, decreased hemoglobin (rare), muscle cramps, myalgia, arthritis, arthralgia, paresthesia, tremor, neuralgia, neuropathy, tinnitus, proteinuria, transient increases BUN/serum creatinine, epistaxis, dyspnea, flu-like symptoms, diaphoresis.


    Overdose/Toxicology: Mild hypotension has been the primary toxic effect seen with acute overdose. Bradycardia may also occur. Hyperkalemia occurs even with therapeutic doses, especially in patients with renal insufficiency and those taking NSAIDs. Treatment is symptom directed and supportive.

    Torsemide


    Nutrients Depleted: Calcium, Magnesium, Potassium, Vitamin B1, Vitamin B6, Vitamin C, Zinc.

    U.S. Brand Names: Demadex®

    Use: Management of edema associated with congestive heart failure and hepatic or renal disease; used alone or in combination with antihypertensives in treatment of hypertension; I.V. form is indicated when rapid onset is desired.

    Pregnancy Risk Factor and Implications: B; Excretion in breast milk unknown/use caution.

    Contraindications: Anuria; hypersensitivity to torsemide or any component, or other sulfonylureas; safety in children <18 years has not been established.

    Warnings/Precautions: Excessive diuresis may result in dehydration, acute hypotensive or thromboembolic episodes and cardiovascular collapse; rapid injection, renal impairment, or excessively large doses may result in ototoxicity; SLE may be exacerbated; sudden alterations in electrolyte balance may precipitate hepatic encephalopathy and coma in patients with hepatic cirrhosis and ascites; monitor carefully for signs of fluid or electrolyte imbalances, especially hypokalemia in patients at risk for such (eg, digitalis therapy, history of ventricular arrhythiamias elderlyi etc), hyperuricema, hypomagnesemia, or hypocalcemia; use caution with exposure to ultraviolet light.

    Adverse Reactions:
    Greater than 10% experience: Cardiovascular: Orthostatic hypotension

    1% to 10% experience: Central nervous system: Headache, dizziness, vertigo, pain
    Dermatologic: Photosensitivity, urticaria
    Endocrine & metabolic: Electrolyte imbalance, dehydration, hyperuricemia
    Gastrointestinal: Diarrhea, loss of appetite, stomach cramps, pancreatitis
    Ocular: Bluured vision

    Less than 1% experience: Rash, gout, pancreatitis, nausea, hepatic dysfunction, agranulocytosis, leukopenia, anemia, thrombocytopenia, redness at injection site, ototoxicity, nephrocalcinosis, prerenal azotemia, interstitial nephritis
    .

    Overdose/Toxicology: Symptoms include electrolyte depletion, volume depletion, hypotension, dehydration, and circulatory collapse. Electrolyte depletion may manifest as weakness, dizziness, mental confusion, anorexia, lethargy, vomiting, and cramps. Treatment is supportive.

    Trandolapril


    Nutrients Depleted: Zinc

    U.S. Brand Names: Mavik®

    Use: Treatment of hypertension (alone or in combination with other antihypertensive medications such as hypdrochlorothiazide). For stable patients who have evidence of left-ventricular systolic dysfunction (identified by wall motion abnormalities) or who are symptomatic from CHF within the first few days after sustaining acute myocardial infarction. Administration to Caucasians decreases the risk of death (principally cardiovascular death) and decreases the risk of heart failure-related admissions.

    Pregnancy Risk Factor and Implications: C (1st trimester); D (2nd and 3rd trimesters); Enters breast milk/constraindicated.

    Contraindications: Hypersensitivity to trandolapril, other ACE inhibitors, in patients with a history of angioedema related to previous treatment with an ACE inhibitor, or any component.

    Warnings/Precautions: Neutropenia, agranulocytosis, angioedema, decreased renal function (hypertension, renal artery stenosis, CHF), hepatic dysfunction (elimination, activation), proteinuria, first-dose hypotension (hypovolema, CHF, dehydrated patients at risk, eg, diuretic use, elderly), elderly (due to renal function changes); use with caution and modify dosage in patients with renal impairment; use with caution in patients with collagen vascular disease, CHF, HYPOVOLEMIA, VALVULAR STENOSIS, HYPERKALEMIA (greater than 5.7 mEq/L), anesthesia.
    Patients taking diuretics are at risk for developing hypotension on initial dosing; to prevent this, discontinue diuretics 2-3 days prior to initiating trandolapril; may restart diuretics if blood pressure is not controlled by trandolapril alone.


    Adverse Reactions:
    1% to 10% experience: Cardiovascular: Chest pain, hypotension, syncope
    Central nervous system: Fatigue
    Gastrointestinal: Dyspepsia
    Neuromuscular & skeletal: Myalgia
    Respiratory: Cough (1.9% to 35%)

    Less than 1% experience: Palpitations, flushing, insomnia, sleep disturbances, vertigo, anxiety, pruritus, rash angioedema, decreased libido, abdominal pain, vomiting, diarrhea, constipation, pancreatitis, urinary tract infection, impotence, paresthesia, muscle cramps, dyspnea, upper respiratory infection.

    Triamterene


    Nutrients Depleted: Calcium, Folic Acid, Zinc

    U.S. Brand Names: Dyrenium®

    Use: Alone or in combination with other diuretics to treat edema and hypertension; decreases potassium excretion caused by kaliuretic diuretics.

    Pregnancy Risk Factor and Implications: B; Excretion in breast milk unknown.

    Contraindications: Hyperkalemia, renal impairment, diabetes, hypersensitivity to triamterene or any component; do not administer to patienst receiving spironolactone, amiloride, or potassium supplementation unless the patient has documented evidence of hypokalemia unresponsive to either agent alone.

    Warnings/Precautions: Use with caution in patients with severe hepatic encyphalopathy, patients with diabetes, renal dysfunction, a history of renal stones, or those receiving potassium supplements, potassium-containing medications, blood or ACE inhibitors.

    Adverse Reactions:
    1% to 10% experience: Cardiovascular: Hypotension, edema, congestive heart failure, bradycardia
    Central nervous system: Dizziness, headache, fatigue
    Dermatologic: Rash
    Gastrointestinal: Constipation, nausea
    Respiratory: Dyspnea

    Less than 1% experience: Flushing, hyperkalemia, dehydration, hyponatremia, gynecomastia, hyperchloremic metabolic acidosis, postmenopausal bleeding, inability to achieve or maintain an erection.


    Overdose/Toxicology: Symptoms of overdose include drowsiness, confusion, clinical signs of dehydration, electrolyte imbalance, and hypotension. Ingestion of large amounts of potassium-sparing diuretics may result in life-threatening hyperkalemia. This can be treated with I.V. glucose, with concurrent regular insulin and I.V. sodium bicarbonate. If needed, Kayexalate® oral or rectal solutions in sorbitol may also be used.

    Trichlormethiazide


    Nutrients Depleted: Coenzyme Q10, Magnesium, Potassium, Zinc.

    U.S. Brand Names: Metahydrin®; Naqua®

    Use: Management of mild to moderate hypertension; treatment of edema in congestive heart failure and nephrotic syndrome.

    Pregnancy Risk Factor and Implications: D

    Contraindications: Hypersensitivity to trichlormethiazide, other thiazides and sulfonamides, or any component.

    Warnings/Precautions: Use with caution in renal disease, hepatic disease, gout, lupus erythematosus, diabetes mellitus; some products may contain tartrazine.

    Adverse Reactions:
    1% to 10% experience: Endocrine & metabolic: Hypokalemia
    Respiratory: Dyspnea (Less than 5%)

    Less than 1% experience: Hypotension, photosensitivity, lichenoid dermatitis, fluid and electrolyte imbalances (hypocalcemia, hypomagnesemia, hyponatremia); hyperglycemia, rarely blood dyscrasias, prerenal azotemia.


    Overdose/Toxicology: Symptoms of overdose include hypotension, dizziness, electrolyte abnormalities, lethargy, confusion, muscle weakness. Following GI decontamination, therapy is supportive with I.V. fluids, electrolytes, and I.V. pressors if needed; dialysis is unlikely to be effective.

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