Options and considerations for changing people from cilazapril plus hydrochlorothiazide: OPTIONS 1. ACEI alone • Lisinopril • Enalapril • Quinapril • Cilazapril
MAY BE SUITABLE FOR • BP low or postural drop • Older people where BP targets are more relaxed as this may be safer to reduce risk of falls
WATCH OUT FOR PROS • Increase in BP • Less medicine • Change in • Possibly fewer electrolytes (e.g. side effects possible hyperkalaemia) • Medication error e.g. person takes old med AND new med
2. Different combination tablet • Quinapril plus hydrochlorothiazide 10mg/12.5mg 20mg/12.5mg
• People with adherence issues who might not be able to take two separate meds • People with financial issues (one prescription fee instead of two if ACEI + diuretic) • People who need slightly better BP control (indapamide and chlorthalidone stronger evidence base than hydrochlorothiazide and bendroflumethiazide, possibly more effective
• Change in BP control with change of RAS blocker
• Straightforward swap • In people with gout, losartan may be useful as it reduces serum uric acid
• Change in BP control with change of diuretic
• Possibly better BP control with indapamide or chlorthalidone
• Losartan plus hydrochlorothiazide 50mg/12.5mg 3. Separate ACEI and diuretic ACEI/ARB plus one of: • Indapamide 2.5mg • Bendroflumethiazide 2.5mg • Chlorthalidone 12.5 to 25mg*
CONS • Possible increase in BP • Cilazapril: possible issues with supply in future • Enalapril and quinapril: May need bd dosing, risk of poor adherence • Possibly don’t last full 24 hour period
• Possibly more electrolyte disturbances with indapamide and chlorthalidone • Two tablets instead of one
*A recent comparative cohort study in JAMA Internal Medicine compared hydrochlorothiazide 25mg/day and chlorthalidone 12.5mg/day in first time users of antihypertensive monotherapy and found similar cardiovascular outcomes but more side effects with chlorthalidone. This study had a number of shortcomings so the results should be interpreted with caution.
ACEI/ARB dose equivalence to cilazapril 5mg • Lisinopril 20mg • Enalapril 10mg • Quinapril 20mg • Losartan 50mg Thiazide or thiazide-like diuretics • Indapamide 2.5mg/day • Bendroflumethiazide 2.5mg/day (NB flat dose-response curve, no additional BP lowering from 5mg but more electrolyte disturbances) • Chlorthalidone 12.5 to 25mg/day (start with 12.5mg to avoid nausea on initiation) Pauline McQuoid, Medwise Clinical Pharmacist