TRANDOLAPRIL

TRANDOLAPRIL (tran-do'la-pril) Mavik Classifications: angiotensin-converting enzyme (ace) inhibitor; antihypertensive; Therapeutic: antihypertensive; ace inhibitor Prototype: Enalapril Pregnancy Category: C first trimester; D second and third trimester

Availability

1 mg, 2 mg, 4 mg tablets

Action

Inhibits ACE and interrupts conversion sequences initiated by renin which leads to the formation of angiotensin II from angiotensin I. Angiotensin II is a potent endogenous vasoconstrictor. Inhibition of ACE leads to vasodilation and also to decreased circulating aldosterone. Decreased aldosterone leads to diuresis and a slight increase in serum potassium.

Therapeutic Effect

Lowers blood pressure by specific inhibition of ACE. Unlike other ACE inhibitors, all racial groups respond to trandolapril, including low-renin hypertensives.

Uses

Treatment of hypertension, alone or in combination with other antihypertensive agents.

Unlabeled Uses

CHF.

Contraindications

Hypersensitivity to trandolapril or ACE inhibitors; history of angioedema related to previous treatment with an ACE inhibitor; pregnancy (category C, first trimester; category D, second and third trimesters), lactation.

Cautious Use

Renal impairment, hepatic insufficiency; patients prone to hypotension (e.g., CHF, ischemic heart disease, aortic stenosis, CVA, dehydration); SLE, scleroderma. Safety and effectiveness in children <18 y are not established.

Route & Dosage

Note: Discontinue diuretics 2–3 d before starting trandolapril. Hypertension Adult: PO 1 mg in nonblack patients, 2 mg in black patients once daily, may increase weekly to 2–4 mg once daily (max: 8 mg/d) Renal Impairment Clcr <30 mL/min: start with 0.5 mg once daily Hepatic Impairment Hepatic cirrhosis: start with 0.5 mg once daily

Administration

Oral

• Note: If concurrently ordered diuretic cannot be discontinued 2–3 d before beginning trandolapril therapy, reduce initial dose to 0.5 mg.
• Make dosage adjustments generally at intervals of at least 1 wk.
• Store at 15°–30° C (59°–86° F).

Adverse Effects (≥1%)

Body as a Whole: Fatigue, angioedema. CNS: Dizziness, headache. CV: Hypotension. GI: Diarrhea. Respiratory: Cough. Skin: Rash, pruritus. Metabolic: Hyperkalemia.

Interactions

Drug: diuretics may enhance hypotensive effects. potassium-sparing diuretics (amiloride, spironolactone, triamterene), potassium supplements, potassium-containing salt substitutes may increase risk of hyperkalemia. May increase serum levels and toxicity of lithium.

Pharmacokinetics

Absorption: Rapidly absorbed from GI tract and converted to active form, trandolaprilat, in liver; 70% of dose reaches systemic circulation as trandolaprilat. Peak: 4–10 h. Distribution: 80% protein bound; crosses placenta, secreted into breast milk of animals (human secretion unknown). Metabolism: In liver to active metabolite, trandolaprilat. Elimination: 33% in urine, 66% in feces. Half-Life: 6 h trandolapril, 10 h trandolaprilat.

Nursing Implications

Assessment & Drug Effects

• Monitor BP carefully for 1–3 h following initial dose, especially in patients using concurrent diuretics, on salt restriction, or volume depleted.
• Lab tests: Monitor BP and cardiac status; serum potassium, sodium, creatinine, and ALT/SGTP; and WBC with differential periodically.
• Monitor serum lithium levels frequently with concurrent use and assess for S&S of lithium toxicity; increase caution when diuretic therapy is also used.

Patient & Family Education

• Discontinue drug and immediately report S&S of angioedema of face or extremities to physician. Advise to seek emergency help for swelling of the tongue or any other sign of potential airway obstruction.
• Be aware that light-headedness can occur, especially during early therapy. Excess fluid loss of any kind will increase risk of hypotension and syncope.

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Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug