Quinapril Hydrochloride / Hydrochlorothiazide	(KWIN-uh-PRILL HIGH-droe-KLOR-ide/high-droe-klor-THIGH-uh-zide)
Trade Name(s):	Accuretic   ·Tablets 10 mg quinapril/12.5 mg hydrochlorothiazide   ·Tablets 20 mg quinapril/12.5 mg hydrochlorothiazide   ·Tablets 20 mg quinapril/25 mg hydrochlorothiazide Indicates Canadian Trade Name.
Class:	Antihypertensive combination
Action:
	Quinapril Competitively inhibits angiotensin I-converting enzyme, resulting in the prevention of angiotensin I conversion to angiotensin II, a potent vasoconstrictor that stimulates aldosterone secretion. This action results in a decrease in sodium and fluid retention, an increase in diuresis, and a decrease in BP.
	Hydrochlorothiazide Increases chloride, sodium, and water excretion by interfering with transport of sodium ions across renal tubular epithelium.
Indications:	Treatment of hypertension.
Contraindications:	Patients with a history of angioedema related to previous treatment with an ACE inhibitor; patients with anuria; hypersensitivity to sulfonamide-derived drugs or any component of the product.
Interactions:
	ACTH, corticosteroids Electrolyte depletion may be intensified, especially hypokalemia.
	Alcohol, barbiturates (eg, phenobarbital), narcotics Orthostatic hypotension may be potentiated.
	Anticoagulants (eg, warfarin) Anticoagulant effect may be decreased.
	Antidiabetic agents (eg, insulin, sulfonylureas), antigout agents (eg, probenecid) Dosage adjustment may be necessary because of possible hydrochlorothiazide-induced elevation in blood glucose levels.
	Cardiac glycosides (eg, digoxin) Possible digitalis toxicity associated with hypokalemia.
	Cholestyramine, colestipol May impair the absorption of hydrochlorothiazide.
	Insulin In diabetic patients, requirements of insulin may be increased, decreased, or unchanged.
	Lithium Plasma levels of lithium may be elevated, increasing the risk of toxicity.
	NSAIDs May reduce the natriuretic and antihypertensive effect of hydrochlorothiazide.
	Potassium supplements, potassium-sparing diuretics (eg, spironolactone) Increased risk of hyperkalemia.
	Nondepolarizing muscle relaxants (eg, tubocurarine) Effects may be increased.
	Pressor amines (eg, norepinephrine) Response to pressor amines may be decreased.
	Tetracycline and other drugs that interact with magnesium Because of the magnesium content in quinapril, absorption of tetracycline may be reduced, decreasing the therapeutic effect.
Lab Test Interferences:
	Hydrochlorothiazide May decrease serum protein-bound iodine levels without signs of thyroid disturbances.
Adverse Reactions:
	cardiovascular: Bradycardia; cor pulmonale; vasculitis; deep thrombosis; vasodilatation; chest pain.
	Quinapril Syncope.
	Hydrochlorothiazide Orthostatic hypotension.
	cns: Dizziness; somnolence; paralysis; hemiplegia; speech disorder; abnormal gait; meningism; amnesia; headache; fatigue; insomnia; vertigo; asthenia.
	Quinapril Depression.
	Hydrochlorothiazide Lightheadedness; paresthesia; weakness; restlessness.
	dermatologic: Urticaria; macropapular rash; petechiases.
	eent: Esophagitis; abnormal vision; rhinitis.
	Quinapril Amblyopia.
	Hydrochlorothiazide Transient blurred vision; xanthopsia.
	gi: GI carcinoma; vomiting; diarrhea; nausea; abdominal pain; constipation; dyspepsia.
	Hydrochlorothiazide Pancreatitis; sialadenitis; diarrhea; cramping; gastric irritation; anorexia.
	gu: Abnormal kidney function; albuminuria; pyuria; hematuria; nephrosis.
	Hydrochlorothiazide Renal failure; renal function impairment; interstitial nephritis.
	hematologic: Anemia.
	Hydrochlorothiazide Aplastic anemia; agranulocytosis; leukopenia; thrombocytopenia; hemolytic anemia.
	hepatic: Cholestatic jaundice; hepatitis.
	Hydrochlorothiazide Jaundice (intrahepatic cholestatic).
	metabolic: Weight loss.
	Hydrochlorothiazide Hyperglycemia; glucosuria; hyperuricemia; hypokalemia; hyponatremia; hypochloremic alkalosis.
	respiratory: Coughing; pneumonia; asthma; respiratory infiltration; lung disorder; upper respiratory tract infection; bronchitis.
	miscellaneous: Shock; accidental injury; neoplasm; cellulitis; ascites; generalized edema; hernia; myopathy; myositis; arthritis; myalgia; viral infection; angioedema.
	Quinapril Back pain; anaphylactoid reactions.
	Hydrochlorothiazide Muscle spasm; hypersensitivity (including necrotizing angiitis, Stevens-Johnson syndrome, respiratory distress [ including pneumonia and pulmonary edema ] , purpura, urticaria, rash, and photosensitivity).
Precautions:
Warning:	When used in pregnancy during the second and third trimesters, ACE inhibitors can cause injury and even death to the developing fetus. When pregnancy is detected, discontinue therapy as soon as possible.
	Monitoring: Monitor blood sugar in diabetic patient when drug is started or dose is changed.
	Pregnancy: Category D (second and third trimester); Category C (first trimester). ACE inhibitors (eg, quinapril) can cause injury or death to fetus if used during second or third trimester. When pregnancy is detected, discontinue as soon as possible.
	Lactation: Excreted in breast milk.
	Children: Safety and efficacy not established.
	Elderly: Select dose with caution, reflecting greater frequency of decreased hepatic, renal, or cardiac function and comorbidity.
	Renal function impairment: Use with caution.
	Hepatic function impairment: Use with caution.
	Anaphylactoid reactions Reported in patients with a history of angioedema, undergoing desensitizing treatment with Hymenoptera venom, and in patients dialyzed with high-flux membranes.
	Angioedema Use with extreme caution in patients with a history of angioedema. Angioedema associated with laryngeal edema may be fatal. Angioedema may occur more frequently in black patients receiving an ACE inhibitor compared with non-black patients.
	Cough Chronic cough may occur during treatment.
	Electrolyte imbalance Treatment with thiazide diuretics has been associated with hypokalemia, hyponatremia, hypochloremic alkalosis, hypercalcemia, and hypomagnesemia. Do not initiate therapy prior to correction of imbalance.
	Hepatic failure Rarely, ACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice and progresses to fulminant hepatic necrosis and death.
	Hypotension Decreases in BP may occur, especially in salt- or volume-depleted patients as a result of dialysis, prolonged diuretic therapy, dietary salt restriction, diarrhea, or vomiting. Volume and salt depletion should be corrected before initiating therapy with quinapril/hydrochlorothiazide.
	Metabolic disturbances Thiazide diuretics tend to reduce glucose tolerance, raise cholesterol, triglycerides, and uric acid levels.
	Neutropenia/Agranulocytosis Has occurred with other ACE inhibitors.
	Surgery/Anesthesia In patients undergoing surgery or during anesthesia with agents that produce hypotension, angiotensin II formation, secondary to compensatory renal release, may be blocked.
	Systemic Lupus Erythematosus (SLE) Hydrochlorothiazide may exacerbate or activate SLE.
Overdosage:	Signs & symptoms Dehydration, electrolyte imbalance (hypokalemia [ which may accentuate cardiac arrhythmias in patients receiving digitalis ] , hypochloremia, hyponatremia), hypotension.
Patient/Family Education:	Advise patient to take prescribed dose every day without regard to meals. Advise patient to try to take each dose at about the same time every day. Inform patient that drug controls, but does not cure, hypertension and to continue taking drug as prescribed even when BP is not elevated. Caution patient not to change the dose or stop taking unless advised by health care provider. Instruct patient to continue taking other BP medications as prescribed by health care provider. Instruct patient in BP and pulse measurement skills. Advise patient to monitor and record BP and pulse at home and to inform health care provider if abnormal measurements are noted. Also, advise patient to take record of BP and pulse to each follow-up visit. Caution patient to avoid sudden position changes to prevent orthostatic hypotension. Instruct patient to lie or sit down if experiencing dizziness or lightheadedness when standing. Caution patient that inadequate fluid intake, excessive perspiration, diarrhea, or vomiting can lead to excessive fall in BP resulting in lightheadedness or fainting. Instruct diabetic patient to monitor blood glucose more frequently when drug is started or dose is changed and to inform health care provider of significant changes in readings. Caution patient to avoid unnecessary exposure to UV light (sunlight, tanning booths) and to use sunscreen and wear protective clothing when exposed to UV light to avoid photosensitivity reaction. Emphasize to hypertensive patient importance of other modalities on BP: weight control, regular exercise, smoking cessation, and moderate intake of alcohol and salt. Instruct patient to stop taking drug and immediately report any of the following symptoms to health care provider: fainting, swelling of the face, lips, eyelids or tongue, difficulty breathing. Instruct patient to inform health care provider if a persistent cough develops while taking this medication. Caution patient not to take any prescription or OTC medications, potassium-containing salt substitutes, potassium supplements, or dietary supplements unless advised by health care provider.