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ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors) - Interactions and Warnings

Iron-drug interactions of clinical significance may occur in many patients and involve a large number of therapies. Concurrent ingestion of iron causes marked decreases in the bioavailability of a number of drugs. The affected drugs, tetracycline, tetracycline derivatives (doxycycline, methacycline and oxytetracycline), penicillamine, methyldopa, levodopa, carbidopa and ciprofloxacin have diverse chemical structures and clinical effects. The major mechanism of these drug interactions is the formation of iron-drug complexes (chelation or binding of iron by the involved drug). A large number of other important and commonly used drugs such as thyroxine, captopril and folic acid have been demonstrated to form stable complexes with iron. There is little known about the effects of concurrent therapy with iron supplements for most of the drugs.
- Br J Clin Pharmacol 1991 Mar;31(3):251-5 -- Iron supplements: a common cause of drug interactions. -- Campbell NR, Hasinoff BB.

ACE inhibitors could increase potassium levels in the body.
- JAMA 1995 Aug 16;274(7):538 -- Diet and serum potassium in patients on ACE inhibitors. -- Good CB, McDermott L, McCloskey B.

Physicians should be aware of possible complications and only prescribe NSAIDs, including the new COX-2 drugs, to the elderly under close monitoring of kidney function and electrolyte tests.
- J Emerg Med 2002 May;22(4):349-52 -- Fatal hyperkalemia related to combined therapy with a COX-2 inhibitor, ACE inhibitor and potassium rich diet. -- Hay E, Derazon H, Bukish N, Katz L, Kruglyakov I, Armoni M.

There is a theoretical possibility that the negative interaction between ACE inhibitors and aspirin may reduce the beneficial effects of ACE inhibitors in patients with heart failure.
- J Am Geriatr Soc 2002 Jul;50(7):1293-6 -- Interaction between aspirin and angiotensin-converting enzyme inhibitors: should they be used together in older adults with heart failure? -- Ahmed A.

Antihypertensive therapy is effective in elderly patients, at least in those under 80 years old. Stepped care may still serve as a therapeutic framework which is modified to fit the individual elderly patient, according to the risk: benefit ratio. However, there are no risk-free drugs and no antihypertensive agent is universally effective. The elderly are probably more sensitive than younger patients to the adverse effects of antihypertensive drugs, for various reasons, among which are age- and disease-related changes that can lead to altered pharmacodynamics and pharmacokinetics. Multiple pathology and multiple drug therapy is likely to lead to an increased number of drug-drug and drug-disease interactions in the elderly. The elderly are probably most at risk from side effects that influence the cardiovascular and the central nervous system.
- J Hypertens Suppl 1988 Nov;6(1):S81-5 -- Potential adverse effects of antihypertensive drugs in the elderly. -- Lamy PP.

Arginine may potentiate the effect of ACE inhibitors.
- Physiol Res 2001;50(2):143-52 -- Effect of ACE inhibitor captopril and L-arginine on the metabolism and on ischemia-reperfusion injury of the isolated rat heart. -- Divisova J, Vavrinkova H, Tutterova M, Kazdova L, Meschisvili E.

last update: November 2008

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