Consumer medicine information

Zestril

Lisinopril

BRAND INFORMATION

Brand name

Zestril

Active ingredient

Lisinopril

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Zestril.

SUMMARY CMI

ZESTRIL®

Consumer Medicine Information (CMI) summary

The full CMI on the next page has more details. If you are worried about using this medicine, speak to your doctor or pharmacist.

1. Why am I using ZESTRIL?

ZESTRIL contains the active ingredient lisinopril. ZESTRIL is used to lower high blood pressure, which doctors call hypertension. It is also used to treat heart failure and patients who have just had a heart attack. For more information, see Section 1. Why am I using ZESTRIL? in the full CMI.

2. What should I know before I use ZESTRIL?

Do not use if you have ever had an allergic reaction to lisinopril or any of the ingredients listed at the end of the CMI. Talk to your doctor if you have any other medical conditions, take any other medicines, or are pregnant or plan to become pregnant or are breastfeeding. For more information, see Section 2. What should I know before I use ZESTRIL? in the full CMI.

3. What if I am taking other medicines?

Some medicines may interfere with ZESTRIL and affect how it works. A list of these medicines is in Section 3. What if I am taking other medicines? in the full CMI.

4. How do I use ZESTRIL?

  • Take ZESTRIL as prescribed by your doctor. This depends on your condition and whether you are taking other medicines.

More instructions can be found in Section 4. How do I use ZESTRIL? in the full CMI.

5. What should I know while using ZESTRIL?

Things you should do
  • Remind any doctor, dentist or pharmacist you visit that you are using ZESTRIL.
  • Have your blood pressure checked when your doctor says to make sure ZESTRIL is working
  • Call your doctor straight away if you: feel any light-headedness or dizziness, become pregnant, have excessive vomiting and/or diarrhoea while taking ZESTRIL
  • Make sure you drink enough water during exercise and hot weather when you are taking ZESTRIL
  • Go to your doctor regularly for a check-up.
Things you should not do
  • Do not take ZESTRIL to treat any other complaints unless your doctor tells you to.
  • Do not give ZESTRIL to anyone else, even if they have the same condition as you.
Driving or using machines
  • Be careful before you drive or use any machines or tools until you know how ZESTRIL affects you.
Drinking alcohol
  • Your doctor may advise you to limit your alcohol intake.
Looking after your medicine
  • Store below 30°C.
  • Store in a cool, dry place, away from young children.

For more information, see Section 5. What should I know while using ZESTRIL? in the full CMI.

6. Are there any side effects?

There are a number of side effects associated with this medicine. It is important to be aware of them so that you can identify any symptoms if they occur (see the full CMI for more details). The most common and serious side effects are passing less urine, chest pain, angina, swelling of the face, lips, mouth, tongue or throat, wheeziness, difficulty breathing, collapse, numbness/weakness of arms or legs, pinkish, hives, fainting, heart beats changes, skin problems, infections, bruising easily, severe abdominal pain, yellowing of the skin and/or eyes, dehydration and hallucinations. For more information, including what to do if you have any side effects, see Section 6. Are there any side effects? in the full CMI.



FULL CMI

ZESTRIL®

Active ingredient(s): lisinopril

Consumer Medicine Information (CMI)

This leaflet provides important information about using ZESTRIL. You should also speak to your doctor or pharmacist if you would like further information or if you have any concerns or questions about using ZESTRIL.

Where to find information in this leaflet:

1. Why am I using ZESTRIL?
2. What should I know before I use ZESTRIL?
3. What if I am taking other medicines?
4. How do I use ZESTRIL?
5. What should I know while using ZESTRIL?
6. Are there any side effects?
7. Product details

1. Why am I using ZESTRIL?

ZESTRIL contains the active ingredient lisinopril. ZESTRIL belongs to a group of medicines called angiotensin converting enzyme (ACE) inhibitors.

ZESTRIL is used to lower high blood pressure, which doctors call hypertension. It is also used to treat heart failure and patients who have just had a heart attack.

2. What should I know before I use ZESTRIL?

Warnings

Do not use ZESTRIL if:

  • you are allergic to lisinopril, or any of the ingredients listed at the end of this leaflet.
  • Always check the ingredients to make sure you can use this medicine.
  • you have taken any medicines called 'ACE inhibitors' before and have had allergic reactions with swelling of the hands, feet, or ankles, the face, lips, tongue and/or throat with difficulty in swallowing or breathing or if you or a member of your family have had a similar reaction.
    - If you or a family member has had an allergic reaction to an ACE inhibitor before, you may be allergic to ZESTRIL.
  • you or a member of your family has a history of swelling of the face, lips, tongue, throat, hands or feet, for no apparent reason.
    - Some of the symptoms of an allergic reaction to ZESTRIL may include skin rash, itchiness, difficulty breathing or swallowing, or swelling of the face, lips, tongue or throat.
  • you are undergoing haemodialysis
  • you are taking a blood pressure medicine containing aliskiren and you have diabetes mellitus.
  • you are taking a blood pressure medicine containing aliskiren and you have kidney problems

Check with your doctor if you:

  • have any other medical conditions, including
    - kidney problems, or are undergoing dialysis
    - low blood pressure (you may notice this as faintness or dizziness, especially when standing)
    - liver problems
    - diabetes
    - aortic stenosis (narrowing of the aorta), renal stenosis (narrowing of the renal artery) or hypertrophic cardiomyopathy (an increase in the thickness of the heart muscle)
    - diarrhoea or vomiting
  • take any medicines for any other condition
  • if you are following a very low salt diet
  • if you are going to receive desensitisation treatment for an allergy, e.g. to insect stings
    - The desensitisation treatment reduces the effects of the allergy (e.g. bee or wasp stings) but sometimes it can cause a more severe allergic reaction if you are taking an ACE inhibitor during the desensitisation treatment.
  • if you are taking medicines called mTOR inhibitors (such as temsirolimus, everolimus, sirolimus) or medicines containing NEP inhibitors (such as racecadotril).
    - Taking these medicines with Zestril may increase the risk of angioedema. Signs of angioedema include swelling of the face, lips, tongue and/or throat with difficulty in swallowing or breathing.

During treatment, you may be at risk of developing certain side effects. It is important you understand these risks and how to monitor for them. See additional information under Section 6. Are there any side effects?

Pregnancy and breastfeeding

Check with your doctor if you are pregnant or intend to become pregnant.

ZESTRIL is not recommended for use during pregnancy

Talk to your doctor if you are breastfeeding or intend to breastfeed.

ZESTRIL should not be used while breastfeeding or if planning to breastfeed.

Your baby may absorb this medicine in the womb or from breast milk and therefore there is a possibility of harm to the baby.

3. What if I am taking other medicines?

Tell your doctor or pharmacist if you are taking any other medicines, including any medicines, vitamins or supplements that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines may interfere with ZESTRIL and affect how it works, and some medicines may be affected by ZESTRIL

  • medicines used to treat high blood pressure or heart problems called angiotensin II receptor blockers, such as candesartan, valdesartan, telmisartan, olmesartan or irbesartan.
  • other medicines used to treat high blood pressure, including any that contain aliskiren (see also information under the heading "When you must not take it").
  • diuretic tablets - also called fluid or water tablets
  • lithium, a medicine used to treat some types of mental disorders
  • potassium tablets, salt substitutes containing potassium or other medicines which can increase potassium in your body.
  • non-steroidal anti-inflammatory medicines used to treat arthritis and muscle pain, such as indomethacin, naproxen or ibuprofen.
  • heparin, a medicine used to prevent blood clots.
  • a medicine used to treat infection containing sulfamethoxazole and trimethoprim, also known as co-trimoxazole.
  • gold injections (such as sodium aurothiomalate) usually used to treat rheumatoid arthritis
  • insulin or other medicines used to treat diabetes.
  • medicines used to break down blood clots such as alteplase or reteplase.
  • medicines called mTOR inhibitors (such as temsirolimus, everolimus, sirolimus) or medicines containing NEP inhibitors (such as racecadotril). t

Check with your doctor or pharmacist if you are not sure about what medicines, vitamins or supplements you are taking and if these affect ZESTRIL.

4. How do I use ZESTRIL?

How much to take

  • Your doctor will tell you how many tablets you need to take each day. This depends on your condition and whether you are taking other medicines.
  • Take ZESTRIL only when prescribed by your doctor.
  • For high blood pressure:
    - For most patients, the usual starting dose is 5 mg to 10 mg taken once a day.
    - Some patients may need a lower starting dose. The dose may need to be increased depending on your blood pressure.
    - Most patients take between 10 mg to 20 mg each day, taken once a day.
  • For heart failure:
    - The usual starting dose is 2.5 mg taken once a day.
    - Depending on your response, this dose may need to be increased.
    - The usual dose is between 5 mg to 20mg each day, taken once a day.
  • For heart attack:
    - ZESTRIL may be started within 24 hours of the onset of the symptoms of heart attack. The usual starting dose is 5 mg, which is followed 24 hours later by another 5 mg dose.
  • This is then followed 48 hours later by a 10 mg dose, and then 10 mg taken once a day thereafter. Some patients may need a lower starting and maintenance dose.

How long to take ZESTRIL

  • Continue taking the tablets for as long as your doctor tells you.
  • ZESTRIL helps control your high blood pressure and helps improve your heart failure, but does not cure it. Therefore, you must take ZESTRIL every day.
  • Follow the instructions provided and use ZESTRIL until your doctor tells you to stop

When to take ZESTRIL

  • ZESTRIL should be used at about the same time each day. Taking your tablet(s) at the same time each day will have the best effect. It will also help you remember when to take the tablets.

How to take ZESTRIL

  • Swallow ZESTRIL with a glass of water or other liquid.
  • It does not matter if you take ZESTRIL before or after food.

If you forget to use ZESTRIL

ZESTRIL should be used regularly at the same time each day.

If it is almost time for your next dose, skip the dose you missed and take your next dose when you are meant to.

Do not take a double dose to make up for the dose you missed.

If you use too much ZESTRIL

If you think that you have used too much ZESTRIL, you may need urgent medical attention. If you take too many tablets you will probably feel light-headed or dizzy, or you may faint.

You should immediately:

  • phone the Poisons Information Centre
    (by calling 13 11 26), or
  • contact your doctor, or
  • go to the Emergency Department at your nearest hospital.

You should do this even if there are no signs of discomfort or poisoning.

5. What should I know while using ZESTRIL?

Things you should do

Have your blood pressure checked when your doctor says to make sure ZESTRIL is working.

Call your doctor straight away if you:

  • feel any light-headedness or dizziness after you take your first dose of ZESTRIL or if your dose is increased
    - This is especially important if you are taking ZESTRIL for heart failure
  • feel light-headed, dizzy or faint, and this problem gets worse or continues
    - Get up slowly when getting out of bed or standing up
    - You may feel light-headed or dizzy, especially if you are also taking a diuretic (fluid tablet). This is because your blood pressure is falling suddenly.
    - Standing up slowly, especially when you get up from bed or chairs, will help your body get used to the change in position and blood pressure
  • become pregnant while taking ZESTRIL
  • are about to be started on any new medicine
  • plan to have surgery (even at the dentist) that needs a general anaesthetic
    - Your blood pressure may drop suddenly during surgery
  • have excessive vomiting and/or diarrhoea while taking ZESTRIL
    - This can result in you losing too much water and may drop your blood pressure too much

Things you must do

  • Make sure you drink enough water during exercise and hot weather when you are taking ZESTRIL, especially if you sweat a lot.
    - If you do not drink enough water while taking ZESTRIL, you may faint or feel light-headed or sick. This is because your blood pressure is dropping suddenly. If you continue to feel unwell, tell your doctor.
  • Go to your doctor regularly for a check-up.
    - Your doctor may occasionally do a blood test to check your potassium level in the blood and see how your kidneys are working.

Remind any doctor, dentist or pharmacist you visit that you are using ZESTRIL.

Things you should not do

  • Do not take ZESTRIL to treat any other complaints unless your doctor tells you to.
  • Do not give ZESTRIL to anyone else, even if they have the same condition as you.

Driving or using machines

Be careful before you drive or use any machines or tools until you know how ZESTRIL affects you.

ZESTRIL may cause dizziness in some people, especially after the first dose or if the dose is increased. Make sure you know how you react to ZESTRIL before you drive a car, operate machinery, or do anything else that could be dangerous if you are dizzy or light-headed. If you drink alcohol, dizziness or light-headedness may be worse.

Drinking alcohol

Tell your doctor if you drink alcohol.

Your doctor may advise you to limit your alcohol intake.

Things that would be helpful for your blood pressure or heart failure

Some self help measures suggested below may help your condition. Talk to your doctor or pharmacist about these measures and for more information.

  • Diet - eat a healthy diet, which includes plenty of fresh vegetables, fruit, bread, cereals and fish. Also eat less fat and sugar.
  • Exercise - regular exercise helps to reduce blood pressure and helps the heart get fitter, but it is important not to overdo it. Walking is good exercise, but try to find a route that is fairly flat. Before starting any exercise, ask your doctor about the best kind of programme for you.
  • Salt - your doctor may advise you to watch the amount of salt in your diet. To reduce your salt intake you should avoid using salt in cooking or at the table.
  • Smoking - your doctor may advise you to stop smoking or at least cut down.
  • Weight - your doctor may suggest losing some weight to help lower your blood pressure and help lessen the amount of work your heart has to do. Some people may need a dietician's help to lose weight.

Looking after your medicine

  • Keep your tablets in the blister pack until it is time to take them.

Follow the instructions in the carton on how to take care of your medicine properly.

Store it in a cool dry place where the temperature stays below 30°C, away from moisture, heat or sunlight; for example, do not store it:

  • in the bathroom or near a sink, or
  • in the car or on window sills.

Keep it where young children cannot reach it.

Getting rid of any unwanted medicine

If you no longer need to use this medicine or it is out of date, take it to any pharmacy for safe disposal.

Do not use this medicine after the expiry date.

6. Are there any side effects?

All medicines can have side effects. If you do experience any side effects, most of them are minor and temporary. However, some side effects may need medical attention.

See the information below and, if you need to, ask your doctor or pharmacist if you have any further questions about side effects.

Less serious side effects

Less serious side effectsWhat to do
Gut-related:
  • mild stomach upsets such as feeling sick, diarrhoea, or stomach pains
  • impotence
Respiratory or breathing-related:
  • dry cough
  • running nose or sinus pain
  • changes in the way things smell
Other:
  • light-headedness or dizziness
  • headache
  • fatigue
  • hair loss or thinning
  • changes in the way things taste
  • feeling sleepy or difficulty in going to sleep, strange dreams
Speak to your doctor if you have any of these less serious side effects and they worry you.

Serious side effects

Serious side effectsWhat to do
Allergic reaction-related:
  • changes in the way our heart beats, for example, if you notice it beating faster
  • yellowing of the skin and/or eyes, also called jaundice
  • tingling or numbness of the hands and feet
  • severe abdominal pain
Skin-related:
  • itchy skin rash, psoriasis or other skin problems
Other:
  • signs of frequent or worrying infections such as fever, severe chills, sore throat or mouth ulcers
  • passing less urine than is normal for you
  • bruising more easily than normal
  • signs of dehydration such as nausea, vomiting, muscle cramps, headache, drowsiness and tiredness.
  • seeing, feeling or hearing things that are not there
Call your doctor straight away, or go straight to the Emergency Department at your nearest hospital if you notice any of these serious side effects.

Very side effects

Very serious side effectsWhat to do
Allergic reaction-related:
  • chest pain, angina
  • swelling of the face, lips, mouth, tongue or throat, which may cause difficulty in swallowing or breathing.
  • wheeziness due to tightness in the chest, difficulty breathing
  • collapse, numbness or weakness of arms or legs
  • pinkish, itchy swellings on the skin, also called hives or nettle rash
  • fainting
Stop taking this medicine and tell your doctor immediately, or go to Accident and Emergency at your nearest hospital.

Tell your doctor or pharmacist if you notice anything else that may be making you feel unwell.

Other side effects not listed here may occur in some people.

Reporting side effects

After you have received medical advice for any side effects you experience, you can report side effects to the Therapeutic Goods Administration online at www.tga.gov.au/reporting-problems. By reporting side effects, you can help provide more information on the safety of this medicine.

Always make sure you speak to your doctor or pharmacist before you decide to stop taking any of your medicines.

7. Product details

This medicine is only available with a doctor's prescription.

What ZESTRIL contains

Active ingredient
(main ingredient)

lisinopril

Other ingredients
(inactive ingredients)

mannitol

calcium hydrogen phosphate dihydrate

maize starch

pregelatinised maize starch

magnesium stearate (E572)

iron oxide red C177491 (E172)

Potential allergens

None.

Do not take this medicine if you are allergic to any of these ingredients.

What ZESTRIL looks like

ZESTRIL 5 mg are pink, round, biconvex tablets with a heart image and the figure 5 marked on one side and a line through the middle on the other side. AUST R 70837

ZESTRIL 10 mg are pink, round, biconvex tablets, with a heart image and the figure 10 marked on one side and are plain on the other side. AUST R 70838

ZESTRIL 20 mg are brownish-red, round, biconvex tablets with a heart image and the figure 20 marked on one side and are plain on the other side. AUST R 70839

A box of ZESTRIL contains 30 tablets.

Who distributes ZESTRIL

Zestril is supplied in Australia by:

Clinect Pty Ltd
20-132 Atlantic Drive, Keysborough VIC 3173, Australia
Free Call Australia: 1800 899 005

®= Registered Trademark

This leaflet was prepared in April 2022.

Published by MIMS June 2022

BRAND INFORMATION

Brand name

Zestril

Active ingredient

Lisinopril

Schedule

S4

 

1 Name of Medicine

Lisinopril dihydrate.

2 Qualitative and Quantitative Composition

Zestril is supplied as 5 mg, 10 mg and 20 mg tablets of lisinopril as dihydrate for oral administration.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Zestril is available as 5 mg, 10 mg and 20 mg tablets. The 5 mg and 10 mg tablets are pink in colour, while the 20 mg is brownish-red. Care should be taken when dispensing. The packaging for the tablets clearly states the strength enclosed and the different strengths can be identified by the following surface markings on the faces of each tablet:

5 mg (round biconvex tablet).

Face 1: Heart image and the figure 5; Face 2: Bisecting line.

10 mg (round biconvex tablet).

Face 1: Heart image and the figure 10; Face 2: Plain.

20 mg (round biconvex tablet).

Face 1: Heart image and the figure 20; Face 2: Plain.

4 Clinical Particulars

4.1 Therapeutic Indications

Hypertension.

Zestril is indicated in the treatment of hypertension. It may be used alone or concomitantly with other classes of antihypertensive agents. Sufficient data have not been provided to support the use of lisinopril in severe hypertension or renovascular hypertension.

Congestive heart failure.

Zestril is also indicated in the treatment of heart failure. In such patients, it is recommended that Zestril be administered together with a diuretic.

Acute myocardial infarction.

Zestril is indicated for the treatment of acute myocardial infarction in haemodynamically stable patients, defined as patients who are not in cardiogenic shock and who have a systolic blood pressure greater than 100 mmHg. Zestril may be initiated within 24 hours of an acute myocardial infarction.

4.2 Dose and Method of Administration

Since there is no clinically significant effect of food on the absorption of Zestril, the tablets may be administered before, during or after meals. Zestril should be administered in a single daily dose.

Hypertension.

In patients with uncomplicated hypertension not on diuretic therapy, the usual recommended starting dose is 5 to 10 mg. The usual maintenance dosage is 10 to 20 mg/day administered in a single daily dosage. Dosage should be adjusted at 2 to 4 week intervals according to blood pressure response. In some patients, doses up to 40 mg/day may be required. If blood pressure is not controlled with Zestril, a low dose of a diuretic may be added. Hydrochlorothiazide (12.5 mg) has been shown to provide an additive effect. After addition of a diuretic, the dose of Zestril may be reduced.

Special patient populations.

Diuretic treated or severely salt/ volume depleted patients.

Symptomatic hypotension following the initial dose of Zestril may occur occasionally in patients receiving concomitant diuretics. The diuretic should be discontinued, if possible, for two to three days before beginning therapy with Zestril (see Section 4.4 Special Warnings and Precautions for Use). In hypertensive patients in whom the diuretic cannot be discontinued, the initial dose of Zestril should be 2.5 mg, followed then by 5 mg. The subsequent dosage of Zestril should be adjusted according to blood pressure response. If required, diuretic therapy may be resumed gradually.

Renal impairment.

The usual dose of Zestril is recommended for patients with a creatinine clearance > 30 mL/min. Dosage in patients with renal impairment should be based on creatinine clearance as outlined in Table 1:
The dosage may be titrated upward until blood pressure is controlled or to a maximum of 20 mg daily.

Use in the elderly.

In general, blood pressure response and adverse experiences were similar in younger and older patients given similar doses of Zestril. Pharmacokinetic studies, however, indicate that maximum blood levels and area under the plasma concentration time curve (AUC) are doubled in older patients so that dosage adjustments should be made with particular caution.

Congestive heart (cardiac) failure.

Note.

Treatment of heart failure with Zestril should be initiated under close medical supervision. In patients not adequately controlled by diuretics (and digitalis, where indicated), Zestril may be added with a starting dose of 2.5 mg once a day. Dose adjustment should be increased:
by increments of no greater than 10 mg;
at intervals of no less than 2 weeks.
The usual dosage is 5-20 mg/day administered as a single dose. The dose of Zestril should not be titrated according to symptoms, as higher doses may not give additional symptomatic relief. The optimal upper dose has not been determined; 35 mg/day has been shown to be more effective than 5 mg/day but there is no evidence regarding the effectiveness of intermediate doses.
Patients at a high risk of symptomatic hypotension, e.g. patients with salt depletion with or without hyponatraemia, patients with hypovolaemia or patients who have been receiving vigorous diuretic therapy, should have these conditions corrected, if possible, prior to therapy with Zestril. The effect of the starting dosage of Zestril on blood pressure should be monitored carefully.

Acute myocardial infarction.

Treatment with Zestril may be started within 24 hours of the onset of symptoms. The first dose of Zestril is 5 mg given orally, followed by 5 mg after 24 hours, 10 mg after 48 hours and then 10 mg once daily thereafter. Patients with a low systolic blood pressure (120 mmHg or less) when treatment is started or during the first 3 days after the infarct should be given a lower dose - 2.5 mg orally (see Section 4.4 Special Warnings and Precautions for Use). If hypotension occurs (systolic blood pressure less than or equal to 100 mmHg), a daily maintenance dose of 5 mg may be given with temporary reductions to 2.5 mg if needed. If prolonged hypotension occurs (systolic blood pressure less than 90 mmHg for more than 1 hour), Zestril should be withdrawn.
Dosing should continue for 6 weeks. Patients who develop symptoms of heart failure should continue with Zestril (see Section 4.2 Dose and Method of Administration, Congestive heart (cardiac) failure).
Patients should receive, as appropriate, the standard recommended treatments, such as thrombolytics, aspirin and a beta-blocker.
Zestril is compatible with intravenous or transdermal glyceryl trinitrate.

4.3 Contraindications

This agent is contraindicated in:
Patients who are hypersensitive to lisinopril or any other component of this product.
Patients with a history of hereditary and/or idiopathic angioedema, anaphylactic/ anaphylactoid reactions or angioedema associated with previous treatment with an angiotensin converting enzyme inhibitor.
Patients with hereditary or idiopathic angioedema.
Pregnancy (see Section 4.6 Fertility, Pregnancy and Lactation).
Patients undergoing haemodialysis with polyacrylonitrile metalylsulphonate high flux membranes. There is a risk of anaphylactoid reaction (hypersensitivity reactions which may be severe, e.g. shock) with the simultaneous use of an ACE inhibitor and polyacrylonitrile metalylsulphonate high flux dialysis membranes (e.g. AN69) or during low density lipoproteins (LDL) apheresis with dextran sulphate within the framework of dialysis treatment. This combination thus needs to be avoided, either by using other medical products to control high blood pressure or cardiac insufficiency or by using other membranes during dialysis.
In combination with aliskiren containing medicines in patients with diabetes mellitus (type I or II) or with moderate to severe renal impairment (GFR < 60 mL/min/1.73 m2).

4.4 Special Warnings and Precautions for Use

Anaphylactoid reactions during Hymenoptera desensitisation.

Patients receiving ACE inhibitors during desensitisation (e.g. to Hymenoptera venom) have sustained anaphylactoid reactions. These reactions have been avoided when ACE inhibitors were temporarily withheld.

Angioedema.

Severe life threatening angioedema has been reported rarely with most of the angiotensin converting enzyme (ACE) inhibitors. There seems to be no sex difference in the incidence of angioedema or in the predisposition to angioedema in patients with heart failure or hypertension. Most commonly, angioedema occurs during the first week of therapy but it has also been reported after long-term therapy. Patients may have multiple episodes of angioedema with long symptom free intervals.
Angioedema of the face, extremities, lips, tongue, glottis and/or larynx has been reported in patients treated with ACE inhibitors. This may occur at any time during treatment. In such cases, the product should be discontinued promptly and appropriate monitoring instituted to ensure complete resolution of symptoms prior to dismissing the patient. Patients who respond to medical treatment should be observed carefully for a possible rebound phenomenon.
In instances when swelling has been confined to the face and lips, the angioedema has generally resolved either without treatment or with antihistamines. Angioedema associated with laryngeal oedema is potentially life threatening. Very rarely, fatalities have been reported due to angioedema associated with laryngeal oedema or tongue oedema. Where involvement of the tongue, glottis, or larynx is likely to cause airway obstruction, appropriate emergency therapy, including adrenaline and oxygen administration and/or the maintenance of a patent airway, should be carried out promptly and the patient may need to be hospitalised. The patient should be under close medical supervision until complete and sustained resolution of symptoms has occurred.
ACE inhibitors cause a higher rate of angioedema in Afro-Caribbean black patients than in non-Afro-Caribbean black patients.
Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema whilst receiving an ACE inhibitor.
Angioedema may occur with or without urticaria.
Some drugs if given concomitantly with ACE inhibitors may increase the risk of angioedema (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Race.

Angiotensin converting enzyme inhibitors cause a higher rate of angioedema in Afro-Caribbean black patients than in non-Afro-Caribbean black patients.
ACE inhibitors may have a lesser effect on blood pressure in black hypertensive patients than in non-black hypertensive patients.

Symptomatic hypotension.

Hypotension may occur in patients commencing treatment with ACE inhibitors. Excessive hypotension is rarely seen in patients with uncomplicated hypertension but can develop in patients with impaired renal function, in those that are salt/ volume depleted because of renovascular disease, diuretic therapy, vomiting or diarrhoea, and in patients undergoing dialysis (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions; Section 4.8 Adverse Effects (Undesirable Effects)). In patients with severe congestive heart failure, with or without associated renal insufficiency, excessive hypotension has been observed. This may be associated with syncope, neurological deficits, oliguria and/or progressive azotemia, and rarely with acute renal failure and/or death. Because of the potential fall in blood pressure in these patients, therapy should be started at low doses under very close supervision. Such patients should be followed closely for the first two weeks of treatment and whenever the dosage is increased, or diuretic therapy is commenced or increased.
Similar considerations may apply to patients with ischaemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in myocardial infarction or cerebrovascular accident, respectively. In all high risk patients, it is advisable to initiate treatment at lower dosages than those usually recommended for uncomplicated patients.
If hypotension occurs, the patient should be placed in a supine position and, if necessary, receive an intravenous infusion of normal saline. A transient hypotensive response is not a contraindication to further doses which usually can be given without difficulty once the blood pressure has increased.
As with other vasodilators, Zestril should be given with caution to patients with aortic stenosis or hypertrophic cardiomyopathy.

Hypotension in acute myocardial infarction.

Treatment with lisinopril must not be initiated in acute myocardial infarction patients who are at risk of further serious haemodynamic deterioration after treatment with a vasodilator. These are patients with systolic blood pressure of 100 mmHg or lower or cardiogenic shock. During the first 3 days following the infarction, the dose should be reduced if the systolic blood pressure is 120 mmHg or lower. Maintenance doses should be reduced to 5 mg or temporarily to 2.5 mg if systolic blood pressure is 100 mmHg or lower. If hypotension persists (systolic blood pressure less than 90 mmHg for more than 1 hour) then Zestril should be withdrawn.

Dual blockade of the renin angiotensin aldosterone system (RAAS).

There is evidence that the concomitant use of ACE inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function (including acute renal failure). Dual blockade of the RAAS through the combined use of ACE inhibitors, angiotensin II receptor blockers or aliskiren should be avoided (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
If dual blockade therapy is considered necessary, this should only occur under specialist supervision and subject to frequent close monitoring of renal function, electrolytes and blood pressure.
ACE inhibitors and angiotensin II receptor blockers should not be used concomitantly in patients with diabetic nephropathy.

Neutropenia/agranulocytosis.

Another angiotensin converting enzyme inhibitor has been shown to cause agranulocytosis and bone marrow depression (including leucopenia/neutropenia). These reports generally involve patients who have pre-existing renal dysfunction and/or collagen vascular disease, some of whom have received concomitant immunosuppressant therapy. Most reports describe transient episodes for which a causal relationship to the ACE inhibitor could not be established. Available data from clinical trials of lisinopril are insufficient to show that lisinopril does not cause agranulocytosis at similar rates. International marketing experience has revealed cases of neutropenia or agranulocytosis in which a causal relationship to lisinopril cannot be excluded.
It is recommended that periodic haematologic monitoring be considered in patients with diseases known to affect bone marrow function (e.g. renal dysfunction, collagen vascular disease, etc) and/or who are taking concomitant therapy known to be associated with bone marrow depression.

Combination use of ACE inhibitors or angiotensin receptor antagonists, anti-inflammatory drugs and thiazide diuretics.

The use of an ACE inhibiting drug (ACE-inhibitor or angiotensin receptor antagonist), an anti-inflammatory drug (NSAID or COX-2 inhibitor) and a thiazide diuretic at the same time increases the risk of renal impairment. This includes use in fixed-combination products containing more than one class of drug. Combined use of these medications should be accompanied by increased monitoring of serum creatinine, particularly at the institution of the combination. The combination of drugs from these three classes should be used with caution particularly in elderly patients or those with pre-existing renal impairment.

Hyperkalaemia.

Because the ACE inhibitors decrease the formation of angiotensin II and the subsequent production of aldosterone, serum potassium concentrations exceeding 5.5 mEq/L may occur. Hyperkalaemia is more likely in patients with some degree of renal impairment, those treated with potassium sparing diuretics or potassium supplements, and in those consuming potassium containing salt substitutes. Diabetics, and elderly diabetics particularly, may be at increased risk of hyperkalaemia. In some patients, hyponatraemia may coexist with hyperkalaemia. It is recommended that patients taking an ACE inhibitor should have serum electrolytes (including potassium, sodium, and urea) measured from time to time. This is more important in patients taking diuretics.

Surgery/ anaesthesia.

In patients undergoing major surgery or who require anaesthesia, hypotension due to anaesthetic agents may be greater in patients receiving ACE inhibitors because of interference with compensatory mechanisms associated with the renin angiotensin system. If perioperative hypotension occurs, volume expansion would be required.

Cough.

A persistent dry (nonproductive) irritating cough has been reported with ACE inhibitors. In various studies, the incidence of cough varies depending upon the drug, dosage, duration of use and method of analysis.
The cough is most likely due to stimulation of the pulmonary cough reflex by kinins (bradykinin) and/or prostaglandins which accumulate because of ACE inhibition. A change to another class of drugs may be required in severe cases.

Dermatological reactions.

Dermatological reactions characterised by maculopapular pruritic rashes and sometimes photosensitivity have been reported rarely with ACE inhibitors. Rare and occasionally severe skin reactions (e.g. lichenoid eruptions, psoriasis, pemphigus-like rash, Stevens-Johnson syndrome) have also been reported with some ACE inhibitors. A causal relationship is sometimes difficult to assess.
Patients who develop a cutaneous reaction with one ACE inhibitor might not when switched to another drug of the same class, but there are reports of cross reactivity.

Taste disturbances (dysgeusia).

The incidence of taste disturbance was reported to be high (up to 12.5%) with high doses of another ACE inhibitor but the overall incidence for the class is probably low. However, the relevant data are scarce and difficult to interpret.
The taste disturbance has been described as a suppression of taste or a metallic sensation in the mouth. The dysgeusia usually occurs in the first few weeks of treatment and may disappear within 1 to 3 months despite continued treatment.

Diabetic patients.

In diabetic patients treated with oral antidiabetic agents or insulin, glycaemic control should be closely monitored during the first month of treatment with lisinopril.

Information for patients.

Angioedema.

Angioedema, including laryngeal oedema, may occur at any time during treatment with Zestril. While this condition is rare, patients should be so advised and told to report immediately any signs or symptoms suggesting angioedema (swelling of face, extremities, eyes, lips, tongue, difficulty in swallowing or breathing) and to take no more drug until they have consulted with the prescribing physician.

Symptomatic hypotension.

Patients should be cautioned to report lightheadedness, especially during the first few days of therapy. If actual syncope occurs, the patients should be told to discontinue the drug until they have consulted with the prescribing physician.
All patients should be cautioned that excessive perspiration and dehydration may lead to an excessive fall in blood pressure because of reduction in fluid volume. Other causes of volume depletion such as vomiting or diarrhoea, may also lead to a fall in blood pressure; patients should be advised to consult with their physician.

Hyperkalaemia.

Patients should be told not to use salt substitutes containing potassium without consulting their physician.

Neutropenia.

Patients should be told to report promptly any indication of infection (e.g. sore throat, fever), which may be a sign of neutropenia.

Note.

As with many other drugs, certain advice to patients being treated with Zestril is warranted. This information is intended to aid in the safe and effective use of this medication. It is not a disclosure of all possible adverse or intended effects.

Use in renal impairment.

Changes in renal function may be anticipated in susceptible individuals. In patients with severe congestive heart failure, whose renal function may depend on the activity of the renin angiotensin aldosterone system, treatment with ACE inhibitors may be associated with oliguria and/or progressive azotemia, and rarely with acute renal failure and/or death.
In patients with unilateral or bilateral renal artery stenosis, increases in blood urea nitrogen and serum creatinine have been observed. These increases are usually reversible upon discontinuation of ACE treatment. ACE inhibitors should be avoided in patients with known or suspected bilateral renal artery stenosis. When an ACE inhibitor is given to a patient with stenosis of the renal artery supplying a solitary kidney or with bilateral renal artery stenosis, acute renal insufficiency may occur. ACE inhibition may also cause a decrease in renal function in patients with stenosis of the artery supplying a transplanted kidney. It is believed that renal artery stenosis reduces glomerular filtration pressure. Under these circumstances, renal function is dependent on angiotensin II induced vasoconstriction of the efferent arteriole. When an ACE inhibitor is given, the efferent arteriole relaxes, glomerular filtration decreases, and renal failure may result. The thrombotic occlusion of a stenosed renal artery can be precipitated by ACE inhibitors.
Some patients with no apparent pre-existing renovascular disease have developed increases in blood urea nitrogen and serum creatinine which is usually minor and transient. This is more likely to occur in patients with pre-existing renal impairment or in those on diuretics.
Dosage reduction of the ACE inhibitor and/or discontinuation of the diuretic may be required.
In acute myocardial infarction, treatment with lisinopril should not be initiated in patients with evidence of renal dysfunction, defined as serum creatinine concentration exceeding 177 micromol/L and/or proteinuria exceeding 500 mg/24 h. If renal dysfunction develops during treatment with Zestril (serum creatinine concentration exceeding 265 micromol/L or a doubling from the pretreatment value), then the physician should consider withdrawal of Zestril.
Evaluation of the hypertensive patient should always include assessment of renal function (see Section 4.2 Dose and Method of Administration). In patients with renal artery stenosis, if a deterioration in renal function has occurred after treatment with one ACE inhibitor, then it is likely to be precipitated by another and in these patients usage of another class of antihypertensive agent would be preferable. Patients with unilateral renal artery stenosis present a special problem as deterioration of function may not be apparent from measurement of blood urea and serum creatinine.
It is possible that in patients with compromised renal function who are being treated with NSAIDs, the coadministration of lisinopril may result in a further deterioration of renal function. This may result in an increase in serum potassium, but it appears that these effects are usually reversible.

Use in hepatic impairment.

Hepatitis (hepatocellular and/or cholestatic), elevations of liver enzymes and/or serum bilirubin have occurred during therapy with other ACE inhibitors in patients with or without pre-existing liver abnormalities. In most cases the changes were reversed on discontinuation of the drug.
There are no adequate studies in patients with cirrhosis and/or liver dysfunction. Lisinopril should be used with particular caution in patients with pre-existing liver abnormalities. In such patients baseline liver function tests should be obtained before administration of the drug and close monitoring of response and metabolic effects should apply.

Use in the elderly.

See Section 4.2 Dose and Method of Administration, Use in the elderly; Section 4.4 Special Warnings and Precautions for Use, Combination use of ACE inhibitors or angiotensin receptor antagonists, anti-inflammatory drugs and thiazide diuretics, Hyperkalaemia.

Paediatric use.

Safety and effectiveness of Zestril in children have not been established.

Effects on laboratory tests.

Serum electrolytes.

Hyperkalaemia (see Section 4.4 Special Warnings and Precautions for Use) and hyponatraemia have occurred.

Creatinine, blood urea nitrogen.

Minor increases in blood urea nitrogen and serum creatinine, reversible upon discontinuation of therapy, were observed in 1.1 and 1.6 percent of patients, respectively, with hypertension treated with Zestril alone. Increases were more common in patients receiving concomitant diuretics and in patients with renal artery stenosis (see Section 4.4 Special Warnings and Precautions for Use).
Reversible minor increases in blood urea nitrogen and serum creatinine were observed in approximately 12.0% of patients with congestive heart failure on concomitant diuretic therapy. Frequently, these abnormalities resolved when the dosage of the diuretic was decreased.

Bone marrow depression.

Bone marrow depression, manifest as anaemia, and/or thrombocytopenia and/or leucopenia has been reported. Agranulocytosis has been rarely reported, although a causal relationship has not been established. Rarely, haemolytic anaemia has been reported.

Haemoglobin and haematocrit.

Small decreases in haemoglobin and haematocrit, rarely of clinical importance unless another cause of anaemia coexisted, have occurred.

Other (causal relationship unknown).

Rarely, elevations of liver enzymes and/or serum bilirubin have occurred. Rare cases of bone marrow depression have been reported. Thrombocytopenia and leucopenia have been reported; a causal relationship to therapy with Zestril cannot be excluded.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Antihypertensive agents.

When combined with other antihypertensive agents, additive falls in blood pressure may occur. Clinical trial data has shown that dual blockade of the RAAS through the combined use of ACE inhibitors, angiotensin II receptor blockers or aliskiren is associated with a higher frequency of adverse events such as hypotension, hyperkalaemia and decreased renal function (including acute renal failure) compared to the use of a single RAAS acting agent.
The combination of lisinopril with aliskiren containing medicines should be avoided (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use).

Drugs that may increase the risk of angioedema.

Concomitant treatment of ACE inhibitors with mammalian target of rapamycin (mTOR) inhibitors (e.g. temsirolimus, sirolimus, everolimus) or neutral endopeptidase (NEP) inhibitors (e.g. racecadotril) or tissue plasminogen activator may increase the risk of angioedema.

Diuretics.

When a diuretic is added to the therapy of a patient receiving an ACE inhibitor, the antihypertensive effect is usually additive. Patients receiving diuretics, especially those in whom diuretic therapy was recently instituted or in those with intravascular volume depletion, may sometimes experience an excessive reduction of blood pressure after initiation of therapy with an ACE inhibitor. The possibility of hypotensive effects may be minimised by discontinuing the diuretic and ensuring adequate hydration and salt intake prior to commencing ACE inhibitor therapy. If it is not possible to discontinue the diuretic, the starting dose of the ACE inhibitor should be reduced and the patient closely observed for several hours following the initial dose of the ACE inhibitor and until the blood pressure has stabilised.

Lithium.

Increased serum lithium levels and symptoms of lithium toxicity have been reported in patients receiving lithium concomitantly with drugs which cause elimination of sodium, including ACE inhibitors. These drugs should be coadministered with caution, and frequent monitoring of serum lithium levels is recommended. If a diuretic is also used, the risk of lithium toxicity may be increased.

Gold.

Nitritoid reactions (symptoms of vasodilatation including flushing, nausea, dizziness and hypotension, which can be very severe) following injectable gold (for example, sodium aurothiomalate) have been reported more frequently in patients receiving ACE inhibitor therapy.

Nonsteroidal anti-inflammatory drugs.

Drugs with prostaglandin synthetase inhibitory properties (e.g. indomethacin) may diminish the antihypertensive efficacy of concomitantly administered ACE inhibitors.
In some patients with compromised renal function who are being treated with nonsteroidal anti-inflammatory drugs (NSAIDs), the coadministration of lisinopril may result in a further deterioration in renal function.

Agents causing renin release.

The antihypertensive effect of Zestril is augmented by antihypertensive agents that cause renin release (e.g. diuretics).

Agents affecting sympathetic activity.

Agents affecting sympathetic activity (e.g. ganglionic blocking agents or adrenergic neuron blocking agents) may be used with caution. Beta-adrenergic blocking drugs are also antihypertensive in action, hence if they are combined with an ACE inhibitor, the patient should be closely monitored.

Serum potassium.

ACE inhibitors can attenuate potassium loss caused by thiazide diuretics and increase serum potassium when used alone. The concomitant therapy of an ACE inhibitor with a potassium sparing diuretic (e.g. spironolactone, triamterene, or amiloride), potassium supplements or potassium containing salt substitutes, or other drugs that may increase serum potassium levels (e.g. heparin, cotrimoxazole) can increase the risk of hyperkalaemia, therefore if coadministration is indicated they should be used with caution and the patient's serum potassium should be monitored frequently.

Antidiabetics.

Epidemiological studies have suggested that concomitant administration of ACE inhibitors and antidiabetic medicines (such as insulins, oral hypoglycaemic agents) may cause increased blood glucose lowering effect with the risk of hypoglycaemia. This phenomenon appeared to be more likely to occur during the first weeks of combined treatment and in patients with renal impairment.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

There were no adverse effects on reproductive performance in male and female rats treated with up to 300 mg/kg/day of lisinopril.
(Category D)
As with all ACE inhibitors, Zestril should not be taken during pregnancy. Pregnancy should be excluded before starting treatment with Zestril and avoided during treatment.
If a patient intends to become pregnant, treatment with ACE inhibitors must be discontinued and replaced by another form of treatment.
If a patient becomes pregnant while on ACE inhibitors, she must immediately inform her doctor to discuss a change in medication and further management.
There are no adequate and well controlled studies of ACE inhibitors in pregnant women, but foetotoxicity is well documented in animal models.
A historical cohort study in over 29,000 infants born to nondiabetic mothers has shown 2.7 times higher risk for congenital malformations in infants exposed to any ACE inhibitor during 1st trimester compared to no exposure. The risk ratios for cardiovascular and central nervous system malformations were 3.7 times (95% confidence interval 1.89 to 7.3) and 4.4 times (95% confidence interval 1.37 to 14.02) respectively, compared to no exposure.
Data show that ACE inhibitors cross the human placenta. Postmarketing experience with all ACE inhibitors suggests that exposure in utero may be associated with hypotension and decreased renal perfusion in the foetus. ACE inhibitors have also been associated with foetal death in utero. Adverse effects appear to be most likely in the second and third trimesters.
When ACE inhibitors have been used during the second and third trimester of pregnancy, there have been reports of foetal hypotension, renal failure, hyperkalaemia, skull hypoplasia and death. It is not known whether exposure limited to the first trimester can adversely affect foetal outcome.
Oligohydramnios has been reported, presumably resulting from decreased foetal renal function; oligohydramnios has been associated with foetal limb contractures, craniofacial deformities, hypoplastic lung development and intrauterine growth retardation. Prematurity and patent ductus arteriosus have been reported, however, it is not clear whether these events were due to ACE inhibitor exposure.
Infants exposed in utero to ACE inhibitors should be closely observed for hypotension, oliguria and hyperkalaemia. If such complications arise, appropriate medical treatment should be initiated to support blood pressure and renal perfusion. Lisinopril has been removed from the neonatal circulation by peritoneal dialysis with some clinical benefit and theoretically may be removed by exchange transfusion.
 Milk of lactating rats contains radioactivity following administration of 14C-lisinopril. It is not known whether this drug is secreted in human milk. Because the possibility exists that Zestril may be secreted in human milk, Zestril should not be given to a nursing mother.

4.7 Effects on Ability to Drive and Use Machines

When driving vehicles or operating machines, patients may experience dizziness or tiredness.

4.8 Adverse Effects (Undesirable Effects)

Zestril has been found to be generally well tolerated in controlled clinical trials. For the most part, adverse experiences were mild and transient in nature. In patients with congestive heart failure high doses of lisinopril may predispose to symptoms related to hypotension (dizziness, syncope) and to biochemical changes related to impaired renal function (hyperkalaemia and increased serum creatinine), as would be expected with ACE inhibitor therapy.
The adverse events which occurred in controlled clinical trials with lisinopril are taken from the case reports of 3702 patients (2633 patients with hypertension, 636 patients with congestive heart failure and 433 diabetes patients) and may be grouped as follows:

Hypertension (2633 patients).

See Table 2.

Congestive heart failure (636 patients).

The most common adverse reaction occurring in this patient population was dizziness (14.2%). The other adverse reactions were as follows (see Table 3):

Renal and retinal complications of diabetes mellitus (433 patients).

Adverse events from 2 clinical trials in diabetic patients (433 patients receiving lisinopril) are as follows:
The adverse events from each trial that were reported by < 1% of the patients are not included. See Table 4.

Hypersensitivity/angioneurotic oedema.

Hypersensitivity/angioneurotic oedema of the face, extremities, lips, tongue, glottis and/or larynx has been reported uncommonly (see Section 4.4 Special Warnings and Precautions for Use). In very rare cases, intestinal angioedema has been reported.
The following adverse reactions have been reported during postmarketing experience with a frequency of common (≥ 1% to < 10%):

Renal and urinary disorders.

Renal dysfunction.
The following adverse reactions have been reported during postmarketing experience with a frequency of uncommon (≥ 0.1% to < 1%):

Metabolism and nutrition disorders.

Hyperkalaemia.

Cardiac and vascular disorders.

Syncope in the hypertensive population, while in the congestive heart failure population the frequency of syncope is common.
Myocardial infarction or cerebrovascular accident; possibly secondary to excessive hypotension in high risk patients (see Section 4.4 Special Warnings and Precautions for Use); tachycardia.

Nervous system and psychiatric disorders.

Mood alterations (incl depressive symptoms); taste disturbance; sleep disturbances, hallucinations.
Additional adverse reactions which occurred rarely, either during controlled clinical trials or after the drug was marketed, include:

Digestive system.

Abdominal pain; dry mouth; hepatitis (hepatocellular and cholestatic) very rarely this may progress to hepatic failure; jaundice; pancreatitis.
Patients receiving Zestril who develop jaundice or marked elevation of hepatic enzymes should discontinue Zestril and receive appropriate medical follow up.

Endocrine disorders.

Inappropriate antidiuretic hormone secretion.

Musculoskeletal system.

Joint pain.

Nervous system and psychiatric disorders.

Mental confusion, olfactory disturbance.

Respiratory system.

Bronchitis; bronchospasm; nasal congestion; pharyngeal pain; sinusitis; rhinitis.

Skin.

Alopecia; urticaria; diaphoresis; cutaneous pseudolymphoma; psoriasis and severe skin disorders have been reported, including pemphigus, toxic epidermal necrolysis, Stevens-Johnson syndrome and erythema multiforme.

Urogenital system.

Uraemia; oliguria/anuria; proteinuria; acute renal failure; impotence; urinary tract infection.

Body as a whole.

A symptom complex has been reported which may include fever, vasculitis, myalgia, arthralgia/ arthritis, a positive ANA, an elevated erythrocyte sedimentation rate, eosinophilia and leukocytosis. Rash, photosensitivity, or other dermatologic manifestations may occur.

Immune system disorders.

Frequency not known: anaphylactic/anaphylactoid reaction.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at www.tga.gov.au/reporting-problems.

4.9 Overdose

There are no data on overdosage in humans. The most likely manifestation of overdosage would be hypotension, for which the usual treatment would be intravenous infusion of normal saline solution. Lisinopril may be removed from the general circulation by haemodialysis.
For information on the management of overdose, contact the Poison Information Centre on 131126 (Australia).

5 Pharmacological Properties

Zestril (lisinopril dihydrate), a synthetic peptide derivative, is an oral long-acting angiotensin converting enzyme inhibitor. It is a lysine analogue of enalaprilat (active metabolite of enalapril).

5.1 Pharmacodynamic Properties

Mechanism of action.

Lisinopril is a peptidyl dipeptidase inhibitor. It inhibits the angiotensin converting enzyme (ACE) that catalyses the conversion of angiotensin I to the vasoconstrictor substance, angiotensin II. Angiotensin II also stimulates aldosterone secretion by the adrenal cortex. Inhibition of ACE results in decreased concentrations of plasma angiotensin II which results in decreased vasopressor activity and to decreased aldosterone secretion. The latter decrease may result in a small increase of serum potassium.
In hypertensive patients with normal renal function treated with lisinopril alone for up to 24 weeks, the mean increase in serum potassium was approximately 0.1 mmol/L; however, approximately 15% of patients had increases greater than 0.5 mmol/L and approximately 6% had a decrease greater than 0.5 mmol/L. In the same study, patients treated with lisinopril and hydrochlorothiazide for up to 24 weeks had a mean decrease in serum potassium of 0.1 mmol/L; approximately 4% of patients had increases greater than 0.5 mmol/L and approximately 12% had a decrease greater than 0.5 mmol/L (see Section 4.4 Special Warnings and Precautions for Use). Removal of angiotensin II negative feedback on renin secretion leads to increased plasma renin activity.
While the mechanism through which lisinopril lowers blood pressure is believed to be primarily suppression of the renin angiotensin aldosterone system, lisinopril is antihypertensive even in patients with low renin hypertension. Although lisinopril was antihypertensive in all races studied, black hypertensive patients (usually a low renin hypertensive population) had a smaller average response to monotherapy than nonblack patients. Concomitant administration of lisinopril and hydrochlorothiazide further reduced blood pressure in black and nonblack patients and any racial differences in blood pressure response was no longer evident.
ACE is identical to kininase II, an enzyme that degrades bradykinin. Whether increased levels of bradykinin, a potent vasodepressor peptide, play a role in the therapeutic effects of lisinopril remains to be elucidated.
When combined with other antihypertensive agents, additive falls in blood pressure may occur.
ACE is known to be present in the endothelium and increased ACE activity in diabetic patients which results in the formation of angiotensin II and destruction of bradykinin, potentiates the damage to the endothelium caused by hyperglycaemia. ACE inhibitors, including lisinopril, inhibit the formation of angiotensin II and breakdown of bradykinin and hence ameliorate endothelial dysfunction.
The effects of lisinopril on urinary albumin excretion rate in diabetic patients is mediated by a reduction in blood pressure as well as a direct mechanism on the renal tissues.
Lisinopril treatment is not associated with an increased incidence of hypoglycaemic events in diabetic patients and it does not affect glycaemic control as shown by a lack of significant effect on levels of glycosylated haemoglobin (HbA1c).

Pharmacodynamics.

Administration of lisinopril to patients with hypertension results in a reduction of supine and standing blood pressure to about the same extent, with no compensatory tachycardia. Symptomatic postural hypotension is usually not observed although it can occur and should be anticipated in volume and/or salt depleted patients (see Section 4.4 Special Warnings and Precautions for Use). When given together with thiazide type diuretics, the blood pressure lowering effects of the two drugs are approximately additive.
In most patients studied, onset of antihypertensive activity was seen one to two hours after oral administration of an individual dose of lisinopril, with peak reduction of blood pressure achieved by 6 hours. Although an antihypertensive effect was observed 24 hours after dosing with recommended single daily doses, the effect was more consistent and the mean effect was considerably larger in some studies with doses of 20 mg or more than with lower doses. However, in all doses studied, the mean antihypertensive effect was substantially smaller 24 hours after dosing than it was 6 hours after dosing.
In some patients achievement of optimal blood pressure reduction may require two to four weeks of therapy.
The antihypertensive effects of lisinopril are maintained during long-term therapy. Abrupt withdrawal of lisinopril has not been associated with a rapid increase in blood pressure, or a significant increase in blood pressure compared to pretreatment levels.
Two dose response studies utilising a once daily regimen were conducted in 438 mild to moderate hypertensive patients not on a diuretic. Blood pressure was measured 24 hours after dosing. An antihypertensive effect of lisinopril was seen with 5 mg in some patients. However, in both studies blood pressure reduction occurred sooner and was greater in patients treated with 10, 20 or 80 mg of lisinopril. In controlled clinical studies, lisinopril 20 to 80 mg has been compared in patients with mild to moderate hypertension with hydrochlorothiazide 12.5 to 50 mg and with atenolol 50 to 200 mg, and in patients with moderate to severe hypertension with metoprolol 100 to 200 mg. It was superior to hydrochlorothiazide in effects on systolic and diastolic blood pressure in a population that was 3/4 Caucasian. Lisinopril was approximately equivalent to atenolol and metoprolol in effects on diastolic blood pressure, and had somewhat greater effects on systolic blood pressure.
Zestril had similar effectiveness and adverse effects in younger and older (> 65 years) patients. It was less effective in blacks than in Caucasians.
In haemodynamic studies in patients with hypertension, blood pressure reduction was accompanied by a reduction in peripheral arterial resistance with little or no change in cardiac output and in heart rate. In a study in nine hypertensive patients, following administration of lisinopril, there was an increase in mean renal blood flow that was not significant. Data from several small studies are inconsistent with respect to the effect of lisinopril on glomerular filtration rate in hypertensive patients with normal renal function, but suggest that changes, if any, are not large.

Clinical trials.

Acute myocardial infarction.

Zestril is indicated in the management of patients with acute myocardial infarction to prevent the subsequent development of left ventricular dysfunction (as defined by an ejection fraction equal to or less than 35%) or heart failure and to improve survival, based on the outcome of the GISSI-3 trial. The Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-3) study was a multicentre, controlled, randomised, unblinded clinical trial conducted in 19,394 patients with acute myocardial infarction admitted to a coronary care unit. It was designed to examine the effects of short-term (6 week) treatment with lisinopril, nitrates, their combination, or no therapy on short-term (6 week) mortality and on longer-term death and markedly impaired cardiac function. Patients presenting within 24 hours of the onset of symptoms who were haemodynamically stable were randomised, in a 2 x 2 factorial design, to six weeks of either 1) Zestril alone (n = 4841), 2) nitrates alone (n = 4869), 3) Zestril plus nitrates (n = 4841), or 4) open control (n = 4843). All patients received routine therapies, including thrombolytics (72%), aspirin (84%), and a beta-blocker (31%), as appropriate, normally utilised in acute myocardial infarction (MI) patients.
The protocol excluded patients with hypotension (systolic blood pressure ≤ 100 mmHg), severe heart failure, cardiogenic shock, and renal dysfunction (serum creatinine > 2 mg/dL and/or proteinuria > 500 mg/24 h). Doses of Zestril were adjusted as necessary according to protocol (see Section 4.2 Dose and Method of Administration).
Study treatment was withdrawn at six weeks except where clinical conditions indicated continuation of treatment.
The primary outcomes of the trial were the overall mortality at 6 weeks and a combined endpoint at 6 months after the myocardial infarction, consisting of a number of patients who died, had late (day 4) clinical congestive heart failure, or had extensive left ventricular damage defined as ejection fraction ≤ 35% or an akinetic-dyskinetic [A-D] score ≥ 45%. Patients receiving Zestril (n = 9646), alone or with nitrates, had an 11% lower risk of death (2p [two tailed] = 0.04) compared to patients receiving no Zestril (n = 9672) (6.4% vs 7.2%, respectively) at six weeks. The reduction in mortality at six months was not significant, but this was not a primary outcome measure. Although patients randomised to receive Zestril for up to six weeks also fared numerically better on the combined endpoint at 6 months, the open nature of the assessment of heart failure, substantial loss to follow-up echocardiography, and substantial excess use of lisinopril between 6 weeks and 6 months in the group randomised to 6 weeks of lisinopril, preclude any conclusion about this endpoint.
Patients with acute myocardial infarction treated with Zestril had a higher (9.0% versus 3.7%) incidence of persistent hypotension (systolic blood pressure < 90 mmHg for more than 1 hour) and renal dysfunction (2.4% versus 1.1%) in hospital and at six weeks (increasing creatinine concentration to over 3 mg/dL or a doubling or more of the baseline serum creatinine concentration).

Renal complication of diabetes.

EUCLID (EURODIAB controlled trial of lisinopril in insulin dependent diabetes mellitus) was an 18 centre, multinational, randomised, double blind, placebo controlled trial. It investigated the effects of lisinopril on the urinary albumin excretion rate (AER) in 530 normotensive men and women aged 20-59 years with insulin dependent diabetes mellitus (IDDM) and normoalbuminuria or microalbuminuria. The study recruited patients with a DBP in the range 75-90 mmHg inclusive provided that the SBP was ≤ 155 mmHg. Patients received either lisinopril 10 mg od or matching placebo for 2 years. Titration up to 20 mg od of lisinopril or 2 placebo tablets was permitted if sitting DBP had not reached the target value of less than 75 mmHg after 3 months of treatment. Nifedipine treatment (20 mg bd) was initiated if the BP remained inadequately controlled (SBP > 160 mmHg, DBP > 95 mmHg).
The primary efficacy variable was the rate of change in the urinary albumin excretion rate (AER) measured from two consecutive overnight urine collections at six monthly intervals from baseline to 24 months in the whole patient group (i.e. normoalbuminuric and microalbuminuric at baseline). After 24 months treatment the AER was 18.8% [95% CI: 2.0, 32.7] lower in the lisinopril group (n = 230) compared to the placebo group (n = 226) with a between group difference of 2.2 microgram/min (p = 0.03) when adjusted for baseline AER and centre. After adjustment for DBP reduction produced by lisinopril, the between group relative difference in AER was reduced to 17.3% (95% CI: 0.2, 31.5, p = 0.05). There were no statistically significant differences in AER between lisinopril and placebo in patients with good baseline glycaemic control (HbA1c < 7%) or with a baseline DBP > 80 mmHg.
In patients with baseline microalbuminuria the AER was 49.7% [95% CI: -14.5, 77.9] lower in the lisinopril group (n = 39) compared to placebo (n = 34), p = 0.1. Only 15% (n = 79) of the randomised patients had baseline microalbuminuria compared to 40% anticipated by the protocol. This may have left the study underpowered to detect a statistically significant difference in the AER between treatments in patients with baseline microalbuminuria. In a nonprotocol specified subgroup analysis in patients with baseline microalbuminuria (AER 20-200 microgram/min) and endpoint AER the absolute difference in mean AER between the lisinopril group (n = 39) and the placebo group (n = 34) was 38.5 microgram/min (p = 0.001).
The results also show that lisinopril does not increase the risk of hypoglycaemic events in IDDM as there was no treatment difference in hypoglycaemic events or glycaemic control throughout the study.

Congestive heart failure.

The effect of lisinopril on mortality and morbidity in congestive heart failure has been studied by comparing a high dose (32.5 mg or 35 mg once daily) with a low dose (2.5 mg or 5 mg once daily). Patients receiving high dose Zestril were titrated gradually up to the highest dose tolerated, up to a maximum of 32.5 mg or 35 mg once daily. Patients who were intolerant to lisinopril were excluded from the study. In a study of 3164 patients, with a median follow up period of 46 months for surviving patients, statistically nonsignificant reductions were observed in the primary endpoint all cause mortality or the secondary endpoint of cardiovascular mortality. However, compared with low dose, high dose lisinopril produced a 12% risk reduction in the combined endpoint of all cause mortality and all cause hospitalisation (p = 0.002), an endpoint added during the trial. In a post hoc analysis, the number of hospitalisations for heart failure was reduced by 24% (p = 0.002) in patients treated with high dose lisinopril compared with low dose. Symptomatic benefits were similar in patients treated with high and low doses of lisinopril. This trial did not study whether 35 mg is more effective than the currently recommended upper limit of the usual dose of 20 mg.
The results of the study showed that the overall adverse event profiles for patients treated with high or low dose lisinopril were similar in both nature and number. The overall adverse event rate included deaths and hospitalisations that contributed to the estimation of efficacy. The percentage of drug related adverse events was 8% higher in the high dose group (a relative difference of 25%). The excess in the high dose group was due to events of the type which would be expected from the pharmacological actions of lisinopril. Predictable events resulting from ACE inhibition, such as hypotension or altered renal function, were manageable and rarely led to treatment withdrawal. Cough was less frequent in patients treated with high dose lisinopril compared with low dose. NYHA classification (a measure of quality of life) did not differ between treatment groups.

5.2 Pharmacokinetic Properties

Following oral administration of Zestril, peak serum concentrations of lisinopril occur within about 7 hours, although there was a trend to a small delay in time taken to reach peak serum concentrations in acute myocardial infarction patients. Declining serum concentrations exhibit a prolonged terminal phase which does not contribute to drug accumulation. This terminal phase probably represents saturable binding to ACE and is not proportional to dose. Lisinopril does not appear to be bound to other serum proteins.
Lisinopril does not undergo metabolism and absorbed drug is excreted unchanged entirely in the urine. Based on urinary recovery, the mean extent of absorption of lisinopril is approximately 25%, with large interpatient variability (6% to 60%) at all doses tested (5 to 80 mg). Lisinopril absorption is not affected by the presence of food in the gastrointestinal tract.
Upon multiple dosing, lisinopril exhibits an effective half-life of accumulation of 12.6 hours.
Impaired renal function decreases elimination of lisinopril, which is excreted principally through the kidneys, but this decrease becomes clinically important only when the glomerular filtration rate is below 30 mL/min. Above this glomerular filtration rate, the elimination half-life is little changed. With greater impairment, however, peak and trough lisinopril levels increase, time to peak concentration increases and time to attain steady state is prolonged. Older patients, on average, have (approximately doubled) higher blood levels and higher values for the area under the plasma concentration time curve (AUC) than younger patients (see Section 4.2 Dose and Method of Administration). Lisinopril can be removed by haemodialysis. Studies in rats indicate that lisinopril crosses the blood brain barrier poorly. Multiple doses of lisinopril in rats do not result in accumulation in any tissues. Milk of lactating rats contained radioactivity following administration of 14C-lisinopril. By whole body autoradiography, radioactivity was found in the placenta following administration of labelled drug to pregnant rats, but none was found in the foetuses.

5.3 Preclinical Safety Data

Genotoxicity.

Lisinopril was not genotoxic in assays for gene mutations, chromosomal damage and DNA damage.

Carcinogenicity.

There was no evidence of a tumourigenic effect when lisinopril was administered for 105 weeks to male and female rats at doses up to 90 mg/kg/day or when lisinopril was administered for 92 weeks to male and female mice at doses up to 135 mg/kg/day. At least one other ACE inhibitor has caused an increase in the incidence of oxyphilic renal tubular cells and oncocytomas in rats. The potential for lisinopril to cause a similar effect is unknown.

6 Pharmaceutical Particulars

6.1 List of Excipients

Zestril tablets also contain mannitol, calcium hydrogen phosphate dihydrate, maize starch, pregelatinised maize starch, magnesium stearate and iron oxide red.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.
For information on interactions with other medicines and other forms of interactions, see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 30°C.

6.5 Nature and Contents of Container

Zestril is available in PVC/Al blister packs of 7 (10 mg only) and 30 tablets*.
*Not all pack sizes may be available in Australia.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of in accordance with local requirements.

6.7 Physicochemical Properties

Lisinopril dihydrate is a white to off-white, crystalline powder, with a molecular weight of 441.53. It is soluble in water and sparingly soluble in methanol and practically insoluble in ethanol.

Chemical structure.

Lisinopril dihydrate is chemically described as (S)-1-[N2-(1-carboxy-3-phenylpropyl)-L-lysyl]-L-proline dihydrate. Its empirical formula is C21H31N3O5.2H2O and its structural formula is:

CAS number.

The CAS number for lisinopril dihydrate: 83915-83-7.

7 Medicine Schedule (Poisons Standard)

Prescription Only Medicine (Schedule 4).

Summary Table of Changes