Consumer medicine information

APO-Lisinopril Tablets

Lisinopril

BRAND INFORMATION

Brand name

APO-Lisinopril Tablets

Active ingredient

Lisinopril

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using APO-Lisinopril Tablets.

What is in this leaflet

Read this leaflet carefully before taking your medicine.

This leaflet answers some common questions about lisinopril. It does not contain all the available information. It does not take the place of talking to your doctor or pharmacist.

The information in this leaflet was last updated on the date listed on the last page. More recent information on this medicine may be available.

Ask your doctor or pharmacist:

  • if there is anything you do not understand in this leaflet,
  • if you are worried about taking your medicine, or
  • to obtain the most up-to-date information.

You can also download the most up to date leaflet from www.apotex.com.au.

All medicines have risks and benefits. Your doctor has weighed the risks of you using this medicine against the benefits they expect it will have for you.

Pharmaceutical companies cannot give you medical advice or an individual diagnosis.

Keep this leaflet with your medicine. You may want to read it again.

What this medicine is used for

The name of your medicine is APO-Lisinopril. It contains the active ingredient lisinopril (as lisinopril dihydrate).

It is used to treat the following:

  • People with mild or moderate hypertension (high blood pressure)
  • People with congestive heart failure
  • People with acute myocardial infarction (heart attack)

High Blood Pressure
Everyone has blood pressure. This pressure helps get your blood all around your body.

Your blood pressure may be different at different times of the day, depending on how busy or worried you are. You have hypertension (high blood pressure) when your blood pressure stays higher than is needed, even when you are calm and relaxed.

People with high blood pressure often feel fine and have no symptoms. You can only tell if you have high blood pressure by having your blood pressure regularly checked. If high blood pressure is not treated it can lead to serious health problems, including stroke, heart disease and kidney failure.

Lisinopril is used to lower high blood pressure (hypertension).

Congestive Heart Failure
Heart failure means that the heart muscle cannot pump blood strongly enough to supply all the blood needed throughout the body. Heart failure is not the same as heart attack and does not mean that the heart stops working.

Heart failure may start off with no symptoms, but as the condition progresses, people may feel short of breath or may get tired easily after light physical activity such as walking. Some people may wake up short of breath at night. Fluid may collect in different parts of the body, often first noticed as swollen ankles and feet.

Lisinopril may help to improve the symptoms of heart failure.

When used to treat heart failure, lisinopril is almost always used with other medicines called diuretics or fluid tablets. These medicines help the kidney to get rid of excess fluid from the body.

Heart Attack
A heart attack occurs when one of the major blood vessels supplying blood to the heart muscle becomes blocked. As a result of the blockage, the heart does not receive the oxygen it needs and the heart muscle becomes damaged. This may lead to further complications such as heart failure, irregular heart rhythms and blood clots.

In some patients, lisinopril may help to prevent some of the further complications of heart attack, such as heart failure.

Ask your doctor if you have any questions about why this medicine has been prescribed for you. Your doctor may have prescribed this medicine for another reason.

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

How it works

Lisinopril belongs to a group of medicines called Angiotensin Converting Enzyme (ACE) inhibitors.

It widens the blood vessels so that blood can pass through them more easily. This means that your blood pressure will drop, and it also means that if you have heart failure your heart can cope with doing some exercise and you won't run out of breath as easily.

Lisinopril also helps prevent complications which follow a heart attack, such as heart failure.

There is no evidence that this medicine is addictive.

Use in children

This medicine should not be used in children.

Before you take this medicine

When you must not take it

Do not take this medicine if:

You have or have had any of the following:

  • renal artery stenosis (a problem with the blood vessels to one or both kidneys).
  • renal dialysis using polyacrylonitrile high flux membranes.
  • You are taking the following medications:
    - aliskiren-containing medicines in patients with diabetes
    - aliskiren-containing medicines in patients with moderate to severe kidney problems

You are pregnant.

Lisinopril may affect your developing baby if you take it during pregnancy.

You have had an allergic reaction to lisinopril or any of the ingredients listed at the end of this leaflet.

Symptoms of an allergic reaction may include cough, shortness of breath, wheezing or difficulty breathing; swelling of the face, lips, tongue, throat or other parts of the body, rash, itching or hives on the skin; fainting or hayfever-like symptoms

If you think you are having an allergic reaction, do not take any more of the medicine and contact your doctor immediately or go to the Accident and Emergency department at the nearest hospital.

You have had a reaction to other types of ACE inhibitors which made your face, lips, tongue, throat, hands or feet swell up, or you had trouble breathing.

If you have had this type of allergic reaction to another ACE inhibitor you may have the same reaction to lisinopril.

You have previously had swollen face, lips, tongue, throat, hands or feet or breathlessness, for no apparent reason (a rare allergic condition known as angio-oedema).

The expiry date (EXP) printed on the pack has passed.

The packaging is torn, shows signs of tampering or it does not look quite right.

Before you start to take it

  1. You have allergies to:
  • any other medicines
  • any other substances, such as foods, preservatives or dyes.
  1. You have or have had any medical conditions, especially the following:
  • kidney problems, or you are having dialysis
  • diabetes
  • liver problems
  • heart problems
  • cerebrovascular disease (which affects blood flow to the brain)
  • low blood pressure (you may notice this as faintness or dizziness, especially when standing)
  • recent diarrhoea or vomiting
  • low levels of sodium, or high levels of potassium in your blood
  1. You are currently pregnant or you plan to become pregnant. Do not take this medicine whilst pregnant.
  2. You are currently breastfeeding or you plan to breast-feed. Do not take this medicine whilst breastfeeding until you and your doctor have discussed the risks and benefits involved.
  3. You are planning to have surgery or a general anaesthetic.
  4. You are following a very low salt diet.
  5. You are having desensitisation treatment or have had an allergic reaction during previous desensitisation treatment (e.g. treatments using bee, wasp or ant venom).
  6. You are currently receiving or are planning to receive dental treatment.
  7. You are taking or are planning to take any other medicines. This includes vitamins and supplements that are available from your pharmacy, supermarket or health food shop.

Some medicines may interact with lisinopril. These include:

  • other medicines used for treating high blood pressure
  • diuretics (fluid, or water tablets)
  • potassium- sparing diuretics such as spironolactone, eplerenone, triamterene and amiloride
  • potassium tablets or potassium- containing salt substitutes
  • lithium, used for mood swings and depression
  • medicines to relieve pain, swelling and other symptoms of inflammation, including arthritis, such as gold therapy, Non-Steroidal Anti-inflammatory Drugs (NSAIDs) (e.g. indomethacin) or COX-2 inhibitors (e.g. Celebrex). It is especially important to tell your doctor when taking blood pressure, water and/or heart tablets together with NSAIDs or COX-2 inhibitors and lisinopril.
  • tablets or injections used for treating diabetes. Your blood glucose levels should be closely monitored whilst taking lisinopril, especially during the first month.
  • general anaesthetics

If you are taking any of these you may need a different dose or you may need to take different medicines.

Other medicines not listed above may also interact with lisinopril.

How to take this medicine

Follow carefully all directions given to you by your doctor. Their instructions may be different to the information in this leaflet.

How much to take

Your doctor or pharmacist will tell you how much of this medicine you should take. This will depend on your condition and whether you are taking any other medicines. If you need to take 2.5 mg then you must use a different brand of lisinopril, as the 5 mg tablets must not be broken in half to give a 2.5 mg dose.

High blood pressure
Most people start with 5 to 10 mg per day (although some may have less). The doctor will monitor your blood pressure and will gradually increase the dose of lisinopril if necessary. Most patients take between 10 and 20 mg once each day.

Heart Failure
The usual starting dose is 2.5 mg, taken once a day.

Depending on your response, this dose may need to be gradually increased.

The usual dose is 5 to 20 mg each day, taken once a day.

Heart Attack
You may start taking lisinopril within 24 hours of the start of a heart attack, and continue taking it for six weeks or more.

The usual starting dose is 5 mg, followed by 5 mg 24 hours later. Then 10 mg is taken 48 hours later, and once every day after that.

Some patients may have lower doses.

Do not stop taking your medicine or change your dosage without first checking with your doctor.

How to take it

Swallow your tablets with a glass of water.

When to take it

Take this medicine at the same time each day. Taking it at the same time each day will have the best effect and will also help you remember when to take it.

It does not matter if you take it before, with or after food.

How long to take it for

Lisinopril can help control blood pressure, improve heart failure and prevent complications of heart attack, but it cannot cure them. Therefore you will need to take this medicine every day.

Continue taking your medicine for as long as your doctor tells you.

Make sure you have enough to last over weekends and holidays.

If you forget to take it

If it is almost time to take your next dose, skip the missed dose and take your next dose at the usual time. Otherwise, take it as soon as you remember and then go back to taking your medicine as you would normally.

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

This may increase the chance of you experiencing side effects.

If you have trouble remembering to take your medicine, ask your pharmacist for some hints to help you remember.

If you take too much (overdose)

If you think that you or anyone else may have taken too much of this medicine, immediately telephone your doctor or the Poisons Information Centre (Tel: 13 11 26 in Australia) for advice. Alternatively, go to the Accident and Emergency department at your nearest hospital.

Do this even if there are no signs of discomfort or poisoning. You may need urgent medical attention.

If you take too much lisinopril, you may feel dizzy or light-headed, or you may faint.

While you are taking this medicine

Things you must do

Tell your doctor that you are taking this medicine if:

  • you are about to be started on any new medicine
  • you are pregnant or are planning to become pregnant
  • you are breast-feeding or are planning to breast-feed
  • you are about to have any blood tests
  • you are going to have surgery or an anaesthetic or are going into hospital. Your blood pressure may drop suddenly during a general anaesthetic.
  • you have diarrhoea or vomiting. This may lead to dehydration, and your blood pressure may drop too much.

Your doctor will do regular blood tests and may occasionally do other tests to make sure the medicine is working and to prevent side effects. Go to your doctor regularly for a check-up.

Tell your doctor immediately if you feel light-headed, dizzy or faint, after taking your first dose of lisinopril, or after your dose is increased.

This is especially important if you are taking lisinopril for heart failure.

To avoid feeling light-headed, dizzy or faint, get up slowly when getting out of bed or standing up.

This feeling may be because your blood pressure is falling suddenly, especially if you are also taking a diuretic (water) tablet. Standing up slowly from a lying or sitting position will help your body get used to the change in position and blood pressure. If this problem gets worse or continues, tell your doctor.

Drink plenty of water during exercise and hot weather, especially if you sweat a lot.

If you become dehydrated your blood pressure may drop too much and you may feel light-headed or sick. If you continue to feel unwell, see your doctor.

Things you must not do

Do not:

  • Give this medicine to anyone else, even if their symptoms seem similar to yours.
  • Take your medicine to treat any other condition unless your doctor tells you to
  • Stop taking your medicine, or change the dosage, without first checking with your doctor.

Things to be careful of

Be careful when driving or operating machinery or doing any other dangerous activity until you know how this medicine affects you.

Lisinopril may cause dizziness or light-headedness in some people, which may affect their reaction times. This is more likely to happen after the first dose or after increasing the dose.

Make sure you know how you react to lisinopril before you drive a car, operate machinery, or do anything else that could be dangerous if you are dizzy or light-headed. If this occurs, avoid the above activities.

If you drink alcohol, the dizziness or light-headedness may be worse.

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.

  • Alcohol
    Your doctor may advise you to limit your alcohol intake.
  • 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.
  • 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.

Possible side effects

Tell your doctor as soon as possible if you do not feel well while you are taking lisinopril or if you have any questions or concerns.

Do not be alarmed by the following lists of side effects. You may not experience any of them. All medicines can have side effects. Sometimes they are serious but most of the time they are not.

Tell your doctor or pharmacist if you notice any of the following and they worry you.

This list includes the more common side effects. Mostly, these are mild:

  • headache
  • dizziness
  • fatigue, weakness
  • a persistent, dry cough
  • mild stomach upsets such as feeling or being sick, indigestion, diarrhoea, constipation, wind or stomach pains

Other possible reactions include:

  • flushing
  • loss of appetite
  • feeling sleepy or having problems going to sleep, strange dreams
  • hair loss or thinning
  • changes in the way things taste or smell
  • blurred vision
  • gout
  • flu-like symptoms
  • blocked or runny nose or sinus pain.
  • muscle, joint, back, neck, leg or shoulder pain
  • skin problems including itchiness, rash, or painful areas
  • sunburn-type rash following short exposure to the sun
  • psoriasis and other serious skin conditions

Tell your doctor as soon as possible if you notice any of the following.

These may be serious side effects. You may need medical attention. Most of these side effects are rare.

  • light-headedness or dizziness, especially during the first few days of taking lisinopril
  • changes in the way your heart beats, for example, if you notice it beating faster
  • chest pain
  • difficulty breathing, wheezing
  • feeling confused, anxious or depressed
  • signs of frequent or worrying infections such as fever, severe chills, sore throat or mouth ulcers
  • bruising more easily than normal
  • severe abdominal pain
  • high or low blood sugar levels
  • weakness, tingling or numbness of the hands or feet
  • passing urine more or less than is normal for you; burning feeling when urinating, kidney pain, blood in the urine or cloudy urine
  • signs of dehydration such as dry mouth, muscle cramps, headache, nausea, vomiting, drowsiness, irritability and tiredness. This may be caused by vomiting, diarrhoea, excessive perspiration or not enough water. If untreated, mental confusion and fits may develop. Your doctor may need to monitor your blood sodium levels.

If you experience any of the following, stop taking your medicine and contact your doctor immediately or go to the Accident and Emergency department at your nearest hospital.

These are very serious side effects and are usually very rare. You may need urgent medical attention or hospitalisation.

  • swelling of the hands, feet, ankles, face, lips, mouth or throat, difficulty in swallowing or breathing
  • fainting, especially during the first few days of taking lisinopril
  • pinkish, itchy swellings on the skin, also called hives or nettle rash
  • yellowing of the skin and/or eyes, also called jaundice
  • severe skin reaction which starts with painful red areas, then large blisters and ends with peeling of layers of skin. This may be accompanied by fever and chills, aching muscles and generally feeling unwell.

Other side effects not listed above may occur in some patients.

Allergic reactions

If you think you are having an allergic reaction to lisinopril, do not take any more of this medicine and tell your doctor immediately or go to the Accident and Emergency department at your nearest hospital.

Symptoms of an allergic reaction may include some or all of the following:

  • cough, shortness of breath, wheezing or difficulty breathing
  • swelling of the face, lips, tongue, throat or other parts of the body
  • rash, itching or hives on the skin
  • fainting
  • hay fever-like symptoms.

Storage and disposal

Storage

Keep your medicine in its original packaging until it is time to take it.

If you take your medicine out of its original packaging it may not keep well.

Keep your medicine in a cool dry place where the temperature will stay below 25°C.

Do not store your medicine, or any other medicine, in the bathroom or near a sink.

Do not leave it on a window sill or in the car.

Heat and dampness can destroy some medicines.

Keep this medicine where children cannot reach it.

A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines.

Disposal

If your doctor tells you to stop taking this medicine or it has passed its expiry date, your pharmacist can dispose of the remaining medicine safely.

Product description

What APO-Lisinopril Tablets look like

Lisinopril 5 mg tablets:
Light pink coloured, circular, biconvex, uncoated tablets with "5" embossed and break line on one side and "BL" embossing on other side.

Lisinopril 10 mg tablets:
Light pink coloured, circular, biconvex, uncoated tablets with "10" embossed on one side and "BL" embossing on other side.

Lisinopril 20 mg tablets:
Pink coloured, circular, biconvex, uncoated tablets with "20" embossed on one side and "BL" embossing on other side.

Alternative lisinopril products should be used if a 2.5 mg dose is required. The 5 mg tablets must not be broken in half to give a 2.5 mg dose.

Ingredients

Each tablet contains 5, 10 or 20 mg of lisinopril, present as lisinopril dihydrate, as the active ingredient.

It also contains the following inactive ingredients:

  • calcium hydrogen phosphate
  • Mannitol
  • maize starch
  • magnesium stearate
  • iron oxide red.

This medicine is gluten-free, lactose-free, sucrose-free, tartrazine-free and free of other azo dyes.

Australian Registration Numbers

APO-Lisinopril 5 mg tablets:
PVC/Al blister packs of 10, 14, 28, 30, 50, 56, 84 and 100 tablets.

AUST R 213393.

APO-Lisinopril 10 mg tablets:
PVC/Al blister packs of 10, 14, 28, 30, 50, 56, 84 and 100 tablets.

AUST R 213394.

APO-Lisinopril 20 mg tablets:
PVC/Al Blister packs of 10, 14, 28, 30, 50, 56, 84 and 100 tablets.

AUST R 213395.

*Not all strengths or pack sizes may be available

Sponsor

Apotex Pty Ltd
16 Giffnock Avenue
Macquarie Park NSW 2113

APO and APOTEX are registered trade marks of Apotex Inc.

This leaflet was prepared in May 2016

BRAND INFORMATION

Brand name

APO-Lisinopril Tablets

Active ingredient

Lisinopril

Schedule

S4

 

1 Name of Medicine

Lisinopril dihydrate.

6.7 Physicochemical Properties

Chemical Name: N-[N-[(1S)-1-carboxy-3-phenylpropyl]-L-lysyl]-L-proline dihydrate. Molecular Formula: C21H31N3O5.2H2O. Molecular Weight: 441.53.

Chemical structure.


CAS number.

83915-83-7.

2 Qualitative and Quantitative Composition

Lisinopril dihydrate is a white to off white crystalline powder that is soluble in water, sparingly soluble in methanol and practically insoluble in ethanol.
Each tablet contains lisinopril dihydrate as the active ingredient. In addition, each tablet contains the following inactive ingredients: calcium hydrogen phosphate dihydrate, mannitol, maize starch, magnesium stearate and iron oxide red (C177491).

3 Pharmaceutical Form

5 mg tablets.

Light pink coloured, circular, biconvex, uncoated tablets with "5" embossed and break line on one side and "BL" embossing on other side.

10 mg tablets.

Light pink, circular, biconvex, uncoated tablets with "10" embossed and on one side and "BL" embossing on other side.

20 mg tablets.

Pink, circular, biconvex, uncoated tablets with "20" embossed and on one side and "BL" embossing on other side.
Alternative lisinopril products should be used if a 2.5 mg dose is required. The 5 mg tablets must not be broken in half to give a 2.5 mg dose.

5 Pharmacological Properties

A synthetic peptide derivative, lisinopril dihydrate 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 ll. Angiotensin ll also stimulates aldosterone secretion by the adrenal cortex. Inhibition of ACE results in decreased concentrations of plasma angiotensin ll 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 ll 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 1 to 2 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 2 to 4 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 ¾ Caucasian. Lisinopril was approximately equivalent to atenolol and metoprolol in effects on diastolic blood pressure, and had somewhat greater effects on systolic blood pressure.
Lisinopril 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 9 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.

Lisinopril 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 Sporavvienza 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 6 weeks of either: 1) lisinopril alone (n = 4841), 2) nitrates alone (n = 4869), 3) lisinopril 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 hr). Doses of lisinopril were adjusted as necessary according to protocol (see Section 4.2 Dose and Method of Administration).
Study treatment was withdrawn at 6 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 lisinopril (n = 9646), alone or with nitrates, had an 11% lower risk of death (2p [two tailed] = 0.04) compared to patients receiving no lisinopril (n = 9672) (6.4% vs. 7.2%, respectively) at 6 weeks. The reduction in mortality at 6 months was not significant, but this was not a primary outcome measure. Although patients randomised to receive lisinopril for up to 6 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 lisinopril, had a higher (9.0% vs. 3.7%) incidence of persistent hypotension (systolic blood pressure < 90 mmHg for more than 1 hr) and renal dysfunction (2.4% vs. 1.1%) in hospital and at 6 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 6 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 = 0.10. 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 lisinopril 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

Absorption.

Following oral administration, 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.
Lisinopril absorption is not affected by the presence of food in the gastrointestinal tract.

Distribution.

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.
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.

Metabolism.

Lisinopril does not undergo metabolism.

Excretion.

Upon multiple dosing, lisinopril exhibits an effective half-life of accumulation of 12.6 hours.
The 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).

Renal impairment.

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.

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 tumorigenic 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.

4 Clinical Particulars

4.1 Therapeutic Indications

Hypertension.

Lisinopril is indicated in the treatment of mild to moderate essential 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.

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

Acute myocardial infarction.

Lisinopril 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. Lisinopril may be initiated within 24 hours of an acute myocardial infarction.

4.3 Contraindications

Lisinopril is contraindicated in:
Patients who are hypersensitive to lisinopril or any other ingredient listed (see Section 2 Qualitative and Quantitative Composition).
Patients with a history of hereditary and/or idiopathic angioedema 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, Use in pregnancy).
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.
Angioedema may occur with or without urticaria.

Race.

Angiotensin converting enzyme 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.

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, Use in renal impairment; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions and 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 2 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, lisinopril 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 lisinopril should be withdrawn.

Dual blockade of the renin angiotensin aldosterone system (RAAS) with aliskiren containing medicines.

Dual blockade of the renin angiotensin aldosterone system by combining lisinopril with aliskiren is not recommended since there is an increased risk of hypotension, hyperkalaemia and changes in renal function (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

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.

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 hr. If renal dysfunction develops during treatment with lisinopril (serum creatinine concentration exceeding 265 micromol/L or a doubling from the pre-treatment value) then the physician should consider withdrawal of lisinopril.
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.

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.

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.

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.

Paediatric use.

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

Information for patients.

Angioedema.

Angioedema, including laryngeal oedema, may occur at any time during treatment with lisinopril. 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 light headedness 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.

Use in the elderly.

For use in elderly see Section 4.4 Special Warnings and Precautions for Use, Combination use of ACE inhibitors or angiotensin receptor antagonists, anti-inflammatory drugs and thiazide diuretics and Hyperkalaemia.

Effects on laboratory tests.

Currently, there are no available data regarding the effects on laboratory tests.

Note.

As with many other drugs, certain advice to patients being treated with lisinopril 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.

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.
The combination of lisinopril with aliskiren containing medicines should be avoided (see Section 4.3 Contraindications and Section 4.4 Special Warnings and Precautions for Use).

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 co-administered 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 vasodilation including flushing, nausea, dizziness and hypotension, which can be very severe) following injectable gold (e.g. sodium aurothiomalate) have been reported more frequently in patients receiving ACE inhibitor therapy.

Nonsteroidal anti-inflammatory drugs (NSAIDs).

Nonsteroidal anti-inflammatory drugs (NSAIDS) including selective cyclooxygenase-2 inhibitors (COX-2 inhibitors) may reduce the effect of diuretics and other antihypertensive drugs. Therefore, the antihypertensive effect of ACE inhibitors may be attenuated by NSAIDS including selective COX-2 inhibitors.
In some patients with compromised renal function (e.g. elderly patients or patients who are volume depleted, including those on diuretic therapy) who are being treated with nonsteroidal anti-inflammatory drugs including selective cyclooxygenase-2 inhibitors, the coadministration of angiotensin II receptor antagonists or ACE inhibitors may result in a further deterioration in renal function, including possible renal failure. These effects are usually reversible.
These interactions should be considered in patients taking NSAIDs including selective COX-2 inhibitors concomitantly with diuretics and ACE inhibitors. Therefore, the combination should be administered with caution, especially in the elderly.

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.

Agents causing renin release.

The antihypertensive effect of lisinopril 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 neurone 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 supplement, or potassium containing salt substitute 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. In diabetic patients treated with oral antidiabetic agents or insulin, glycaemic control should be closely monitored for hypoglycaemia, especially during the first month of treatment with an ACE inhibitor.

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, lisinopril should not be taken during pregnancy. Pregnancy should be excluded before starting treatment with lisinopril 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, however, 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 2nd and 3rd trimesters.
When ACE inhibitors have been used during the 2nd and 3rd trimesters 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 lisinopril may be secreted in human milk, lisinopril should not be given to a nursing mother.

4.8 Adverse Effects (Undesirable Effects)

Lisinopril 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. See Tables 2 - 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.

Nervous system and psychiatric disorders.

Mood alterations (including 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:

Cardiovascular.

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.

Digestive system.

Abdominal pain; dry mouth; hepatitis (hepatocellular and cholestatic) very rarely this may progress to hepatic failure; jaundice; pancreatitis.

Endocrine disorders.

Inappropriate antidiuretic hormone secretion.

Musculoskeletal system.

Joint pain.

Nervous system and psychiatric disorders.

Mental confusion; stroke; 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.

Clinical laboratory test findings.

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% of patients respectively with essential hypertension treated with lisinopril 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 lisinopril cannot be excluded.
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 http://www.tga.gov.au/reporting-problems.

4.2 Dose and Method of Administration

Since there is no clinically significant effect of food on the absorption of lisinopril, the tablets may be administered before, during or after meals. Lisinopril should be administered in a single daily dose. As the 5 mg lisinopril tablets do not have a breakline, alternative lisinopril products should be used if a 2.5 mg dose is required. The 5 mg tablets must not be broken in half to give a 2.5 mg dose.

Essential hypertension.

In patients with uncomplicated essential 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 as a single daily dose. 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 lisinopril, 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 lisinopril may be reduced.

Diuretic treated or severely salt/ volume depleted patients.

Symptomatic hypotension following the initial dose of lisinopril may occur occasionally in patients receiving concomitant diuretics. The diuretic should be discontinued if possible, for 2 to 3 days before beginning therapy with lisinopril (see Section 4.4 Special Warnings and Precautions for Use). In hypertensive patients in whom the diuretic cannot be discontinued, the initial dose of lisinopril should be 2.5 mg, followed then by 5 mg. The subsequent dosage of lisinopril should be adjusted according to blood pressure response. If required, diuretic therapy may be resumed gradually.

Dosage adjustment in renal impairment.

The usual dose of lisinopril 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.
Dosage and/or frequency of administration should be adjusted depending on the blood pressure response.
The dosage may be titrated upward until blood pressure is controlled or to a maximum of 20 mg daily.

Dosage in the elderly.

In general, blood pressure response and adverse experiences were similar in younger and older patients given similar doses of lisinopril. 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 lisinopril should be initiated under close medical supervision.
In patients not adequately controlled by diuretics (and digitalis, where indicated), lisinopril 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 lisinopril 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 lisinopril. The effect of the starting dosage of lisinopril on blood pressure should be monitored carefully.

Acute myocardial infarction.

Treatment with lisinopril may be started within 24 hours of the onset of symptoms. The first dose of lisinopril 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) lisinopril should be withdrawn.
Dosing should continue for 6 weeks. Patients who develop symptoms of heart failure should continue with lisinopril (see Section 4.2 Dose and Method of Administration, Congestive heart failure).
Patients should receive, as appropriate, the standard recommended treatments such as thrombolytics, aspirin and a beta-blocker.
Lisinopril is compatible with intravenous or transdermal glyceryl trinitrate.

4.7 Effects on Ability to Drive and Use Machines

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

4.9 Overdose

Symptoms.

There are no data on overdosage in humans. The most likely manifestation of overdosage would be hypotension.

Treatment.

The usual treatment for hypotension 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).

7 Medicine Schedule (Poisons Standard)

S4.

6 Pharmaceutical Particulars

6.1 List of Excipients

See Section 2 Qualitative and Quantitative Composition.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine. 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 25°C.

6.5 Nature and Contents of Container

5 mg tablets.

Blister packs (PVC/Al) of 10, 14, 28, 30, 50, 56, 84 and 100 tablets (AUST R 213393).

10 mg tablets.

Blister packs (PVC/Al) of 10, 14, 28, 30, 50, 56, 84 and 100 tablets (AUST R 213394).

20 mg tablets.

Blister packs (PVC/Al) of 10, 14, 28, 30, 50, 56, 84 and 100 tablets (AUST R 213395).
Not all strengths or pack sizes may be available.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

Summary Table of Changes