An Older Adult Patient Who Has Hypertension Is Prescribed Enalapril

Before Taking This Medicine

You should not use enalapril if you are allergic to it, or if you have:

• you have a history of angioedema

• you recently took a heart medicine called sacubatril or

• if you are allergic to any other ACE inhibitor, such as benazepril, captopril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, or trandolapril.

Do not take enalapril within 36 hours before or after taking medicine that contains sacubatril .

If you have diabetes, do not use enalapril together with any medication that contains aliskiren .

You may also need to avoid taking enalapril with aliskiren if you have kidney disease.

To make sure enalapril is safe for you, tell your doctor if you have:

• kidney disease

• liver disease

• a history of blood clot or stroke

• an electrolyte imbalance or

• heart disease.

Do not use if you are pregnant. If you become pregnant, stop taking this medicine and tell your doctor right away. Enalapril can cause injury or death to the unborn baby if you take the medicine during your second or third trimester.

Enalapril can pass into breast milk and may harm a nursing baby. You should not breast-feed while you are using this medicine.

Dosage For Heart Failure

Adult dosage

The starting dose is 2.5 mg taken by mouth twice per day. The usual dose is 2.520 mg taken twice per day. Your doctor may increase your dose over a period of a few days or weeks. The maximum dose is 40 mg per day taken in divided doses.

Child dosage

This medication hasnt been studied in children with heart failure. It shouldnt be used to treat this condition in children younger than 18 years.

Senior dosage

There are no specific recommendations for senior dosing. Older adults may process drugs more slowly. A normal adult dose may cause levels of this drug to be higher than normal in your body. If youre a senior, you may need a lower dose or a different schedule.

Special considerations

Kidney problems: If your blood serum creatinine level is greater than 1.6 mg/dL, the starting dose is 2.5 mg, taken once per day. Your doctor may increase your dose to 2.5 mg twice daily, and then to 5 mg twice daily and higher as needed. The changes will likely be made at intervals of 4 days or more. The maximum dose is 40 mg per day.

Low sodium: If your blood serum sodium level is less than 130 mEq/L, the starting dose is 2.5 mg, taken once per day. Your doctor may increase your dose to 2.5 mg twice daily, and then to 5 mg twice daily and higher as needed. The changes will likely be made at intervals of 4 days or more. The maximum dose is 40 mg per day.

How Many Drugs Are Too Many

Polypharmacy is simply the use of many medications at the same time. Other definitions include prescribing more medication than is clinically indicated, a medical regimen that includes at least one unnecessary medication, or the empiric use of five or more medications.18 Polypharmacy is particularly harmful when the patient receives too many medications for too long and in too high a dosage. The major concern about polypharmacy is the potential for adverse drug reactions and interactions. It has been estimated that for every dollar spent on pharmaceuticals in nursing homes, another dollar is spent treating the iatrogenic illnesses attributed to the medications.19 Drug-induced adverse events can mimic other geriatric syndromes or precipitate confusion, falls, and incontinence ,11 possibly causing the physician to prescribe yet another drug. This prescribing cascade20,21 is a preventable problem that requires the physician to be certain that all medications being taken by the patient are appropriately indicated, safe, and effective.

1.	Have patients âbrown bagâ all medications at each office visit, and keep an accurate record of all medications, including over-the-counter medications and herbs.
2.
As much as possible, use the motto, âone disease, one drug, once-a-day.â

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Special Considerations In The Elderly Population

In the United States, the prevalence of elderly patients with adequately treated hypertension is quite low, estimated to be only 30% .9 Elderly patients are more prone to having isolated systolic hypertension systolic BP 140 mm Hg diastolic BP < 90 mm Hgwhich is likely a result of an increase in arterial stiffness from arteriosclerosis or impairment of nitric oxidemediated vasodilation.1012

ISH occurs in the majority of elderly patients with hypertension: more than 65% of hypertensive patients aged 60 years and more than 90% of those aged > 70 years have ISH.1,13 ISH is associated with a 2- to 4-fold increase in the risk for stroke, myocardial infarction , or cardiovascular mortality.14,15

Elderly persons are more sensitive to salt intake compared with a younger population, leading to higher systolic BP and higher pulse pressure when more salt is consumed by elderly individuals.16

Finally, elderly persons are at increased risk for developing orthostatic hypotension, a potentially dangerous drop in BP during positional change from supine to standing position, increasing the risk for syncope, falls, and injuries.

These characteristics must be taken into account and considered carefully when choosing an appropriate treatment protocol for this patient population.

Randomized Clinical Trials Of Intensive Blood Pressure Control

The ACCORD blood pressure trial examined the effects of intensive blood pressure control versus standard blood pressure control among people with type 2 diabetes. Additional studies, such as Hypertension Optimal Treatment trial and SPRINT, also examined the potential benefits of intensive versus standard blood pressure control, though the relevance of their results to people with diabetes is less clear. The Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled EvaluationBlood Pressure trial, which tested the effects of a fixed-dose combination of antihypertensive interventions versus placebo among people with type 2 diabetes, also informs blood pressure targets . Study details are given in .

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The Bottom Line On An Older Patient Who Has Hypertension Is Prescribed Enalapril

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Recommendations For Clinical Practice

As we await the results of the eighth report of the JNC, which is scheduled to become available for review and comment by December 2009, we need to remain focused on the physiologic changes that occur in the elderly population and how medications and disease states can be affected by these changes. With little information available regarding the specific guidelines to treat the aging, pharmacists need to stay current on evidence-based medicine and its role in treating hypertension in an effort to prevent future serious cardiovascular complications. There are several classes of medications available for the treatment of hypertension in the elderly, of which alpha-blockers, beta-blockers, CCBs, diuretics, ACE inhibitors, and ARBs are the most commonly prescribed, as well as combination agents. Caution must be used when individualizing an appropriate course of therapy, and medications should be titrated carefully in the elderly in order to attain desired clinical goals. Thus remember, when beginning drug therapy in the elderly, it is always best to start low and go slow.

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What Blood Pressure Medicines Cause Coughing

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How Do Drugs Interact With The Aging Body

Pharmacokinetics includes absorption, distribution, metabolism, and excretion. Of the four, absorption is least affected by aging.16 In older persons, absorption is generally complete, just slower. In addition to age-related changes, common medical conditions such as heart failure may reduce the rate and extent of absorption. Distribution of most medications is related to body weight and composition changes that occur with aging . Drug dosage recommendations may have to be modified based on estimates of lean body mass. Loading doses of drugs may be lowered because of decreased total body water. Fat-soluble drugs may have to be administered in lower dosages because of the potential for accumulation in fatty tissues and a longer duration of action.16

Renal excretion of drugs is affected by aging, although there is great interindividual variation. Drug elimination is correlated with creatinine clearance, which declines by 50 percent between 25 and 85 years of age.16 Because lean body mass decreases with aging, the serum creatinine level is a poor indicator of the creatinine clearance in older adults. The Cockroft-Gault formula17 should be used to estimate creatinine clearance in older adults:

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Individualization Of Treatment Targets

Patients and clinicians should engage in a shared decision-making process to determine individual blood pressure targets, with the acknowledgment that the benefits and risks of intensive blood pressure targets are uncertain and may vary across patients. Following the ADA approach to the management of hyperglycemia, factors that influence treatment targets may include risks of treatment , life expectancy, comorbidities including vascular complications, patient attitude and expected treatment efforts, and resources and support system . Specific factors to consider are the absolute risk of cardiovascular events , risk of progressive kidney disease as reflected by albuminuria, adverse effects, age, and overall treatment burden. Patients who have higher risk of cardiovascular events or albuminuria and who can attain intensive blood pressure control relatively easily and without substantial adverse effects may be best suited to intensive blood pressure control. In contrast, patients with conditions more common in older adults, such as functional limitations, polypharmacy, and multimorbidity, may be best suited to less intensive blood pressure control.

What You Should Take Away From This Study

I consider this study very important, because most clinical research focuses on benefits of medication, rather than studying the potential harms and downsides of medication. Its probably not a coincidence that the main author is a geriatrician we tend to feel that a little goes a long way when it comes to medications in aging adults!

Key take-aways for family caregivers:

• Serious falls are a fair possibility in all older adults aged 70+. Over 3 years, 9% of these Medicare patients had a fall involving a fracture, a dislocation, or a brain bleed. Its probably reasonable for you to assume that your loved one has at least a roughly 10% chance of a serious fall within a few years. This risk is higher if your loved one has already had a serious fall.
• Consider learning practical approaches to reducing fall risk in your loved one. Along with learning to be careful with medications, there is lots more that you can do! Visit our fall prevention topic page to see all our articles on this topic.
• Consider a plan or system to call for help in the event of a fall. This is especially important for those independent older adults who live alone! Last year I saw a patient who lay at home with a broken hip for 2 days before he was found
• Home sensors and/or a personal emergency response system can help alert a care circle when an older person falls.

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Blood Pressure Readings Lower In The Morning

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Sample Size And Statistical Analysis

Both descriptive and inferential statistics were used to document prevalence and correlates of PIM use among our sample. Pearson correlation coefficients, chi-squared tests, and the binary logistic regression techniques were used to examine the correlation between the PIM use and 1) number of medication use 2) number of chronic conditions and 3) type of chronic conditions. Examining correlation between several types of chronic conditions and PIM, the Bonferroni correction was used to counteract the problem of inflated type I errors. All statistical analyses were performed with the Statistical Package for Social Sciences version 22. Based on previous studies, we expected at least 30% of study participants will be using at least one PIM . Therefore the sample size of 193 subjects is sufficient to determine the extent of PIM use among older African American adults.

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Worst Side Effects Of High Blood Pressure Medication

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Warnings For People With Certain Health Conditions

For people with swelling : If you have swelling throughout your body, this drug can make it worse. If you have a history of swelling throughout your body, you shouldnt take enalapril.

For people with low blood pressure: Enalapril can make your blood pressure lower. Tell your doctor if you already have low blood pressure. They may change your dose, especially if you have heart or kidney problems, or diabetes.

For people with heart problems: Use this drug with caution if you have ischemic heart disease. Enalapril may increase your risk for low blood pressure.

For people with moderate to severe kidney damage: Your doctor may lower your dosage of enalapril.

For people who plan to have surgery or an anesthetic: You may experience low blood pressure while having major surgery or during anesthesia.

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