Ramipril vs Lisinopril in the Treatment of Mild to Moderate Primary Hypertension — A Randomised Double-Blind Multicentre Trial

Clinical Pharmacy Specialist Implementation of Lisinopril Therapy in Patients with Coronary Artery Disease and Diabetes Mellitus

STUDY OBJECTIVE

As the results of the Heart Outcomes Prevention Evaluation trial suggested that patients with both coronary artery disease (CAD) and diabetes mellitus would benefit from angiotensin-converting enzyme (ACE) inhibitor therapy, our objective was to increase the percentage of patients with both of these conditions receiving the goal dosage (20 mg/day) or highest tolerated dosage of the ACE inhibitor lisinopril through intervention of a clinical pharmacy service.

STUDY DESIGN

Prospective study with historic comparison (control group).

SETTING

Clinical Pharmacy Cardiac Risk Service.

PATIENTS

Hospitalized patients with CAD and type 2 diabetes mellitus.

MEASUREMENTS AND MAIN RESULTS

At hospital discharge, lisinopril 5 mg/day was started in eligible patients; the drug was titrated to a goal dosage of 20 mg/day or the highest tolerated dosage. Potassium level, serum creatinine level, and blood pressure were monitored at baseline, at each dosage titration, and 2 weeks after the goal or highest tolerated dosage was reached. The group receiving usual care (control group) consisted of 95 patients; the treatment group had 101 patients. At baseline, 19 patients (20%) in the control group were receiving the goal dosage of lisinopril, 34 (36%) were taking a suboptimal dosage, 16 (17%) were excluded from treatment, and 26 (27%) were eligible but were not receiving lisinopril therapy. After 9 months, ACE inhibitor dosages had changed minimally in the control group. In the treatment group, at baseline, 37 patients (36%) were at their goal dosage and therefore titration was not necessary; 15 (15%) were receiving a suboptimal dosage, 35 (35%) were excluded from treatment, and 14 (14%) were eligible but not receiving therapy. After the titration period, 55 (54%) treatment group patients were at the goal dosage, 11 (11%) were taking a suboptimal dosage, and 35 (35%) were not candidates for ACE inhibitor therapy. The most common reasons for exclusion were renal insufficiency, cough, and baseline hypotension. Changes in potassium level, serum creatinine level, and blood pressure were not significant during the study.

CONCLUSION

The clinical pharmacy service more than doubled the number of patients with CAD and diabetes who achieved the goal dosage of an ACE inhibitor, a drug class that has been shown to decrease morbidity and mortality in this patient population.

Effect of angiotensin-converting enzyme inhibitors on fructose induced hypertension and hyperinsulinaemia in rats

1. The effect of angiotensin-converting enzyme inhibitors (ACEI) enalapril, lisinopril and ramipril was studied on fructose-induced hypertensive and hyperinsulinaemic rats. 2. 60 Sprague-Dawley rats were fed a fructose-enriched diet for 5 weeks, which produced hyperinsulinaemia, hypertriglyceridaemia and hypertension. Beginning with week 3 of the diet, lisinopril (10 and 20 mg per kg per day), ramipril (5 and 10 mg/kg per day) and enalapril (20 mg/kg per day) were given daily in drinking water for 2 weeks to 10 rats in each drug group. Ten rats fed only the fructose-enriched diet served as control. 3. Systolic blood pressure was measured weekly by the indirect tail-cuff method. Plasma insulin level was determined using RIA. 4. Data indicate that ACEI improve insulin resistance induced by high-fructose intake in rats; that despite their equal hypotensive effect, ACEI differ in their ability to improve insulin resistance; and that improvement of insulin resistance by ACEI is dose-dependent.