Enalapril Thiazide diuretics

Amiloride is a potassium-sparing diuretic, whereas hydrochlorthiazide is a thiazide diuretic that causes loss of potassium. Enalapril is an angiotensinconverting enzyme inhibitor that retains potassium, thereby counteracting the loss of potassium caused by the thiazide diuretic. 

Cardiovascular Acetyldigosin, ajmaline, amiodarone, aprindine, bepridil, bezaflbrate, captopril, dinepazide, clopidogrel, coumarins, diazoxide, digoxin, dipyridamole, disopyramide, doxazosin, enalapril, flurbiprofen, fur-oxemide, hydralazine, lisinopril methyldopa, metolazone, nifedipine, phenindione, procainamide, propanolol, propafenone, quinidine, ramapril, spironolactone, thiazide diuretics, ticlopidine, vesnarinone... 

Following the guidelines of the British Hypertension Society, Mr WD should be prescribed a thiazide diuretic and a calcium channel blocker, so a good combination might be nifedipine LA 20 mg or 30 mg once daily or amlodipine 5 mg once daily, plus bendroflumethiazide 2.5 mg once daily. However, we know that his renal function is poor, with a calculated GFR of approximately 25 mL/min, so he is borderline for thiazides to be clinically effective. In this instance, it might be prudent to prescribe an ACE inhibitor instead, for example, enalapril 5-fO mg twice daily. 

The risk of ACE inhibitor-induced renal impairment in patients with or without renovascular disease can be potentiated by diuretics. " In an analysis of 74 patients who had been treated with captopril or lisinopril, reversible acute renal failure was more coimnon in those who were also treated with a diuretic (furosemide and/or hydrochlorothiazide) than those who were not (11 of 33 patients compared with 1 of 41 patients). Similarly, in a prescription-event monitoring study, enalapril was associated with raised creatinine or urea in 75 patients and it was thought to have contributed to the deterioration in renal function and subsequent deaths in 10 of these patients. However, 9 of these 10 were also receiving loop or thiazide diuretics, sometimes in high doses. Retrospective analysis of a controlled study in patients with hypertensive nephrosclerosis identified 8 of 34 patients who developed reversible renal impairment when treated with enalapril and various other antihypertensives including a diuretic (furosemide or hydrochlorothiazide). In contrast, 23 patients treated with placebo and various other antihypertensives did not develop renal impairment. Subsequently, enalapril was tolerated by 7 of the 8 patients without deterioration in renal function and 6 of these patients later received diuretics. One patient was again treated with enalapril with recurrence of renal impairment, but discontinuation of the diuretics (furosemide, hydrochlorothiazide, and triamterene) led to an improvement in renal function despite the continuation of enalapril. ... 

In a randomised, double-blind study over 52 weeks in 220 obese, hypertensive patients, whose hypertension was well controlled with an ACE inhibitor (benazepril, enalapril or lisinopril) with or without a thiazide diuretic, two-thirds of the patients were also given sibutramine and one-third were given placebo. Sibutramine 20 mg daily caused small increases in mean blood pressure compared with placebo (133.1/85.5 mmHg compared with 130.4/82.8 mmHg, at 52 weeks, respectively), but overall, hypertension remained well controlled. ... 

---