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Quinapril: Drug information

Quinapril: Drug information
(For additional information see "Quinapril: Patient drug information" and see "Quinapril: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Fetal toxicity:

When pregnancy is detected, discontinue quinapril as soon as possible. Drugs that act directly on the renin-angiotensin system can cause injury and death to the developing fetus.

Brand Names: US
  • Accupril
Brand Names: Canada
  • Accupril;
  • APO-Quinapril;
  • PMS-Quinapril
Pharmacologic Category
  • Angiotensin-Converting Enzyme (ACE) Inhibitor;
  • Antihypertensive
Dosing: Adult
Heart failure with reduced ejection fraction

Heart failure with reduced ejection fraction:

Note: If tolerated, an angiotensin II receptor-neprilysin inhibitor is generally preferred over an angiotensin-converting enzyme inhibitor (Ref).

Oral: Initial: 5 mg twice daily; increase dose (eg, double) as tolerated every ≥1 to 2 weeks to a target dose of 20 mg twice daily (Ref). In hospitalized patients, may titrate more rapidly as tolerated (Ref).

Hypertension

Hypertension:

Note: For patients who warrant combination therapy (BP >20/10 mm Hg above goal or suboptimal response to initial monotherapy), may use with another appropriate agent (eg, long-acting dihydropyridine calcium channel blocker or thiazide diuretic) (Ref).

Oral: Initial: 10 to 20 mg once daily; evaluate response after ~2 to 4 weeks and titrate dose (eg, increase the daily dose by doubling) as needed up to 80 mg/day in 1 or 2 divided doses; if additional BP control is needed, consider combination therapy (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

Heart failure: Oral: If initial dose is tolerated, increase to twice daily administration the following day and then adjust dose at weekly intervals to optimal response:

CrCl >30 mL/minute: Initial: 5 mg once daily

CrCl 10 to 30 mL/minute: Initial: 2.5 mg once daily

CrCl <10 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling.

Hypertension: Oral:

CrCl >60 mL/minute: Initial: 10 mg once daily

CrCl 30 to 60 mL/minute: Initial: 5 mg once daily

CrCl 10 to 30 mL/minute: Initial: 2.5 mg once daily

CrCl <10 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied). Use with caution, particularly in patients with ascites due to cirrhosis (Ref).

Dosing: Older Adult

Heart failure: Refer to adult dosing.

Hypertension: Oral: Initial: 10 mg once daily; titrate to optimal response.

Dosing: Pediatric

(For additional information see "Quinapril: Pediatric drug information")

Hypertension

Hypertension: Limited data available: Children and Adolescents: Oral: Initial: 5 mg once daily; may titrate every 2 weeks; maximum daily dose: 80 mg/day; for younger patients or those who are small for age, begin at lower end of range. A pharmacokinetic analyses of a 0.2 mg/kg single-dose in 24 pediatric patients <7 years of age, reported similar serum concentrations to those in adults who received a single 10 mg dose; long-term, weight-based efficacy and safety data are lacking (Ref)

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

There are no pediatric specific recommendations; based on experience in adult patients, dosing adjustment suggested.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied). In adult patients with alcoholic cirrhosis, hydrolysis of quinapril to quinaprilat is impaired; however, the subsequent elimination of quinaprilat is unaltered.

Adverse Reactions (Significant): Considerations
Acute kidney injury

Use may be associated with increased blood urea nitrogen and increased serum creatinine, resulting in oliguria and acute kidney injury (AKI). Increases in serum creatinine are expected and usually stabilize within 20% to 30% of the baseline; higher increases may indicate high efferent tone (such as with hypovolemia, congestive heart failure, or renal artery stenosis) (Ref).

Mechanism: Related to pharmacologic action; inhibits efferent arteriolar vasoconstriction, lowering glomerular filtration pressure, which can lead to a reduction in the glomerular filtration rate (GFR). Kidney hypoperfusion from systemic hypotension may also occur (Ref).

Onset: Intermediate; increases in serum creatinine generally occur within 2 weeks of initiation and stabilize within 2 to 4 weeks (Ref). However, more immediate increases can occur in patients with other risk factors for AKI (Ref).

Risk factors:

• Patients with low renal blood flow whose GFR is dependent on efferent arteriolar vasoconstriction by angiotensin II including (Ref):

- Low effective circulating volume (sodium or volume depletion)

- Congestive heart failure

- Hypotension or shock

- Renal artery stenosis

• High dose at initiation (Ref)

• Older patients (Ref)

• Preexisting kidney impairment (Ref)

• Concurrent diuretic and/or nonsteroidal anti-inflammatory drug use (Ref)

Angioedema

Angioedema may occur rarely; edema may manifest in the head and neck (potentially compromising airway) or the intestine (presenting as abdominal pain). Use is contraindicated in patients with idiopathic or hereditary angioedema or previous angioedema associated with any angiotensin-converting enzyme inhibitors or neprilysin inhibitors (Ref).

Mechanism: Related to pharmacologic action (ie, increased bradykinin and substance P, vascular permeability, vasodilation) (Ref).

Onset: Varied; may occur at any time during treatment. Most cases occur within the first week of therapy but may also occur years after therapy (Ref).

Risk factors:

• Black patients (estimated 4- to 5-fold higher risk); the mechanism for this is not completely understood but may be related to genetic variants (Ref).

• Females (Ref)

• Smoking history (Ref)

• Previous history of angioedema (Ref)

• Age >65 years (Ref)

• Seasonal allergies (Ref)

• Concurrent use of mechanistic target of rapamycin (mTOR) inhibitors (eg, everolimus) (Ref)

• Concurrent use of neprilysin inhibitor (contraindicated)

Cough

A dry, hacking, nonproductive cough that is typically associated with tickling or scratching in the throat may occur with angiotensin-converting enzyme inhibitors (ACEI) in adult and pediatric patients (Ref). Recurrence is likely with rechallenge (Ref). Resolution of cough typically occurs 1 to 4 weeks after ACEI discontinuation but may persist for up to 3 months (Ref).

Mechanism: Various proposed mechanisms. May be related to pharmacologic action (ie, increased bradykinin and substance P), resulting in accumulation in the lungs and bronchoconstriction (Ref).

Onset: Varied; within hours to 4 weeks after initiation but can be delayed for up to 6 months (Ref).

Risk factors:

• Females (Ref)

• Possibly certain genetic variants (some of which may be independent of the bradykinin pathway) (Ref)

Hyperkalemia

Hyperkalemia (elevated serum potassium) may occur on therapy with angiotensin-converting enzyme inhibitors (ACEI), including quinapril (Ref)

Mechanism: Related to pharmacologic action; inhibits formation of circulating angiotensin II, which leads to efferent arteriole vasodilation and subsequent lowering of glomerular filtration rate, which lowers potassium elimination. Additionally, interferes with the generation and release of aldosterone from the adrenal cortex, leading to an impairment of potassium excretion from the kidney (Ref).

Risk factors:

• Disease states associated with hyperkalemia (congestive heart failure, diabetes mellitus, chronic kidney disease) (Ref)

• Concurrent use of medications which cause hyperkalemia (ACEI, angiotensin receptor blockers, spironolactone, nonsteroidal anti-inflammatory drugs, beta blockers, heparin, tacrolimus, cyclosporine, trimethoprim) (Ref)

• Acute kidney injury (elevated BUN and/or serum creatinine) (Ref)

• High dietary intake of potassium or concomitant use of potassium supplements (including potassium-containing salt substitutes) (Ref)

• Baseline elevated potassium level (≥5 mmol/L) (Ref)

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency ranges include data from hypertension and heart failure trials. Higher rates of adverse reactions have generally been noted in patients with heart failure. However, the frequency of adverse effects associated with placebo is also increased in this population.

1% to 10%:

Cardiovascular: Chest pain (2%), hypotension (3%)

Endocrine & metabolic: Hyperkalemia (≤2%)

Gastrointestinal: Abdominal pain (1%), diarrhea (2%), nausea (≤2%), vomiting (≤2%)

Nervous system: Dizziness (4% to 8%), fatigue (3%), headache (2%)

Neuromuscular & skeletal: Back pain (1%)

Renal: Increased blood urea nitrogen (2%), increased serum creatinine (2%)

Respiratory: Cough (2% to 4%) (table 1)

Quinapril: Adverse Reaction: Cough

Drug (Quinapril)

Placebo

Indication

Number of Patients (Quinapril)

Number of Patients (Placebo)

4%

1%

Cardiac failure

585

295

2%

0%

Hypertension

1,563

579

<1%:

Cardiovascular: Acute myocardial infarction, angina pectoris, cardiac arrhythmia, cardiac failure, cardiogenic shock, cerebrovascular accident, edema, hypertensive crisis, orthostatic hypotension, palpitations, syncope, tachycardia, vasodilation

Dermatologic: Alopecia, diaphoresis, exfoliative dermatitis, pemphigus, pruritus, skin photosensitivity

Endocrine & metabolic: Hyponatremia

Gastrointestinal: Constipation, dyspepsia, flatulence, gastrointestinal hemorrhage, pancreatitis, xerostomia

Genitourinary: Impotence, urinary tract infection

Hematologic & oncologic: Agranulocytosis, hemolytic anemia, thrombocytopenia

Hepatic: Abnormal hepatic function tests, hepatitis

Hypersensitivity: Angioedema, nonimmune anaphylaxis

Infection: Viral infection

Nervous system: Depression, drowsiness, insomnia, malaise, nervousness, paresthesia, vertigo

Neuromuscular & skeletal: Arthralgia, polymyositis (dermatopolymyositis)

Ophthalmic: Amblyopia

Renal: Acute kidney injury, exacerbation of renal failure

Respiratory: Dry throat, eosinophilic pneumonitis, pharyngitis

Postmarketing:

Dermatologic: Psoriasis (Song 2021)

Nervous system: Visual hallucination (Doane 2013)

Contraindications

Hypersensitivity to quinapril or any component of the formulation; angioedema related to previous treatment with an angiotensin-converting enzyme (ACE) inhibitor; concomitant use with aliskiren in patients with diabetes mellitus; concomitant use with neprilysin inhibitor (eg, sacubitril) or within 36 hours of switching to or from neprilysin inhibitor.

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Canadian labeling: Additional contraindications (not in US labeling): Women who are pregnant, intend to become pregnant, or of childbearing potential and not using adequate contraception; breastfeeding; concomitant use with aliskiren, angiotensin receptor blockers (ARBs), or other ACE inhibitors in patients with moderate to severe kidney impairment (GFR <60 mL/minute/1.73 m2), hyperkalemia (>5 mmol/L), or heart failure who are hypotensive; concomitant use with ARBs or other ACE inhibitors in diabetic patients with end organ damage; hereditary problems of galactose intolerance, glucose-galactose malabsorption or congenital lactase deficiency.

Warnings/Precautions

Concerns related to adverse effects:

• Cholestatic jaundice: A rare toxicity associated with ACE inhibitors includes cholestatic jaundice, although there are no published reports with quinapril.

• Hypersensitivity reactions: Anaphylaxis/nonimmune anaphylaxis can occur with ACE inhibitors. Severe nonimmune anaphylaxis may be seen during hemodialysis (eg, CVVHD) with high-flux dialysis membranes (eg, AN69), and rarely, during low density lipoprotein apheresis with dextran sulfate cellulose. Rare cases of nonimmune anaphylaxis have been reported in patients undergoing sensitization treatment with hymenoptera (bee, wasp) venom while receiving ACE inhibitors.

• Hypotension/syncope: Symptomatic hypotension with or without syncope can occur with ACE inhibitors (usually with the first several doses). Effects are most often observed in volume-depleted patients; correct volume depletion prior to initiation. Close monitoring of patient is required, especially with initial dosing and dosing increases. Blood pressure must be lowered at a rate appropriate for the patient's clinical condition. Although dose reduction may be necessary, hypotension is not a reason for discontinuation of future ACE inhibitor use, especially in patients with heart failure where a reduction in systolic blood pressure is a desirable observation.

Disease-related concerns:

• Aortic stenosis: Use with caution in patients with severe aortic stenosis; may reduce coronary perfusion resulting in ischemia.

• Ascites: Generally, avoid use in patients with ascites due to cirrhosis or refractory ascites; if use cannot be avoided in patients with ascites due to cirrhosis, monitor BP and kidney function carefully to avoid rapid development of kidney failure (AASLD [Runyon 2013]).

• Cardiovascular disease: Initiation of therapy in patients with ischemic heart disease or cerebrovascular disease warrants close observation due to the potential consequences posed by falling blood pressure (eg, MI, stroke). Fluid replacement, if needed, may restore blood pressure; therapy may then be resumed. Discontinue therapy in patients whose hypotension recurs.

• Hypertrophic cardiomyopathy with left ventricular outflow tract obstruction: Use with caution in patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction since reduction in afterload may worsen symptoms associated with this condition (AHA/ACC [Ommen 2020]).

• Kidney impairment: Use with caution in patients with kidney impairment; dosage adjustment may be needed. Avoid rapid dosage escalation, which may lead to further kidney impairment.

Special populations:

• Race/Ethnicity: In Black patients, the BP-lowering effects of ACE inhibitors may be less pronounced. The exact mechanism is not known; differences in the renin-angiotensin-aldosterone system, low renin levels, and salt sensitivity more commonly found in Black patients may contribute (Brewster 2013; Helmer 2018).

• Surgical patients: In patients on chronic ACE inhibitor therapy, intraoperative hypotension may occur with induction and maintenance of general anesthesia; use with caution before, during, or immediately after major surgery. Cardiopulmonary bypass, intraoperative blood loss, or vasodilating anesthesia increases endogenous renin release. Use of ACE inhibitors perioperatively will blunt angiotensin II formation and may result in hypotension; however, discontinuation of therapy prior to surgery is controversial. If continued preoperatively, avoidance of hypotensive agents during surgery is prudent (Hillis 2011). Based on current research and clinical guidelines in patients undergoing non-cardiac surgery, continuing ACE inhibitors is reasonable in the perioperative period. If ACE inhibitors are held before surgery, it is reasonable to restart postoperatively as soon as clinically feasible (ACC/AHA [Fleisher 2014]).

Dosage forms specific issues:

• Lactose: Some formulations may contain lactose.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Accupril: 5 mg [scored; contains magnesium carbonate]

Accupril: 10 mg, 20 mg, 40 mg [contains magnesium carbonate]

Generic: 5 mg, 10 mg, 20 mg, 40 mg

Generic Equivalent Available: US

Yes

Pricing: US

Tablets (Accupril Oral)

5 mg (per each): $6.14

10 mg (per each): $6.14

20 mg (per each): $6.14

40 mg (per each): $6.14

Tablets (Quinapril HCl Oral)

5 mg (per each): $1.22

10 mg (per each): $1.22

20 mg (per each): $1.22

40 mg (per each): $1.22

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Accupril: 5 mg, 10 mg, 20 mg, 40 mg [contains magnesium carbonate]

Generic: 5 mg, 10 mg, 20 mg, 40 mg

Administration: Pediatric

Oral: May be administered without regard to food

Use: Labeled Indications

Heart failure with reduced ejection fraction: Treatment of heart failure.

Hypertension: Management of hypertension.

Medication Safety Issues
Sound-alike/look-alike issues:

Accupril may be confused with Accolate, Accutane, AcipHex, Monopril

Quinapril may be confused with Quinagolide

International issues:

Accupril [U.S., Canada] may be confused with Acepril which is a brand name for captopril [Great Britain]; enalapril [Hungary, Switzerland]; lisinopril [Malaysia]

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Aliskiren: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Aliskiren may enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Aliskiren may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Management: Aliskiren use with ACEIs or ARBs in patients with diabetes is contraindicated. Combined use in other patients should be avoided, particularly when CrCl is less than 60 mL/min. If combined, monitor potassium, creatinine, and blood pressure closely. Risk D: Consider therapy modification

Allopurinol: Angiotensin-Converting Enzyme Inhibitors may enhance the potential for allergic or hypersensitivity reactions to Allopurinol. Risk C: Monitor therapy

Alteplase: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Alteplase. Specifically, the risk for angioedema may be increased. Risk C: Monitor therapy

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When used at chemotherapy doses, hold blood pressure lowering medications for 24 hours before amifostine administration. If blood pressure lowering therapy cannot be held, do not administer amifostine. Use caution with radiotherapy doses of amifostine. Risk D: Consider therapy modification

Amphetamines: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Angiotensin II: Angiotensin-Converting Enzyme Inhibitors may enhance the therapeutic effect of Angiotensin II. Risk C: Monitor therapy

Angiotensin II Receptor Blockers: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Angiotensin II Receptor Blockers may increase the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Management: Use of telmisartan and ramipril is not recommended. It is not clear if any other combination of an ACE inhibitor and an ARB would be any safer. Consider alternatives when possible. Monitor blood pressure, renal function, and potassium if combined. Risk D: Consider therapy modification

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor therapy

Aprotinin: May diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Arginine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

AzaTHIOprine: Angiotensin-Converting Enzyme Inhibitors may enhance the myelosuppressive effect of AzaTHIOprine. Risk C: Monitor therapy

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Brigatinib: May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Bromperidol: May diminish the hypotensive effect of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Risk X: Avoid combination

Dapoxetine: May enhance the orthostatic hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Dexmethylphenidate: May diminish the therapeutic effect of Antihypertensive Agents. Risk C: Monitor therapy

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Dipeptidyl Peptidase-IV Inhibitors: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Drospirenone-Containing Products: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Risk C: Monitor therapy

Eplerenone: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Everolimus: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Ferric Gluconate: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Ferric Gluconate. Risk C: Monitor therapy

Ferric Hydroxide Polymaltose Complex: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Ferric Hydroxide Polymaltose Complex. Specifically, the risk for angioedema or allergic reactions may be increased. Risk C: Monitor therapy

Finerenone: Angiotensin-Converting Enzyme Inhibitors may enhance the hyperkalemic effect of Finerenone. Risk C: Monitor therapy

Flunarizine: May enhance the therapeutic effect of Antihypertensive Agents. Risk C: Monitor therapy

Gelatin (Succinylated): Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Gelatin (Succinylated). Specifically, the risk of a paradoxical hypotensive reaction may be increased. Risk C: Monitor therapy

Grass Pollen Allergen Extract (5 Grass Extract): Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Grass Pollen Allergen Extract (5 Grass Extract). Specifically, ACE inhibitors may increase the risk of severe allergic reaction to Grass Pollen Allergen Extract (5 Grass Extract). Risk X: Avoid combination

Heparin: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Heparins (Low Molecular Weight): May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Herbal Products with Blood Pressure Increasing Effects: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Herbal Products with Blood Pressure Lowering Effects: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Icatibant: May diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Indoramin: May enhance the hypotensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Iron Dextran Complex: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Iron Dextran Complex. Specifically, patients receiving an ACE inhibitor may be at an increased risk for anaphylactic-type reactions. Risk C: Monitor therapy

Lanthanum: May decrease the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Management: Administer angiotensin-converting enzyme (ACE) inhibitors at least two hours before or after lanthanum. Risk D: Consider therapy modification

Levodopa-Foslevodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Foslevodopa. Risk C: Monitor therapy

Lithium: Angiotensin-Converting Enzyme Inhibitors may increase the serum concentration of Lithium. Management: Lithium dosage reductions will likely be needed following the addition of an ACE inhibitor. Monitor for increased concentrations/toxic effects of lithium if an ACE inhibitor is initiated/dose increased, or if switching between ACE inhibitors. Risk D: Consider therapy modification

Loop Diuretics: May enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Loop Diuretics may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Methylphenidate: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicorandil: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Nonsteroidal Anti-Inflammatory Agents may diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents (Topical): May diminish the therapeutic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Risk D: Consider therapy modification

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Risk C: Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Polyethylene Glycol-Electrolyte Solution: Angiotensin-Converting Enzyme Inhibitors may enhance the nephrotoxic effect of Polyethylene Glycol-Electrolyte Solution. Risk C: Monitor therapy

Potassium Salts: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Potassium-Sparing Diuretics: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Prazosin: Antihypertensive Agents may enhance the hypotensive effect of Prazosin. Risk C: Monitor therapy

Pregabalin: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Pregabalin. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Racecadotril: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk for angioedema may be increased with this combination. Risk C: Monitor therapy

Ranolazine: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Sacubitril: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Sacubitril. Specifically, the risk of angioedema may be increased with this combination. Risk X: Avoid combination

Salicylates: May enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Salicylates may diminish the therapeutic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Silodosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Sirolimus Products: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk for angioedema may be increased. Risk C: Monitor therapy

Sodium Phosphates: Angiotensin-Converting Enzyme Inhibitors may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Risk C: Monitor therapy

Sparsentan: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Risk X: Avoid combination

Tacrolimus (Systemic): Angiotensin-Converting Enzyme Inhibitors may enhance the hyperkalemic effect of Tacrolimus (Systemic). Risk C: Monitor therapy

Temsirolimus: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Terazosin: Antihypertensive Agents may enhance the hypotensive effect of Terazosin. Risk C: Monitor therapy

Tetracyclines: Quinapril may decrease the serum concentration of Tetracyclines. Risk C: Monitor therapy

Thiazide and Thiazide-Like Diuretics: May enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Thiazide and Thiazide-Like Diuretics may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Tolvaptan: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Trimethoprim: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Urapidil: May interact via an unknown mechanism with Angiotensin-Converting Enzyme Inhibitors. Management: Avoid concomitant use of urapidil and angiotensin-converting enzyme (ACE) inhibitors. Risk D: Consider therapy modification

Urokinase: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Reproductive Considerations

Medications considered acceptable for the treatment of chronic hypertension during pregnancy may generally be used in patients trying to conceive. Angiotensin-converting enzyme (ACE) inhibitors are fetotoxic. Transition patients prior to conception to an agent preferred for use during pregnancy unless treatment with an ACE inhibitor is absolutely necessary (ACC/AHA [Whelton 2018]; ACOG 2019; NICE 2019).

Pregnancy Considerations

Quinapril crosses the placenta.

Drugs that act on the renin-angiotensin system can cause injury and death to the developing fetus. Exposure to an angiotensin-converting enzyme (ACE) inhibitor during the first trimester of pregnancy may be associated with an increased risk of fetal malformations (ACOG 2019; ESC [Regitz-Zagrosek 2018]). Following exposure during the second or third trimesters, drugs that act on the renin-angiotensin system are associated with oligohydramnios. Oligohydramnios, due to decreased fetal renal function, may lead to fetal lung hypoplasia and skeletal malformations. Oligohydramnios may not appear until after an irreversible fetal injury has occurred. ACE inhibitor use during pregnancy is also associated with anuria, hypotension, renal failure, skull hypoplasia, and death in the fetus/neonate. Monitor infants exposed to an ACE inhibitor in utero for hyperkalemia, hypotension, and oliguria. Exchange transfusions or dialysis may be required to reverse hypotension or improve renal function

Chronic maternal hypertension is also associated with adverse events in the fetus/infant. Chronic maternal hypertension may increase the risk of birth defects, low birth weight, premature delivery, stillbirth, and neonatal death. Actual fetal/neonatal risks may be related to duration and severity of maternal hypertension. Untreated chronic hypertension may also increase the risks of adverse maternal outcomes, including gestational diabetes, preeclampsia, delivery complications, stroke and myocardial infarction (ACOG 2019).

Discontinue ACE inhibitors as soon as possible once pregnancy is detected. Agents other than ACE inhibitors are recommended for the treatment of chronic hypertension during pregnancy (ACOG 2019; ESC [Cífková 2020]; SOGC [Magee 2022]). Consider the use of ACE inhibitors only for pregnant patients with hypertension refractory to other medications (ACOG 2019). Closely monitor pregnant patients on ACE inhibitors with serial ultrasounds.

ACE inhibitors are not recommended for the treatment of heart failure during pregnancy (ESC [Regitz-Zagrosek 2018]).

Breastfeeding Considerations

Quinapril is present in breast milk.

Data related to the presence of quinapril in breast milk are available from 6 healthy breastfeeding mothers given a single dose of quinapril 20 mg 16 weeks to 9 months' postpartum. Breast milk samples were collected over 24 hours. Quinapril was only detectable in breast milk during the first postdose collection period (0 to 4 hours). The active metabolite (quinaprilat) was not detected in any milk samples. Authors of the study calculated the relative infant dose (RID) of quinapril to be 1.6% (95% CI 1.0 to 2.2) compared to the weight adjusted maternal dose (Begg 2001). In general, breastfeeding is considered acceptable when the RID of a medication is <10% (Anderson 2016; Ito 2000).

The manufacturer recommends that caution be exercised when administering quinapril to breastfeeding patients. When postpartum treatment with an angiotensin-converting enzyme (ACE) inhibitor is needed, available guidelines consider quinapril to be acceptable for use (ESC [Cífková 2020]). Avoid breastfeeding if high maternal doses of an ACE inhibitor are needed (ACOG 2019).

Monitoring Parameters

Blood pressure; BUN; serum creatinine; electrolytes (eg, potassium [especially in patients on concomitant potassium-sparing diuretics, potassium supplements, and/or potassium-containing salts]); if patient has collagen vascular disease and/or kidney impairment, periodically monitor CBC with differential. If angioedema is suspected, assess risk of airway obstruction (eg, involvement of tongue, glottis, larynx, and/or history of airway surgery).

Mechanism of Action

Competitive inhibitor of angiotensin-converting enzyme (ACE); prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; results in lower levels of angiotensin II which causes an increase in plasma renin activity and a reduction in aldosterone secretion; a CNS mechanism may also be involved in hypotensive effect as angiotensin II increases adrenergic outflow from CNS; vasoactive kallikreins may be decreased in conversion to active hormones by ACE inhibitors, thus reducing blood pressure

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: 1 hour; Peak effect: Antihypertensive: 2 to 4 hours postdose

Duration: 24 hours (chronic dosing)

Absorption: Quinapril: ≥60%

Distribution:

Infants and Children <6 years: 0.7 L/kg (range: 0.27-1.48 L/kg) (Blumer 2003)

Adults: 1.5 L/kg (Aronoff 2007)

Protein binding: Quinapril: 97%; Quinaprilat: 97%

Metabolism: Rapidly hydrolyzed to quinaprilat, the active metabolite (~38% of an oral dose)

Half-life elimination:

Infants and Children <7 years: Quinaprilat: 2.3 hours (Blumer 2003)

Adults: Quinapril: 0.8 hours; Quinaprilat: 3 hours; increases as CrCl decreases

Time to peak, serum:

Infants and Children <7 years: 1.7 hours (range: 1 to 4 hours) (Blumer 2003)

Adults: Quinapril: 1 hour; Quinaprilat: ~2 hours

Excretion: Urine (50% to 60% primarily as quinaprilat)

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Hepatic function impairment: Quinaprilat concentrations are decreased in patients with alcoholic cirrhosis because of impaired de-esterification of quinapril.

Older adult: Elimination of quinaprilat is decreased.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Acuitel;
  • (AR) Argentina: Accupril;
  • (AT) Austria: Accupro;
  • (AU) Australia: Accupril | Acquin | Aquinafil | Asig | Filpril | Qpril | Quinapril Generic Health | Quinapril Pfizer | Quinapril Sandoz | Quinapril-Ga;
  • (BE) Belgium: Accupril | Quinapril | Quinapril Ranbaxy | Quinapril teva;
  • (BG) Bulgaria: Accupro | Corabace;
  • (BR) Brazil: Accupril;
  • (CH) Switzerland: Accupro | Quiril;
  • (CI) Côte d'Ivoire: Acuitel;
  • (CL) Chile: Accupril;
  • (CN) China: Yi heng;
  • (CO) Colombia: Acupril | Quinapril | Quinaten | Quiprex;
  • (CZ) Czech Republic: Accupro | Quinapril teva;
  • (DE) Germany: Accupro | Accupron | Quinalich | Quinapril | Quinapril al | Quinapril beta | Quinapril CT | Quinapril hexal | Quinapril ratiopharm | Quinapril stada;
  • (DO) Dominican Republic: Accupril;
  • (EC) Ecuador: Accupril | Quinapril;
  • (EE) Estonia: Accupro | Quinapril polpharma;
  • (ES) Spain: Acuprel | Ectren | Lidaltrin | Quinapril Bexal | Quinapril Normon | Quinapril Ranbaxy | Quinapril teva;
  • (FI) Finland: Accupro | Quinapril stada;
  • (FR) France: Quinapril Biogaran | Quinapril eg;
  • (GB) United Kingdom: Accupro | Quinapril | Quinapril cox | Quinapril kent | Quinil;
  • (GR) Greece: Accupron | Quinapril Generics;
  • (HK) Hong Kong: Accupril;
  • (HR) Croatia: Accupro;
  • (HU) Hungary: Accupro | Quinawin;
  • (ID) Indonesia: Accupril;
  • (IE) Ireland: Accupro;
  • (IN) India: Acupil | Q-press | Q-pril;
  • (IT) Italy: Accuprin | Acequin | Quinapril eg | Quinapril Merck | Quinapril ran | Quinapril Sandoz | Quinapril Winthrop | Quinazil;
  • (JO) Jordan: Acuitel;
  • (JP) Japan: Conan | Conan gc | Naprishin;
  • (KR) Korea, Republic of: Accupril;
  • (KW) Kuwait: Acuitel;
  • (LB) Lebanon: Acuitel;
  • (LT) Lithuania: Accupro | Quinapril Ranbaxy | Quinapril teva | Quprace;
  • (LU) Luxembourg: Accupril | Quinapril eg;
  • (LV) Latvia: Accupro | Quinapril | Quprace;
  • (MA) Morocco: Accupril;
  • (MX) Mexico: Acupril;
  • (MY) Malaysia: Accupril;
  • (NL) Netherlands: Accupro | Acuprel | Acupril | Quinapril | Quinapril Actavis | Quinapril PCH;
  • (NZ) New Zealand: Accupril | Arrow quinapril;
  • (PE) Peru: Accupril | Quinapril;
  • (PH) Philippines: Accupril;
  • (PK) Pakistan: Accupril;
  • (PL) Poland: Accupro | Acurenal | Aprilgen | Pulsaren | Q Pril | Quinapril teva | Regrace;
  • (PR) Puerto Rico: Accupril | Quinapril | Quinapril HCL;
  • (PT) Portugal: Acupril | Quinapril generis | Quinapril teva;
  • (RO) Romania: Accupro | Aquiril | Quinapril al | Quinaran;
  • (RU) Russian Federation: Accupro | Quinaphar | Quinapril sz;
  • (SA) Saudi Arabia: Acuitel;
  • (SE) Sweden: Accupro;
  • (SG) Singapore: Accupril;
  • (SK) Slovakia: Accupro | Quinpres;
  • (TH) Thailand: Accupril | Quinsil;
  • (TR) Turkey: Acuitel;
  • (TW) Taiwan: Accupril;
  • (UA) Ukraine: Accupro | Quinard;
  • (UY) Uruguay: Accupril;
  • (VE) Venezuela, Bolivarian Republic of: Accupril | Quinapril | Quipresan | Solpres;
  • (ZA) South Africa: Accumax | Accupril | Quinace | Quinaspen;
  • (ZM) Zambia: Accupril
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