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| {{DrugProjectFormSinglePage
| | #REDIRECT [[Fosinopril]] |
| |authorTag={{AZ}}, {{AM}}
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| |genericName=Fosinopril, Monopril
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| |aOrAn=an
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| |drugClass=Angiontensin converting enzyme inhibitor
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| |indication=[[hypertension]], [[heart failure]]
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| |hasBlackBoxWarning=Yes
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| |adverseReactions=[[hypotension]] (2.4% to 4.4%), [[hyperkalemia]] (2.6% ), [[dizziness]] (1.6% to 11.9% ), [[cough]] (2.2% to 9.7%).
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| |blackBoxWarningTitle=USE IN PREGNANCY
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| |blackBoxWarningBody=<i><span style="color:#FF0000;">Condition Name:</span></i> When used in pregnancy during the second and third trimesters, ACE inhibitors can cause injury and even death to the developing fetus. When pregnancy is detected, enalapril maleate should be discontinued as soon as possible.
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| |fdaLIADAdult======Hypertension=====
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| * Dosing Information
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| :* Initial dose (not receiving a diuretic): '''Fosinopril 10 mg PO qd''' should be used.
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| :* Maintenance dose: '''Fosinopril 20-40 mg PO qd on two divided doses, adjust dose based on response (MAX 40 mg/day)'''
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| =====Heart failure=====
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| * Dosing Information
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| :* Initial dose : '''Fosinopril''' 5 -10 mg PO qd or bid
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| :* Maintenance dose: '''Fosinopril 20-40 mg PO qd or Fosinopril 10—20 mg PO bid, in a divided doses (MAX 40 mg/day)'''
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| |contraindications=* History of [[hypersensitivity]] or [[angioedema]] related to previous treatment with an [[angiotensin converting enzyme inhibitor]].
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| * Patients with hereditary or idiopathic angioedema.
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| |warnings=====Anaphylactoid and Possibly Related Reactions====
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| * Presumably because [[angiotensin-converting enzyme inhibitors]] affect the metabolism of [[eicosanoids]] and polypeptides, including endogenous [[bradykinin]], patients receiving ACE inhibitors (including Fosinoprilat) may be subject to a variety of adverse reactions, some of them serious.
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| ====Head and Neck Angioedema====
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| * [[Angioedema]] of the face, extremities, lips, tongue, glottis and/or larynx has been reported in patients treated with angiotensin converting enzyme inhibitors, including Fosinoprilat. This may occur at any time during treatment. In such cases Fosinoprilat should be promptly discontinued and appropriate therapy and monitoring should be provided until complete and sustained resolution of signs and symptoms has occurred. In instances where swelling has been confined to the face and lips the condition has generally resolved without treatment, although antihistamines have been useful in relieving symptoms. Angioedema associated with [[laryngeal edema]] may be fatal. Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, appropriate therapy, e.g., subcutaneous epinephrine solution 1:1000 (0.3 mL to 0.5 mL) and/or measures necessary to ensure a patent airway, should be promptly provided (see ADVERSE REACTIONS).
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| ====Intestinal Angioedema====
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| * [[Intestinal angioedema]] has been reported in patients treated with [[ACE inhibitors]]. These patients presented with [[abdominal pain]] (with or without nausea or vomiting); in some cases there was no prior history of facial angioedema and [[C-1 esterase]] levels were normal. The angioedema was diagnosed by procedures including [[abdominal CT scan]] or ultrasound, or at surgery, and symptoms resolved after stopping the ACE inhibitor. Intestinal angioedema should be included in the differential diagnosis of patients on ACE inhibitors presenting with abdominal pain.
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| ====Anaphylactoid reactions during desensitization====
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| * Two patients undergoing desensitizing treatment with [[hymenoptera venom]] while receiving ACE inhibitors sustained life-threatening [[anaphylactoid reactions]]. In the same patients, these reactions were avoided when ACE inhibitors were temporarily withheld, but they reappeared upon inadvertent rechallenge.
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| ====Anaphylactoid reactions during membrane exposure====
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| * Anaphylactoid reactions have been reported in patients dialyzed with high-flux membranes and treated concomitantly with an ACE inhibitor. Anaphylactoid reactions have also been reported in patients undergoing [[low-density lipoprotein]] apheresis with dextran sulfate absorption.
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| ====Hypotension====
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| * Excessive hypotension is rare in uncomplicated hypertensive patients treated with Fosinoprilat alone. Patients with heart failure given Fosinoprilat commonly have some reduction in blood pressure, especially with the first dose, but discontinuation of therapy for continuing symptomatic hypotension usually is not necessary when dosing instructions are followed; caution should be observed when initiating therapy. Patients at risk for excessive hypotension, sometimes associated with [[oliguria]] and/or progressive [[azotemia]], and rarely with acute renal failure and/or death, include those with the following conditions or characteristics: [[heart failure]], [[hyponatremia]], high dose diuretic therapy, recent intensive diuresis or increase in diuretic dose, [[renal dialysis]], or severe volume and/or salt depletion of any etiology. It may be advisable to eliminate the diuretic (except in patients with heart failure), reduce the diuretic dose or increase salt intake cautiously before initiating therapy with Fosinoprilat in patients at risk for excessive hypotension who are able to tolerate such adjustments. In patients at risk for excessive [[hypotension]], therapy should be started under very close medical supervision and such patients should be followed closely for the first two weeks of treatment and whenever the dose of Fosinopril and/or diuretic is increased. Similar considerations may apply to patients with [[ischemic heart]] or [[cerebrovascular disease]], in whom an excessive fall in blood pressure could result in a [[myocardial infarction]] or [[cerebrovascular accident]].
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| * If excessive [[hypotension]] occurs, the patient should be placed in the supine position and, if necessary, receive an intravenous infusion of normal saline. A transient hypotensive response is not a contraindication to further doses of Fosinoprilat, which usually can be given without difficulty once the blood pressure has stabilized. If symptomatic hypotension develops, a dose reduction or discontinuation of Fosinoprilat or concomitant [[diuretic]] may be necessary.
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| ====Neutropenia/Agranulocytosis====
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| * Another angiotensin converting enzyme inhibitor, captopril, has been shown to cause [[agranulocytosis]] and [[bone marrow depression]], rarely in uncomplicated patients but more frequently in patients with renal impairment especially if they also have a [[collagen vascular disease]]. Available data from clinical trials of Fosinopril are insufficient to show that Fosinopril does not cause agranulocytosis at similar rates. Marketing experience has revealed cases of [[neutropenia]] or [[agranulocytosis]] in which a causal relationship to Fosinopril cannot be excluded. Periodic monitoring of white blood cell counts in patients with collagen vascular disease and renal disease should be considered.
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| ====Hepatic Failure====
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| * Rarely, ACE inhibitors have been associated with a syndrome that starts with [[cholestatic jaundice]] and progresses to [[fulminant hepatic necrosis]], and (sometimes) death. The mechanism of this syndrome is not understood. Patients receiving ACE inhibitors who develop [[jaundice]] or marked elevations of hepatic enzymes should discontinue the ACE inhibitor and receive appropriate medical follow-up.
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| ====Fetal/Neonatal Morbidity and Mortality====
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| * ACE inhibitors can cause fetal and neonatal morbidity and death when administered to pregnant women. Several dozen cases have been reported in the world literature. When pregnancy is detected, ACE inhibitors should be discontinued as soon as possible.
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| * In a published restrospective epidemiological study, infants whose mothers had taken an ACE inhibitor during their first trimester of pregnancy appeared to have an increased risk of major [[congenital malformations]] compared with infants whose mothers had not undergone first trimester exposure to ACE inhibitor drugs. The number of cases of birth defects is small and the findings of this study have not yet been repeated.
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| * The use of ACE inhibitors during the second and third trimesters of pregnancy has been associated with fetal and neonatal injury, including hypotension, neonatal [[skull hypoplasia]], [[anuria]], reversible or irreversible renal failure, and death. Oligohydramnios has also been reported, presumably resulting from decreased fetal renal function; [[oligohydramnios]] in this setting has been associated with fetal limb contractures, craniofacial deformation, and [[hypoplastic lung development]]. [[Prematurity]], [[intrauterine growth retardation]], and [[patent ductus arteriosus]] have also been reported, although it is not clear whether these occurrences were due to the ACE-inhibitor exposure.
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| * These adverse effects do not appear to have resulted from intrauterine ACE-inhibitor exposure that has been limited to the first trimester. Mothers whose embryos and fetuses are exposed to ACE inhibitors only during the first trimester should be so informed. Nonetheless, when patients become pregnant, physicians should make every effort to discontinue the use of Fosinoprilat as soon as possible.
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| * Rarely (probably less often than once in every thousand pregnancies), no alternative to ACE inhibitors will be found. In these rare cases, the mothers should be apprised of the potential hazards to their fetuses, and serial ultrasound examinations should be performed to assess the intraamniotic environment.
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| * If [[oligohydramnios]] is observed, Fosinoprilat should be discontinued unless it is considered lifesaving for the mother. [[Contraction stress testing]] ([[CST]]), a [[non-stress test]] ([[NST]]), or [[biophysical profiling]] ([[BPP]]) may be appropriate, depending upon the week of pregnancy. Patients and physicians should be aware, however, that oligohydramnios may not appear until after the fetus has sustained irreversible injury.
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| * Infants with histories of in utero exposure to ACE inhibitors should be closely observed for hypotension, oliguria, and [[hyperkalemia]]. If [[oliguria]] occurs, attention should be directed toward support of blood pressure and renal perfusion. Exchange transfusion or [[dialysis]] may be required as means of reversing hypotension and/or substituting for disordered renal function. Fosinopril, which crosses the placenta, has been removed from [[neonatal circulation]] by [[peritoneal dialysis]] with some clinical benefit, and theoretically may be removed by [[exchange transfusion]], although there is no experience with the latter procedure.
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| * No teratogenic effects of Fosinopril were seen in studies of pregnant rats and rabbits. On a body surface area basis, the doses used were 57 times and 12 times, respectively, the maximum recommended human daily dose (MRHDD).
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| |clinicalTrials=Fosinopril has been evaluated for safety in more than 2100 individuals in [[hypertension]] and [[heart failure]] trials, including approximately 530 patients treated for a year or more. Generally adverse events were mild and transient, and their frequency was not prominently related to dose within the recommended daily dosage range.
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| ====Hypertension====
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| :* In placebo-controlled clinical trials (688 fosinopril-treated patients), the usual duration of therapy was two to three months. Discontinuations due to any clinical or laboratory adverse event were 4.1% and 1.1% in fosinopril-treated and placebo-treated patients, respectively. The most frequent reasons (0.4 to 0.9%) were [[headache]], [[elevated transaminases]], [[fatigue]], [[cough]], [[diarrhea]], and [[nausea]] and [[vomiting]].
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| :* During clinical trials with any fosinopril regimen, the incidence of adverse events in the elderly ≥65 years old) was similar to that seen in younger patients.
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| :* Clinical adverse events probably or possibly related or of uncertain relationship to therapy, occurring in at least 1% of patients treated with fosinopril alone and at least as frequent on fosinopril as on placebo in placebo-controlled clinical trials are shown in the table below.
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| ====Clinical Adverse Events in Placebo-Controlled Trials (Hypertension)====
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| [[File:Fosinopril Adverse Reactions 01.png|800px|thumb]]
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| :* The following events were also seen at >1% on fosinopril but occurred in the placebo group at a greater rate: [[headache]], [[diarrhea]], [[fatigue]], and [[sexual dysfunctio]]n. Other clinical events probably or possibly related, or of uncertain relationship to therapy occurring in 0.2 to 1% of patients (except as noted) treated with fosinopril in controlled or uncontrolled clinical trials (N = 1479) and less frequent, clinically significant events include (listed by body system):
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| ====General====
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| :* [[Chest pain]], [[edema]], [[weakness]],excessive sweating.
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| ====Cardiovascular====
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| :* [[Angina]]/[[myocardial infarction]], [[cerebrovascular accident]], [[hypertensive crisis]], [[rhythm disturbances]], [[palpitations]], [[hypotension]], [[syncope]], [[flushing]], [[claudication]].
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| ====Orthostatic====
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| :* [[Hypotension]] occurred in 1.4% of patients treated with fosinopril monotherapy. Hypotension or [[orthostatic hypotension]] was a cause for discontinuation of therapy in 0.1% of patients.
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| ====Dermatologic====
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| :* [[Urticaria]], [[rash]], [[photosensitivity]], [[pruritus]].
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| ====Endocrine/Metabolic====
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| :* [[Gout]], [[decreased libido]].
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| ====Gastrointestinal====
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| :* [[Pancreatitis]], [[hepatitis]], [[dysphagia]], [[abdominal distention]], [[abdominal pain]], [[flatulence]], [[constipation]], [[heartburn]], appetite/weight change, [[dry mouth]].
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| ====Hematologic====
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| :* [[Lymphadenopathy]].
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| ====Immunologic====
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| :* [[Angioedema]].
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| ====Musculoskeletal====
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| :* [[Arthralgia]], musculoskeletal pain, [[myalgia]]/[[muscle cramp]].
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| ====Nervous/Psychiatric====
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| :* Memory disturbance, [[tremor]], [[confusion]], [[mood change]], [[paresthesia]], sleep disturbance, [[drowsiness]], [[vertigo]].
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| ====Respiratory====
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| :* [[Bronchospasm]], [[pharyngitis]], [[sinusitis]]/[[rhinitis]], [[laryngitis]]/[[hoarseness]], [[epistaxis]]. A symptom-complex of [[cough]], bronchospasm, and [[eosinophilia]] has been observed in two patients treated with fosinopril.
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| ====Special Senses====
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| :* [[Tinnitus]], vision disturbance, taste disturbance, eye irritation.
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| ====Urogenital====
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| :* [[Renal insufficiency]], [[urinary frequency]].
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| ====Heart Failure====
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| :* In placebo-controlled clinical trials (361 fosinopril-treated patients), the usual duration of therapy was 3 to 6 months. Discontinuations due to any clinical or laboratory adverse event, except for [[heart failure]], were 8% and 7.5% in fosinopril-treated and placebo-treated patients, respectively. The most frequent reason for discontinuation of fosinopril was [[angina pectoris]] (1.1%). Significant hypotension after the first dose of fosinopril occurred in 14/590 (2.4%) of patients; 5/590 (0.8%) patients discontinued due to first dose [[hypotension]].
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| :* Clinical adverse events probably or possibly related or of uncertain relationship to therapy, occurring in at least 1% of patients treated with fosinopril and at least as common as the placebo group, in placebo-controlled trials are shown in the table below.
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| ====Clinical Adverse Events in Placebo-Controlled Trials (Heart Failure)====
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| [[File:Fosinopril Adverse Reactions 02.png|800px|thumb]]
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| :* The following events also occurred at a rate of 1% or more on fosinopril but occurred on placebo more often: [[fatigue]], [[dyspnea]], [[headache]], [[rash]], [[abdominal pain]], [[muscle cramp]], [[angina pectoris]], [[edema]], and [[insomnia]].
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| :* The incidence of adverse events in the elderly (≥65 years old) was similar to that seen in younger patients.
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| :* Other clinical events probably or possibly related, or of uncertain relationship to therapy occurring in 0.4 to 1% of patients (except as noted) treated with fosinopril in controlled clinical trials (N = 516) and less frequent, clinically significant events include (listed by body system):
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| ====General====
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| :* [[Fever]], [[influenza]], weight gain, [[hyperhidrosis]], sensation of cold, fall, pain.
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| ====Cardiovascular====
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| :* Sudden death, [[cardiorespiratory arrest]], shock (0.2%), [[atrial rhythm disturbance]], [[cardiac rhythm disturbances]], [[non anginal chest pain]], [[edema]] lower extremity, [[hypertension]], [[syncope]], [[conduction disorder]], [[bradycardia]], [[tachycardia]].
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| ====Dermatologic====
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| :* [[Pruritus]].
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| ====Endocrine/Metabolic====
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| :* [[Gout]], [[sexual dysfunction]].
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| ====Gastrointestinal====
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| :* [[Hepatomegaly]], [[abdominal distention]], decreased appetite, dry mouth, [[constipation]], [[flatulence]].
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| ====Immunologic====
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| :* [[Angioedema]] (0.2%).
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| ====Musculoskeletal====
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| :* Muscle ache, swelling of an extremity, weakness of an extremity.
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| ====Nervous/Psychiatric====
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| :* [[Cerebral infarction]], [[TIA]], [[depression]], [[numbness]], [[paresthesia]], [[vertigo]], behavior change, [[tremor]].
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| ====Respiratory====
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| :* Abnormal vocalization, [[rhinitis]], sinus abnormality, [[tracheobronchitis]], abnormal breathing, pleuritic chest pain.
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| ====Special Senses====
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| :* Vision disturbance, taste disturbance.
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| ====Urogenital====
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| :* Abnormal urination, kidney pain.
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| ====Potential Adverse Effects Reported with ACE Inhibitors====
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| ====Body as a Whole====
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| :* [[Anaphylactoid reactions]].
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| :* Other medically important adverse effects reported with ACE inhibitors include: [[Cardiac arrest]]; [[eosinophilic pneumonitis]]; [[neutropenia]]/[[agranulocytosis]], [[pancytopenia]], [[anemia]] (including hemolytic and aplastic), [[thrombocytopenia]]; [[acute renal failure]]; [[hepatic failure]], [[jaundice]] (hepatocellular or cholestatic); symptomatic [[hyponatremia]]; [[bullous pemphigus]], [[exfoliative dermatitis]]; a syndrome which may include: [[arthralgia]]/ [[arthritis]], [[vasculitis]], [[serositis]], [[myalgia]], [[fever]], [[rash]] or other dermatologic manifestations, a positive [[ANA]], [[leukocytosis]], [[eosinophilia]], or an elevated [[ESR]].
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| ====Laboratory Test Abnormalities====
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| ====Serum Electrolytes====
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| :* [[Hyperkalemia]]; [[hyponatremia]].
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| ====BUN/Serum Creatinine====
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| :* Elevations, usually transient and minor, of [[BUN]] or [[serum creatinine]] have been observed. In placebo-controlled clinical trials, there were no significant differences in the number of patients experiencing increases in serum creatinine (outside the normal range or 1.33 times the pre-treatment value) between the fosinopril and placebo treatment groups. Rapid reduction of longstanding or markedly elevated blood pressure by any antihypertensive therapy can result in decreases in the [[glomerular filtration rate]], and in turn, lead to increases in BUN or serum creatinine. (See PRECAUTIONS, General.)
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| ====Hematology====
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| :* In controlled trials, a mean hemoglobin decrease of 0.1 g/dL was observed in fosinopril-treated patients. In individual patients decreases in hemoglobin or hematocrit were usually transient, small, and not associated with symptoms. No patient was discontinued from therapy due to the development of anemia.
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| ====Other====
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| :* [[Neutropenia]], [[leukopenia]] and [[eosinophilia]].
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| ====Liver Function Tests====
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| :* Elevations of [[transaminases]], [[LDH]], [[alkaline phosphatase]] and [[serum bilirubin]] have been reported. Fosinopril therapy was discontinued because of serum transaminase elevations in 0.7% of patients. In the majority of cases, the abnormalities were either present at baseline or were associated with other etiologic factors. In those cases which were possibly related to fosinopril therapy, the elevations were generally mild and transient and resolved after discontinuation of therapy.
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| ====Pediatric Patients====
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| :* The adverse experience profile for pediatric patients is similar to that seen in adult patients with hypertension. The long-term effects of fosinopril on growth and development have not been studied.
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| |drugInteractions=====Diuretics====
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| * Patients on diuretics, especially those with intravascular volume depletion, may occasionally experience an excessive reduction of blood pressure after initiation of therapy with fosinopril Na tablets. The possibility of hypotensive effects with fosinopril can be minimized by either discontinuing the [[diuretic]] or increasing salt intake prior to initiation of treatment with fosinopril. If this is not possible, the starting dose should be reduced and the patient should be observed closely for several hours following an initial dose and until blood pressure has stabilized.
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| ====Potassium supplements and potassium-sparing diuretics====
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| * Fosinopril can attenuate [[potassium]] loss caused by [[thiazide]] diuretics. Potassium-sparing diuretics ([[spironolactone]], [[amiloride]], [[triamterene]], and others) or potassium supplements can increase the risk of [[hyperkalemia]]. Therefore, if concomitant use of such agents is indicated, they should be given with caution, and the patient’s serum potassium should be monitored frequently.
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| ====Lithium====
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| * Increased serum [[lithium]] levels and symptoms of [[lithium toxicity]] have been reported in patients receiving ACE inhibitors during therapy with lithium. These drugs should be coadministered 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.
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| ====Antacids====
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| * In a clinical pharmacology study, coadministration of an [[antacid]] ([[aluminum hydroxide]], [[magnesium hydroxide]], and [[simethicone]]) with fosinopril reduced serum levels and urinary excretion of fosinoprilat as compared with fosinopril administrated alone, suggesting that antacids may impair absorption of fosinopril. Therefore, if concomitant administration of these agents is indicated, dosing should be separated by 2 hours.
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| ====Gold====
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| * Nitritoid reactions (symptoms include [[facial flushing]], [[nausea]], [[vomiting]], and [[hypotension]]) have been reported rarely in patients on therapy with injectable gold (sodium aurothiomalate) and concomitant ACE inhibitor therapy including fosinopril.
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| ====Other====
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| * Neither fosinopril nor its metabolites have been found to interact with food. In separate single or multiple dose pharmacokinetic interaction studies with [[chlorthalidone]], [[nifedipine]], [[propranolol]], [[hydrochlorothiazide]], [[cimetidine]], [[metoclopramide]], [[propantheline]], [[digoxin]], and [[warfarin]], the bioavailability of fosinoprilat was not altered by coadministration of fosinopril with any one of these drugs. In a study with concomitant administration of [[aspirin]] and fosinopril, the bioavailability of unbound fosinoprilat was not altered.
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| * In a pharmacokinetic interaction study with [[warfarin]], bioavailability parameters, the degree of protein binding, and the anticoagulant effect (measured by [[prothrombin time]]) of warfarin were not significantly changed.
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| ====Drug/Laboratory Test Interaction====
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| * Fosinopril may cause a false low measurement of serum [[digoxin]] levels with the [[Digi-Tab®]] RIA Kit for Digoxin. Other kits, such as the Coat-A-Count® RIA Kit, may be used.
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| ====Dual Blockade of the Renin-Angiotensin System (RAS)====
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| * Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or [[aliskiren]] is associated with increased risks of [[hypotension]], [[hyperkalemia]], and changes in renal function (including acute renal failure) compared to monotherapy. Closely monitor blood pressure, renal function and electrolytes in patients on fosinopril and other agents that affect the [[RAS]].
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| * Do not co-administer aliskiren with fosinopril in patients with diabetes. Avoid use of aliskiren with fosinopril in patients with renal impairment (GFR<60 mL/min).
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| ====Carcinogenesis, Mutagenesis, Impairment of Fertility====
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| * No evidence of a carcinogenic effect was found when fosinopril was given in the diet to mice and rats for up to 24 months at doses up to 400 mg/kg/day. On a body weight basis, the highest dose in mice and rats is about 250 times the maximum human dose of 80 mg, assuming a 50 kg subject. On a body surface area basis, in mice, this dose is 20 times the maximum human dose; in rats, this dose is 40 times the maximum human dose. Male rats given the highest dose level had a slightly higher incidence of [[mesentery]]/[[omentum lipomas]].
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| * Neither fosinopril nor the active fosinoprilat was mutagenic in the Ames microbial mutagen test, the mouse lymphoma forward mutation assay, or a mitotic gene conversion assay. Fosinopril was also not genotoxic in a mouse micronucleus test in vivo and a mouse bone marrow cytogenetic assay in vivo.
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| * In the Chinese hamster ovary cell cytogenetic assay, fosinopril increased the frequency of chromosomal aberrations when tested without metabolic activation at a concentration that was toxic to the cells. However, there was no increase in chromosomal aberrations at lower drug concentrations without metabolic activation or at any concentration with metabolic activation.
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| * There were no adverse reproductive effects in male and female rats treated with 15 or 60 mg/kg daily. On a body weight basis, the high dose of 60 mg/kg is about 38 times the maximum recommended human dose. On a body surface area basis, this dose is 6 times the maximum recommended human dose. There was no effect on pairing time prior to mating in rats until a daily dose of 240 mg/kg, a toxic dose, was given; at this dose, a slight increase in pairing time was observed. On a body weight basis, this dose is 150 times the maximum recommended human dose. On a body surface area basis, this dose is 24 times the maximum recommended human dose.
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| |FDAPregCat=D
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| |useInPregnancyFDA=Pregnancy Category C (first trimester) and D (second and third trimesters)
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| |useInNursing=Ingestion of 20 mg daily for three days resulted in detectable levels of fosinoprilat in breast milk. Fosinopril sodium should not be administered to nursing mothers.
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| |useInPed=* The antihypertensive effects of fosinopril have been evaluated in a double-blind study in pediatric patients 6 to 16 years of age ''[[{{PAGENAME}}#Pharmacology|Pharmacology]]'') The pharmacokinetics of fosinopril have been evaluated in pediatric patients 6 to 16 years of age. Fosinopril was generally well tolerated and adverse effects were similar to those described in adults''[[{{PAGENAME}}#Warnings|Warnings]]'').
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| |useInGeri=* Clinical studies of fosinopril sodium did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
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| |mechAction=In animals and humans, fosinopril is hydrolyzed by esterases to the pharmacologically active form, fosinoprilat, a specific competitive inhibitor of angiotensin converting enzyme (ACE).
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| ACE is a peptidyl dipeptidase that catalyzes the conversion of [[angiotensin I]] to the vasoconstrictor substance, [[angiotensin II]]. Angiotensin II also stimulates [[aldosterone]] secretion by the [[adrenal cortex]]. Inhibition of ACE results in decreased plasma angiotensin II, which leads to decreased vasopressor activity and to decreased aldosterone secretion. The latter decrease may result in a small increase of serum potassium.
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| In 647 hypertensive patients treated with fosinopril alone for an average of 29 weeks, mean increases in serum potassium of 0.1 mEq/L were observed. Similar increases were observed among all patients treated with fosinopril, including those receiving concomitant diuretic therapy. Removal of angiotensin II negative feedback on [[renin]] secretion leads to increased plasma renin activity.
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| ACE is identical to kininase, an enzyme that degrades [[bradykinin]]. Whether increased levels of bradykinin, a potent vasodepressor peptide, play a role in the therapeutic effects of fosinopril remains to be elucidated.
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| While the mechanism through which fosinopril lowers blood pressure is believed to be primarily suppression of the [[renin-angiotensin-aldosterone system]], fosinopril has an antihypertensive effect even in patients with low-renin hypertension.
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| Although fosinopril was antihypertensive in all races studied, black hypertensive patients (usually a low-renin hypertensive population) had a smaller average response to ACE inhibitor monotherapy than non-black patients.
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| In patients with heart failure, the beneficial effects of fosinopril are thought to result primarily from suppression of the renin-angiotensin-aldosterone system; inhibition of the angiotensin converting enzyme produces decreases in both preload and afterload.
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| |PD=Serum ACE activity was inhibited by ≥90% at 2 to 12 hours after single doses of 10 to 40 mg of fosinopril. At 24 hours, serum ACE activity remained suppressed by 85%, 93%, and 93% in the 10, 20, and 40 mg dose groups, respectively.
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| |PK=Following oral administration, fosinopril (the [[prodrug]]) is absorbed slowly. The absolute absorption of fosinopril averaged 36% of an oral dose. The primary site of absorption is the proximal small intestine ([[duodenum]]/[[jejunum]]). While the rate of absorption may be slowed by the presence of food in the gastrointestinal tract, the extent of absorption of fosinopril is essentially unaffected.
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| Fosinoprilat is highly protein-bound (approximately 99.4%), has a relatively small volume of distribution, and has negligible binding to cellular components in blood. After single and multiple oral doses, plasma levels, areas under plasma concentration-time curves (AUCs), and peak concentrations (Cmaxs) are directly proportional to the dose of fosinopril. Times to peak concentrations are independent of dose and are achieved in approximately 3 hours.
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| After an oral dose of radiolabeled fosinopril, 75% of radioactivity in plasma was present as active fosinoprilat, 20 to 30% as a [[glucuronide]] conjugate of fosinoprilat, and 1 to 5% as a p-hydroxy metabolite of fosinoprilat. Since fosinoprilat is not biotransformed after intravenous administration, fosinopril, not fosinoprilat, appears to be the precursor for the glucuronide and p-hydroxy metabolites. In rats, the p-hydroxy metabolite of fosinoprilat is as potent an inhibitor of ACE as fosinoprilat; the glucuronide conjugate is devoid of ACE inhibitory activity.
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| After intravenous administration, fosinoprilat was eliminated approximately equally by the liver and kidney. After oral administration of radiolabeled fosinopril, approximately half of the absorbed dose is excreted in the urine and the remainder is excreted in the feces. In two studies involving healthy subjects, the mean body clearance of intravenous fosinoprilat was between 26 and 39 mL/min.
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| In healthy subjects, the terminal elimination half-life (t1/2) of an intravenous dose of radiolabeled fosinoprilat is approximately 12 hours. In hypertensive patients with normal renal and hepatic function, who received repeated doses of fosinopril, the effective t1/2 for accumulation of fosinoprilat averaged 11.5 hours. In patients with heart failure, the effective t1/2 was 14 hours.
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| In patients with mild-to-severe [[renal insufficiency]] ([[creatinine clearance]] 10 to 80 mL/ min/1.73m2), the clearance of fosinoprilat does not differ appreciably from normal, because of the large contribution of hepatobiliary elimination. In patients with [[end-stage renal disease]] (creatinine clearance < 10 mL/min/1.73m2) the total body clearance of fosinoprilat is approximately one-half of that in patients with normal renal function.
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| Fosinopril is not well dialyzed. Clearance of fosinoprilat by [[hemodialysis]] and [[peritoneal dialysis]] averages 2% and 7%, respectively, of [[urea]] clearances.
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| In patients with [[hepatic insufficiency]] (alcoholic or [[biliary cirrhosis]]), the extent of hydrolysis of fosinopril is not appreciably reduced, although the rate of hydrolysis may be slowed; the apparent total body clearance of fosinoprilat is approximately one-half of that in patients with normal hepatic function.
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| In elderly (male) subjects (65 to 74 years old) with clinically normal renal and hepatic function, there appear to be no significant differences in pharmacokinetic parameters for fosinoprilat compared to those of younger subjects (20 to 35 years old).
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| In pediatric patients – (N=20) age 6 to 16 years, with [[glomerular filtration rate]] ≥25 mL/min, given a single dose of fosinopril (0.3 mg/kg given as solution), the mean AUC and Cmax values of fosinoprilat (the active form of fosinopril) were similar to those seen in healthy adults receiving 20 mg (about 0.3 mg/kg for a 70 kg adult) of fosinopril as a solution. The terminal elimination half-life of fosinoprilat in pediatric patients was 11 to 13 hours, also similar to that observed in adults.
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| Fosinoprilat was found to cross the placenta of pregnant animals.
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| Studies in animals indicate that fosinopril and fosinoprilat do not cross the blood-brain barrier.
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| |nonClinToxic=====Carcinogenesis, Mutagenesis, Impairment of Fertility====
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| No evidence of a carcinogenic effect was found when fosinopril was given in the diet to mice and rats for up to 24 months at doses up to 400 mg/kg/day. On a body weight basis, the highest dose in mice and rats is about 250 times the maximum human dose of 80 mg, assuming a 50 kg subject. On a body surface area basis, in mice, this dose is 20 times the maximum human dose; in rats, this dose is 40 times the maximum human dose. Male rats given the highest dose level had a slightly higher incidence of [[mesentery]]/[[omentum lipomas]].
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| Neither fosinopril nor the active fosinoprilat was mutagenic in the Ames microbial mutagen test, the mouse lymphoma forward mutation assay, or a mitotic gene conversion assay. Fosinopril was also not genotoxic in a mouse micronucleus test in vivo and a mouse bone marrow cytogenetic assay in vivo.
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| In the Chinese hamster ovary cell cytogenetic assay, fosinopril increased the frequency of chromosomal aberrations when tested without metabolic activation at a concentration that was toxic to the cells. However, there was no increase in chromosomal aberrations at lower drug concentrations without metabolic activation or at any concentration with metabolic activation.
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| There were no adverse reproductive effects in male and female rats treated with 15 or 60 mg/kg daily. On a body weight basis, the high dose of 60 mg/kg is about 38 times the maximum recommended human dose. On a body surface area basis, this dose is 6 times the maximum recommended human dose. There was no effect on pairing time prior to mating in rats until a daily dose of 240 mg/kg, a toxic dose, was given; at this dose, a slight increase in pairing time was observed. On a body weight basis, this dose is 150 times the maximum recommended human dose. On a body surface area basis, this dose is 24 times the maximum recommended human dose.
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| |lookAlike=:* Fosinopril may be confused with FLUoxetine, Fosamax®, furosemide, lisinopril
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| :* Monopril may be confused with Accupril®, minoxidil, moexipril, Monoket®, Monurol®, ramipril
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| }}
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