Formulary
Captopril: Indications, Dosing, Side Effects and Interactions
Captopril clinical drug profile including indications, dosing, side effects, cautions and interactions.
MedNext Academy | 10 min read
Captopril: Indications, Dosing, Side Effects and Interactions
Captopril clinical drug profile including indications, dosing, side effects, cautions and interactions.
Indications and dose
**Hypertension**
- **Adult** (By Mouth): Initially 12.5-25 mg twice daily, then increased if necessary up to 150 mg daily in 2 divided doses, doses to be increased at intervals of at least 2 weeks, once-daily dosing may be appropriate if other concomitant antihypertensive drugs taken.
- **Elderly** (By Mouth): Initially 6.25 mg twice daily, then increased if necessary up to 150 mg daily in 2 divided doses, doses to be increased at intervals of at least 2 weeks, once-daily dosing may be appropriate if other concomitant antihypertensive drugs taken.
**Essential hypertension if used in volume depletion, cardiac decompensation, or renovascular hypertension**
- **Adult** (By Mouth): Initially 6.25-12.5 mg for 1 dose (under close medical supervision), then 6.25-12.5 mg twice daily; increased if necessary up to 100 mg daily in 1-2 divided doses, doses to be increased at intervals of at least 2 weeks, once-daily dosing may be appropriate if other concomitant antihypertensive drugs taken.
**Heart failure**
- **Adult** (By Mouth): (under close medical supervision) Initially 6.25-12.5 mg 2-3 times a day, then increased if tolerated to up to 150 mg daily in divided doses, dose to be increased gradually at intervals of at least 2 weeks.
**Short-term treatment within 24 hours of onset of myocardial infarction in clinically stable patients**
- **Adult** (By Mouth): Initially 6.25 mg, then increased to 12.5 mg after 2 hours, followed by 25 mg after 12 hours; increased if tolerated to 50 mg twice daily for 4 weeks.
**Prophylaxis of symptomatic heart failure after myocardial infarction in clinically stable patients with asymptomatic left ventricular dysfunction (starting 3-16 days after infarction) (under close medical supervision)**
- **Adult** (By Mouth): Initially 6.25 mg daily, then increased to 12.5 mg 3 times a day for 2 days, then increased if tolerated to 25 mg 3 times a day, then increased if tolerated to 75-150 mg daily in 2-3 divided doses, doses exceeding 75 mg per day to be increased gradually.
**Diabetic nephropathy in type 1 diabetes mellitus**
- **Adult** (By Mouth): 75-100 mg daily in divided doses.
**Hypertension for captopril**
- **Preterm neonate (initiated under specialist supervision)** (By mouth): Test dose 10 micrograms/kg, monitor blood pressure carefully for 1-2 hours; usual dose 10-50 micrograms/kg 2-3 times a day, then increased if necessary up to 300 micrograms/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Neonate (initiated under specialist supervision)** (By mouth): Test dose 10-50 micrograms/kg, monitor blood pressure carefully for 1-2 hours; usual dose 10-50 micrograms/kg 2-3 times a day, then increased if necessary up to 2 mg/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Child 1-11 months (initiated under specialist supervision)** (By mouth): Test dose 100 micrograms/kg (max. per dose 6.25 mg), monitor blood pressure carefully for 1-2 hours; usual dose 100-300 micrograms/kg 2-3 times a day, then increased if necessary up to 4 mg/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Child 1-11 years (initiated under specialist supervision)** (By mouth): Test dose 100 micrograms/kg (max. per dose 6.25 mg), monitor blood pressure carefully for 1-2 hours; usual dose 100-300 micrograms/kg 2-3 times a day, then increased if necessary up to 6 mg/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Child 12-17 years (initiated under specialist supervision)** (By mouth): Test dose 100 micrograms/kg, alternatively test dose 6.25 mg, monitor blood pressure carefully for 1-2 hours; usual dose 12.5-25 mg 2-3 times a day, then increased if necessary up to 150 mg daily in divided doses, ongoing doses should only be given if test dose tolerated.
**Heart failure for captopril**
- **Preterm neonate (initiated under specialist supervision)** (By mouth): Test dose 10 micrograms/kg, monitor blood pressure carefully for 1-2 hours; usual dose 10-50 micrograms/kg 2-3 times a day, then increased if necessary up to 300 micrograms/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Neonate (initiated under specialist supervision)** (By mouth): Test dose 10-50 micrograms/kg, monitor blood pressure carefully for 1-2 hours; usual dose 10-50 micrograms/kg 2-3 times a day, then increased if necessary up to 2 mg/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Child 1-11 months (initiated under specialist supervision)** (By mouth): Test dose 100 micrograms/kg (max. per dose 6.25 mg), monitor blood pressure carefully for 1-2 hours; usual dose 100-300 micrograms/kg 2-3 times a day, then increased if necessary up to 4 mg/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Child 1-11 years (initiated under specialist supervision)** (By mouth): Test dose 100 micrograms/kg (max. per dose 6.25 mg), monitor blood pressure carefully for 1-2 hours; usual dose 100-300 micrograms/kg 2-3 times a day, then increased if necessary up to 6 mg/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Child 12-17 years (initiated under specialist supervision)** (By mouth): Test dose 100 micrograms/kg, alternatively test dose 6.25 mg, monitor blood pressure carefully for 1-2 hours; usual dose 12.5-25 mg 2-3 times a day, then increased if necessary up to 150 mg daily in divided doses, ongoing doses should only be given if test dose tolerated.
**Proteinuria in nephritis (under expert supervision) for captopril**
- **Preterm neonate** (By mouth): Test dose 10 micrograms/kg, monitor blood pressure carefully for 1-2 hours; usual dose 10-50 micrograms/kg 2-3 times a day, then increased if necessary up to 300 micrograms/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Neonate** (By mouth): Test dose 10-50 micrograms/kg, monitor blood pressure carefully for 1-2 hours; usual dose 10-50 micrograms/kg 2-3 times a day, then increased if necessary up to 2 mg/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Child 1-11 months** (By mouth): Test dose 100 micrograms/kg (max. per dose 6.25 mg), monitor blood pressure carefully for 1-2 hours; usual dose 100-300 micrograms/kg 2-3 times a day, then increased if necessary up to 4 mg/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Child 1-11 years** (By mouth): Test dose 100 micrograms/kg (max. per dose 6.25 mg), monitor blood pressure carefully for 1-2 hours; usual dose 100-300 micrograms/kg 2-3 times a day, then increased if necessary up to 6 mg/kg daily in divided doses, ongoing doses should only be given if test dose tolerated.
- **Child 12-17 years** (By mouth): Test dose 100 micrograms/kg, alternatively test dose 6.25 mg, monitor blood pressure carefully for 1-2 hours; usual dose 12.5-25 mg 2-3 times a day, then increased if necessary up to 150 mg daily in divided doses, ongoing doses should only be given if test dose tolerated.
**Diabetic nephropathy in type 1 diabetes mellitus for captopril**
- **Child 12-17 years (under expert supervision)** (By mouth): Test dose 100 micrograms/kg, alternatively test dose 6.25 mg, monitor blood pressure carefully for 1- 2 hours; usual dose 12.5-25 mg 2-3 times a day, increased if necessary up to 100 mg daily in divided doses, ongoing doses should only be given if test dose tolerated.
Cautions
For all angiotensin-converting enzyme inhibitors Concomitant diuretics; diabetes (may lower blood glucose; increased risk of hyperkalaemia); first dose hypotension (especially in patients taking high doses of diuretics, on a low-sodium diet, on dialysis, dehydrated, or with cerebrovascular disease, ischaemic heart disease, or heart failure); patients of black African or African-Caribbean origin (may respond less well to ACE inhibitors); peripheral vascular disease or generalised atherosclerosis (risk of clinically silent renovascular disease); primary aldosteronism (patients may respond less well to ACE inhibitors); the risk of agranulocytosis is possibly increased in collagen vascular disease (blood counts recommended); use with care in patients with aortic or mitral valve stenosis (risk of hypotension); use with care in patients with hypertrophic cardiomyopathy Cautions, further information Anaphylactoid reactions To prevent anaphylactoid reactions, ACE inhibitors should be avoided during dialysis with high-flux membranes (e.g. polyacrylonitrile) and during low-density lipoprotein apheresis with dextran sulfate; they should also be withheld before desensitisation with wasp or bee venom. M Elderly Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria to aid medication reviews (see Prescribing in the elderly for information). Potentially inappropriate: with hyperkalaemia with persistent postural hypotension i.e. recurrent drop in systolic blood pressure 20 mmHg (risk of syncope and falls)
Contraindications
For all angiotensin-converting enzyme inhibitors Hereditary or idiopathic angioedema; history of angioedema associated with prior ACE inhibitor therapy; the combination of an ACE inhibitor with aliskiren is contra-indicated in patients with an eGFR less than 60 mL/minute/1.73 m 2 ; the combination of an ACE inhibitor with aliskiren is contra-indicated in patients with diabetes mellitus
Side effects
For all angiotensin-converting enzyme inhibitors Common or very common Alopecia; angina pectoris; angioedema (can be delayed; more common in black patients); arrhythmias; asthenia; chest pain; constipation; cough; depression; diarrhoea; dizziness; drowsiness; dry mouth; dyspnoea; electrolyte imbalance; gastrointestinal discomfort; headache; hypotension; myalgia; nausea; palpitations; paraesthesia; renal impairment; rhinitis; skin reactions; sleep disorder; syncope; taste altered; tinnitus; vertigo; vomiting Uncommon Arthralgia; confusion; eosinophilia; erectile dysfunction; fever; haemolytic anaemia; hyperhidrosis; myocardial infarction; pancreatitis; peripheral oedema; photosensitivity reaction; respiratory disorders; stroke Rare or very rare Agranulocytosis; hepatitis; leucopenia; neutropenia; pancytopenia; Stevens-Johnson syndrome; thrombocytopenia Side-effects, further information In light of reports of cholestatic jaundice, hepatitis, fulminant hepatic necrosis, and hepatic failure, ACE inhibitors should be discontinued if marked elevation of hepatic enzymes or jaundice occur. Side-effects For captopril Common or very common Insomnia; peptic ulcer Uncommon Appetite decreased; flushing; malaise; pallor; Raynaud's phenomenon Rare or very rare Alveolitis allergic; anaemia; aplastic anaemia; autoimmune disorder; cardiac arrest; cardiogenic shock; cerebrovascular insufficiency; gynaecomastia; hepatic disorders; hypoglycaemia; lymphadenopathy; nephrotic syndrome; oral disorders; proteinuria; urinary disorders; vision blurred
Interactions
**Severe interactions:**
- Potassium sparing diuretics (e.g.
- However, no clinically significant drug interactions have been found in specific studies with hydrochlorothiazide or furosemide.
**Other interactions (21):**
- Potassium sparing diuretics, potassium supplements or potassium-containing salt substitutes: Although serum potassium usually remains within normal limits, hyperkalaemia may occur in some patients...
- Care should also be taken when captopril is co-administered with other agents that increase serum potassium, such as trimethoprim and cotrimoxazole (trimethoprim/sulfamethoxazole) as trimethoprim is...
- Therefore, the combination of captopril with the above-mentioned drugs is not recommended.
- Ciclosporin: Hyperkalaemia may occur during concomitant use of ACE inhibitors with ciclosporin.
- Heparin: Hyperkalaemia may occur during concomitant use of ACE inhibitors with heparin.
- Diuretics (thiazide or loop diuretics): Prior treatment with high dose diuretics may result in volume depletion and a risk of hypotension when initiating therapy with captopril (see section 4.4).
Pregnancy
Important safety information For all angiotensin-converting enzyme inhibitors MHRA/CHM advice: ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy (December 2014) See Conception and contraception and Pregnancy . MHRA/CHM advice: ACE inhibitors and angiotensin II receptor antagonists: recommendations on how to use for breastfeeding (December 2014) See Breast feeding .
Breast feeding
For all angiotensin-converting enzyme inhibitors Information on the use of ACE inhibitors in breast-feeding is limited. Breast feeding For captopril Avoid in first few weeks after delivery, particularly in preterm infants-risk of profound neonatal hypotension; can be used in mothers breast-feeding older infants if essential but monitor infant's blood pressure.
Renal impairment
For all angiotensin-converting enzyme inhibitors Caution (hyperkalaemia and other side-effects of ACE inhibitors are more common in those with impaired renal function). M Dose adjustments Start with low dose and adjust according to response. M Renal impairment For captopril Dose adjustments Max. initial dose 25 mg daily (do not exceed 100 mg daily) if creatinine clearance 20-40 mL/minute. M Max. initial dose 12.5 mg daily (do not exceed 75 mg daily) if creatinine clearance 10-20 mL/minute. M Max. initial dose 6.25 mg daily (do not exceed 37.5 mg daily) if creatinine clearance less than 10 mL/minute. M See Prescribing in renal impairment .
Medicinal forms
Tablet,Tablet,Solution
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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