Universal reference book for medicines
Product name: VAZOLONG N (VASOLONG N)

Active substance: hydrochlorothiazide, ramipril

Type: ACE inhibitor

Manufacturer: MICRO LABS (India)
Composition, form of production and packaging
Capsules
hard gelatinous, the case of white color, a lid of gray color, the size №4.
On the capsules ink is written "MICRO / MICRO" in black; the contents of the capsules are white or almost white powder.
1 caps.

ramipril 2.5 mg

hydrochlorothiazide 12.5 mg

10 pieces.
- blisters aluminum bilateral (5) - packs cardboard.
INSTRUCTION FOR THE SPECIALIST.

Description of the drug approved by the manufacturer for the printed edition of 2012.

PHARMACHOLOGIC EFFECT

Vazolong ® H is a combination of an ACE inhibitor - ramipril and a thiazide diuretic hydrochlorothiazide.
Ramipril and hydrochlorothiazide - are used in mono or as an antihypertensive drug. Their combination has an additive antihypertensive effect, reducing blood pressure to a higher degree than each of these drugs individually.
Ramipril

Ramipril and the active metabolite of ramipril-ramiprilat, which is formed under the influence of "hepatic" transaminases, are long-acting ACE inhibitors.
In blood plasma and tissues, ACE catalyzes the conversion of angiotensin I into angiotensin II and the breakdown of bradykinin. Therefore, when taking ramipril, the formation of angiotensin II decreases and the accumulation of bradykinin occurs, which leads to vasodilation and a decrease in blood pressure. An increase in the activity of the kalikrein-kinin system in blood and tissues causes cardioprotective and endothelioprotective action of ramipril due to activation of the prostaglandin system and, accordingly, an increase in the synthesis of prostaglandins stimulating the formation of nitric oxide in endotheliocytes. Angiotensin II stimulates the production of aldosterone, therefore, taking ramipril leads to a decrease in the secretion of aldosterone and an increase in the potassium content. With a decrease in the concentration of angiotensin II in the blood, its inhibiting effect on renin secretion by negative feedback is eliminated, which leads to an increase in renin activity of the blood plasma. It is assumed that the development of some undesirable phenomena (in particular, "dry" cough) is also associated with an increase in bradykinin activity.
In patients with hypertension, taking ramipril causes a decrease in blood pressure in the "lying" and "standing" positions without compensatory increase in the heart rate (heart rate).
The use of ramipril leads to a significant reduction in total peripheral vascular resistance (OPSS), usually not causing changes in renal blood flow and glomerular filtration rate.
Ramipril significantly reduces the overall peripheral vascular resistance, virtually without causing changes in the renal blood flow and glomerular filtration rate.Antihypertensive effect begins to develop 1-2 hours after ingestion of a single dose of the drug, reaching the highest value after 3-9 hours, and persists for 24 hours. At the course of treatment, the antihypertensive effect can gradually increase, usually stabilizing to 3-4 weeks of regular intake drug and then persisting for a long time.
Sudden discontinuation of the drug does not lead to a rapid and significant increase in blood pressure (the absence of the "withdrawal" syndrome).
Ramipril increases the sensitivity of tissues to insulin and has a beneficial effect on carbohydrate metabolism and lipid profile, increases the concentration of fibrinogen, reduces platelet aggregation, stimulates the synthesis of the tissue activator of plasminogen (plasminogen), promoting thrombolysis.

Hydrochlorothiazide

Hydrochlorothiazide is a thiazide diuretic, it breaks the reabsorption of sodium, chlorine, potassium, magnesium ions in the distal nephron, delays the excretion of calcium, uric acid.
The increase in renal excretion of these ions is accompanied by an increase in the amount of urine (due to the osmotic binding of water).Hydrochlorothiazide reduces the volume of blood plasma, increases the activity of renin in the blood plasma and the secretion of aldosterone. When taken in high doses of hydrochlorothiazide increases the excretion of bicarbonates, with prolonged intake reduces calcium excretion.
The antihypertensive effect develops due to a decrease in the volume of circulating blood (BCC), changes in the reactivity of the vascular wall, a decrease in the pressor effect of vasoconstrictive amines (epinephrine, noradrenaline) and an increase in the depressor effect on the ganglion.
Does not affect normal blood pressure.
Diuretic effect occurs after 1-2 hours, reaches a maximum after 4 hours and lasts for 6-12 hours. Antihypertensive effect occurs in 3-4 days, but 3-4 weeks are necessary to achieve the optimal therapeutic effect.

PHARMACOKINETICS

Ramipril

After ingestion, ramipril is rapidly absorbed from the digestive tract (50-60%), food does not affect the degree of absorption, but slows absorption.

In the liver, ramipril is metabolized to form an active metabolite of ramiprilate (6 times more active inhibits ACE than ramipril) and inactive diketopiperazine, which are then glucuronized.
All metabolites formed, with the exception of ramiprilate, have no pharmacological activity. The semipresidence of ramipril is approximately 1 hour. After taking ramipril, the maximum plasma concentrations of ramipril and ramiprilate are reached after 1 and 2-4 hours, respectively.
Bioavailability for ramipril after oral administration 2.5-5 mg - 15-28%, for ramiprilata - 45%.
After a daily intake of 5 mg / day, the steady concentration of ramiprilate in plasma is reached by day 4. The half-life (T 1/2 ) for ramipril is 5.1 h; in the distribution and elimination phase, the drop in the concentration of ramiprilata in the blood serum occurs with T 1/2 - 3 h, followed by a transition phase with T 1/2 - 15 h and a long terminal phase with very low plasma ramiprilate concentrations and T 1/2 - 4-5 days.
T 1/2 increases with chronic renal failure.
The volume of distribution of ramipril - 90 liters, ramiprilata - 500 liters.
The connection with blood plasma proteins for ramipril - 73%, ramiprilata - 56%.

It is excreted by the kidneys - 60%, through the intestines - 40% (mainly in the form of metabolites).
If renal function is impaired, excretion of ramipril and its metabolites slows in proportion to a decrease in creatinine clearance (CC). The use of ramipril in high doses (10 mg) in patients with impaired liver function leads to a delay in the conversion of ramipril to active ramiprilate, as well as to slowing the excretion of ramiprilate.
In patients with hypertension, after a two-week treatment with ramipril in a daily dose of 5 mg, there is no clinically significant accumulation of ramipril and ramiprilate.
In patients with heart failure, after a two-week ramipril treatment with a daily dose of 5 mg 1.5-1.8 times the plasma concentrations of ramiprilate and the area under the pharmacokinetic concentration-time curve (AUC) are observed.
Hydrochlorothiazide

After oral administration, the absorption and bioavailability of hydrochlorothiazide is about 70%.
Connection with blood plasma proteins - 60-80%.
When ingestion of 12.5 mg of hydrochlorothiazide, the maximum plasma concentration is reached after 1.5-4 hours and is 70 ng / ml, and when administered 25 mg of hydrochlorothiazide, the maximum plasma concentration
is achieved after 2-5 hours and is 142 ng / ml.
In the therapeutic range of doses, the average AUC increases in direct proportion to the increase in dose, with the appointment of once a day, cumulation is negligible.

It penetrates through the hematoplacental barrier and into breast milk T 1/2 - 5-6 hours. Hydrochlorothiazide is slightly metabolized in the liver.

Hydrochlorothiazide is excreted almost completely (more than 95%) by the kidneys in the unchanged form of 50-70% of the ingested dose is excreted within 24 hours.

It is excreted by the kidneys: 95% unchanged and about 4% as hydrolyzate-2-amino-4-chloro-m-benzenedisulfonamide (reduced in alkaline urine) by glomerular filtration and active tubular secretion in the proximal nephron.

INDICATIONS

- arterial hypertension (with
indications for the use of combined antihypertensive therapy).
DOSING MODE

The drug Vazolong® H is not intended for initial treatment of hypertension, since patients who had not previously received antihypertensive medication, who immediately started concurrent treatment with ramipril and a diuretic, may have an excessive decrease in blood pressure.

Capsules should be swallowed whole and washed down with a sufficient amount (1/2 cup) of water.
A significant effect of food intake on the bioavailability of the drug is not expected. It is usually recommended that the daily dose be taken in the morning once.
Doses of the drug are selected individually.
The choice of doses is performed by a doctor in accordance with the severity of arterial hypertension and the presence of associated risk factors.
The dose of Vazolong ® H is selected by titration (gradual increase) of the doses of its individual active substances.
Especially careful titration of doses in patients on hemodialysis should be performed.
After the patient's doses of ramipril and hydrochlorothiazide are selected, for greater comfort for patients, their admission can be replaced by taking the appropriate dose of Vazolong® H to receive these doses of ramipril and hydrochlorothiazide in one tablet.

Usual, the initial dose: 2.5 mg of ramipril and 12.5 mg of hydrochlorothiazide (corresponds to one capsule of Vazolong ® H 2.5 mg / 12.5 mg), in the morning once.

The maximum daily dose: 2 capsules Vazolong ® N.

In most cases, blood pressure is reduced sufficiently when taking Vazolong® H at doses of 2.5 mg ramipril / 12.5 mg hydrochlorothiazide to 5 mg ramipril / 25 mg hydrochlorothiazide.

If a dose adjustment is required during maintenance therapy, then it is better to do this with the use of separate preparations of ramipril and hydrochlorothiazide.

Treatment of patients receiving diuretics

Patients who received previous treatment with diuretics should, before taking Vazolong® H, 2-3 or more days (depending on the duration of diuretics), or, at least, reduce doses.

Treatment of patients with impaired renal function

Treatment begins with monotherapy of ramipril in a daily dose of 1.25 mg.
After a gradual increase in the dose of ramipre, treatment with a combination drug begins with a dose of 2.5 mg ramipril / 12.5 mg hydrochlorothiazide (corresponding to 1 capsule of Vazolong ® H 2.5 mg / 12.5 / mg).
The maximum permitted dose for patients with renal insufficiency is 5
mg ramipril / 25 mg hydrochlorothiazide (corresponding to 2 capsules of Vazolong ® H 2.5 mg / 12.5 mg).
If you miss the next dose of the drug;
The missed dose should be taken as soon as possible. However, if this is found very close to the time of taking the next dose, it is necessary to skip the missed dose and return to the usual dosing regimen, avoiding taking a double dose in a short time.
SIDE EFFECT

Since Vazolong® H is an antihypertensive drug, many unwanted reactions in its application are secondary to its lowering blood pressure, which leads to reflex activation of the sympathetic nervous system or hypoperfusion of various organs.
The number of other adverse effects, such as the effect on the water-electrolyte balance, some anaphylactoid reactions or inflammatory responses on the mucous membranes, are a consequence of inhibition of ACE or other pharmacological effects of ramipril or hydrochlorothiazide.
The undesirable effects that occur with the use of Vazolong® H, its active substances (ramipril and hydrochlorothiazide), other ACE inhibitors or other diuretics like hydrochlorothiazide, which are given in accordance with the following gradations of their frequency, are listed below: very often: 10%);
often: (? 1% - <10%);infrequently: (? 0.1% - <1%); rarely: (0.01% -0.1%); very rarely: (<0.01%) (including individual messages).
The frequency is unknown: it is impossible to determine the frequency of the occurrence of an undesirable effect from the available data.

Heart Disease

Infrequently: myocardial ischemia, including angina pectoris development;
tachycardia, heart rhythm disturbances, palpitations, peripheral edema.
Unknown frequency: myocardial infarction.

Violations of the blood and lymphatic system

Infrequent: a decrease in the number of erythrocytes in peripheral blood, a decrease in hemoglobin, hemolytic anemia, a decrease in the number of platelets in the peripheral blood.

The frequency is unknown: agranulocytosis, pancytopenia, eosinophilia, hemoconcentration. Due to a decrease in the fluid content in the body, including in the peripheral blood.

Disturbances from the nervous system

Often: headache, dizziness (a feeling of "lightness" in the head).

Infrequently: vertigo, paresthesia, tremor, disturbances, balance, burning sensation of the skin, dysgeusia (a violation of taste sensations), agevzia (loss of taste sensations).

The frequency is unknown: cerebral ischemia, including ischemic stroke and transient ischemic stroke;
violation of psychomotor reactions, parasemia.
Disturbances on the part of the organ of sight

Infrequent: visual impairment, including vagueness of the visible image;
conjunctivitis.
The frequency is unknown: xanthonia, a decrease in tear fluid (due to the presence of hydrochlorothiazide in the formulation).

Hearing impairment and labyrinthine disorders

Infrequent: ringing in the ears.

Frequency unknown: hearing loss.

Disturbances from the respiratory system, chest and mediastinal organs

Often: "dry" cough, bronchitis.

Infrequently: sinusitis, dyspnea, nasal congestion.

The frequency is unknown: bronchospasm, including increased symptoms of bronchial asthma, allergic alveolitis (pneumonitis);
not cardiogenic pulmonary edema (due to the presence of hydrochlorothiazide in the formulation).
Disturbances from the digestive tract

Infrequent: inflammation of the mucous membrane of the gastrointestinal tract, digestive disorders, a feeling of discomfort in the abdomen, dyspepsia, gastritis, nausea, constipation;
Gingivitis (due to the presence of hydrochlorothiazide in the formulation)
Rare: vomiting, aphthous stomatitis, glossitis, diarrhea, epigastric pain, dryness of the oral mucosa.

The frequency is unknown: pancreatitis (in exceptional cases, when taking LPP inhibitors, pancreatitis was observed, with a fatal outcome) increased activity of "pancreatic" enzymes in the blood angioedema of the small intestine;
sialoadenitis (due to the presence of hydrochlorothiazide in the formulation).
Disorders from the kidneys and urinary tract

Infrequent: decreased renal function including acute renal failure;
increasing the amount of urine released, increasing the concentration and urea in the blood, increasing the concentration of creatinine in the blood, (even a slight increase in the concentration of creatinine in unilateral renal artery stenosis may indicate a violation of renal function)
The frequency is unknown: an increase in pre-existing proteinuria, interstitial nephritis (due to the presence of hydrochlorothiazide in the formulation)

Disturbances from the skin and subcutaneous tissues

Infrequently: angioedema; in exceptional cases, airway obstruction can lead to death;
psoriasis-like dermatitis, hyperhidrosis, skin rash, in particular maculopapular rash, skin itch, alopecia.
The frequency is unknown: toxic epidermal necrolysis, Stevens-Johnson syndrome, erythema multiforme, pemphigus, psoriasis, exfoliative photosensitization reaction dermatitis, onycholysis, pemphigoid or lichenoidal exanthema, urticaria;
systemic lupus erythematosus (due to the presence of hydrochlorothiazide in the formulation).
Disturbances from musculoskeletal and connective tissue

Infrequently: myalgia.

The frequency is unknown: arthralgia, spastic muscle contractions,

muscle weakness, muscle rigidity, tetany (due to the presence of hydrochlorothiazide in the formulation).

Disorders from the metabolism and nutrition

Often: decompensation of diabetes mellitus, decreased tolerance, glucose, increased blood glucose concentration, increased uric acid concentration in the blood, increased gout symptoms, increased concentrations of cholesterol and triglycerides in the blood (due to the presence of hydrochlorothiazide in the formulation).

Infrequent: anorexia, depression, appetite, decrease in potassium in the blood, thirst (due to the presence of hydrochlorothiazide in the formulation).

Rarely: an increase in the potassium content in the blood (due to the presence of ramipril in the formulation).
The frequency is unknown: decrease in sodium content, in the blood, glucosuria, metabolic alkalosis, hypochloraemia, hypomagnesemia, hypercalcemia, dehydration (due to the presence of hydrochlorothiazide in the formulation)
Vascular disorders

Infrequent: excessive decrease in blood pressure, orthostatic hypotension, fainting, "tides" of blood to the skin of the face.

The frequency is unknown: thrombosis with pronounced fluid loss, vessel stenosis, the appearance or strengthening of hyponeurfusion disorders Raynaud's syndrome, vasculitis.

General disorders and disorders at the site of administration

Often: increased fatigue, asthenia.

Infrequent: pain in the chest, increased body temperature.

Immune system disorders

Frequency unknown: anaphylactic or anaphylactoid reactions (with ACE inhibition may increase severe anaphylactic or anaphylactoid reactions to insect venoms) or anaphylactic reaction to hydrochlorothiazide; increase in titer of antinuclear antibodies.
Disorders of the liver and biliary tract
Uncommon: cytolytic or cholestatic hepatitis (in exceptional cases fatal), increased activity of "liver" enzymes conjugated bilirubin in the blood; calculary cholecystitis (due to the presence in the composition of hydrochlorothiazide drug).
Frequency not known: Acute hepatic failure, cholestatic jaundice, hepatocellular damage.
Violations by the genitals and breast
Uncommon: Transient erectile impotence.
Frequency unknown: decreased libido, gynecomastia.
Mental Disorders
Uncommon: depressed mood, apathy, anxiety, sleep disorders, including drowsiness.
Frequency unknown: confusion, dysphoria, attention disorders (problems with kontsetstratsiey attention).
CONTRAINDICATIONS

- Hypersensitivity to ramipril, other ACE inhibitors, hydrochlorothiazide, other thiazide diuretics, sulfanamidam or any of the excipients of the formulation;
- angioedema (hereditary or idiopathic, and upon receiving an ACE inhibitor) in history;
- severe renal impairment (creatinine clearance less than 30 mL / min per 1.73 m 2 body surface area) or hemodialysis;
- hemodynamically significant renal artery stenosis (bilateral or unilateral in the case of a solitary kidney);
- disorders clinically significant fluid and electrolyte balance, such as hypokalemia, hypomagnesemia, or hypercalcemia (possibility of worsening);
- severe hepatic dysfunction (for these conditions minimum disruption of water and electrolyte balance may provoke a hepatic coma, as well as no application experience);
- anuria (due to the presence of hydrochlorothiazide drug);
- Pregnancy;

- lactation period;

- 18 years of age;
- Extracorporeal treatments leading to contact of blood with negatively charged surfaces; such as hemodialysis or hemofiltration with certain highly wetted membranes (poliakriloitrilovye membrane) and apheresis, low density lipoproteins with dextran sulfate (high risk of severe anaphylactoid reactions).
Carefully

- in conditions in which there is hyperstimulation of the renin-angiotensin-aldosterone system (RLAS) and / or renal function
- independent of its activity, as there is a risk of severe arterial hypotension or renal impairment (see section "Special instructions".)
- severe and particularly malignant hypertension; heart failure, particularly hard (see "Cautions.");
- hemodynamically significant impairment of blood from the left ventricle outflow or inflow of blood into the left ventricle (aortic stenosis or mitral valve), hypertrophic obstructive cardiomyopathy (GOKMP);
- renovascular disease, including unilateral hemodynamically significant stenosis of renal arteries (requires careful control of the concentration of creatinine in the blood, see "Special instructions", "Side effects".);
- previous treatment with diuretics;
- available or capable occur hypovolemia or hyponatremia in low fluid consumption or table salt, as well as diarrhea, vomiting, sweating replenishing losses with inadequate fluid and sodium;
- under conditions in which excessive lowering of blood pressure is particularly dangerous (hemodynamically significant stenosis of the coronary or cerebral arteries, it requires careful monitoring especially at the beginning of drug treatment).
- renal impairment (increased risk of hyperkalemia and leukopenia required correction mode
dispensing, see section "Dosage" and close monitoring of renal function, especially in the beginning of treatment, see "Cautions"..);
- if condition after kidney transplantation (requires careful monitoring of renal function, especially in the beginning of the treatment);
- liver diseases (risk of deterioration of liver function, no sufficient clinical experience with the drug, refer to "Side effect", "Special instructions.");
- with systemic connective tissue diseases such as lupus erythematosus or scleroderma (increased risk of immune reactions disorders, reducing the risk of, a number of peripheral blood leukocytes);
- the oppression of bone marrow hematopoiesis, concomitant therapy glyukokortikostsroidami, immunomodulators, cytotoxic agents, anti-metabolites, allopurinol, procainamide (an increased risk of leukopenia in the peripheral blood, see the sections on "Side effects", "Drug Interactions", "Cautions.");
- diabetes (risk of hyperkalemia, and in the case of hypoglycemic drugs - insulin, sulfonylurea derivatives - the risk of hypoglycemic reactions due to the presence of the drug ramipril and risk of increased blood glucose concentration due to the presence of hydrochlorothiazide drug) (see . Forums "Side effects", "Drug interactions");
- in elderly patients (over 65 years) (the risk of a more pronounced hypotensive action, little experience of the drug).
PREGNANCY AND LACTATION

Vazolong ® H can not be used during pregnancy. Therefore, before taking the drug in women of childbearing age should exclude pregnancy and during treatment they should use reliable methods of contraception. In case of pregnancy during treatment with the drug, it should be as soon as possible to stop taking it and move the patient to the treatment with other drugs, the application of which will be the least risk to the child.
Because of the risk of adverse effects of ramipril and hydrochlorothiazide on a fetus are advised to avoid pregnancy for women who can not be transferred to another / treatment of hypertension (without ACE inhibitors and diuretics).
If treatment with Vazolong ® H must lactation, then should stop breastfeeding.
APPLICATION FOR FUNCTIONS OF THE LIVER

In patients with renal dysfunction require special care in the use of the drug Vazolong ® H, and smaller doses of the drug (see. The section "Method of administration and dose") used in these cases.
APPLICATION FOR VIOLATIONS OF THE FUNCTION OF KIDNEYS

In patients with impaired hepatic function or progressive liver disease the use of thiazides requires caution, as these patients even minimal changes in fluid and electrolyte balance may provoke a hepatic coma.
APPLICATION FOR CHILDREN

Contraindicated for children under 18 years.

APPLICATION IN ELDERLY PATIENTS

With caution is prescribed for the elderly (over 65 years).
SPECIAL INSTRUCTIONS

Angioedema
When treatment with ACE inhibitors, mainly after the first dose, cases angioedema observed. Angioedema involving the larynx may be fatal. In the case of edema face, extremities, lips, tongue, or glottis, and especially the development of stridor should stop taking the drug Vazolong ® H and immediately begin treatment, directed to the relief of angioedema. In cases where the swelling is limited to the face and lips are usually permitted state without treatment, however, antihistamines may be administered to relieve symptoms. When the spread of edema on the tongue, glottis or throat possible airway obstruction, in such cases, an urgent need to start the appropriate treatment, including immediate subcutaneous or slow intravenous administration of epinephrine (adrenaline) under the control of ECG and blood pressure.
Cough
Before the drug Vazolong ® H may cause "dry" cough usually disappears after drug withdrawal. This possibility should be considered in the differential diagnosis of cough.
Anafiloktoidnye response to ACE inhibitors
With the use of ACE inhibitors have been described life-threatening anaphylactoid rapidly developing hypersensitivity reactions, sometimes up to the development of shock during hemodialysis using vysokoprotochnyh certain membranes (e.g., polyacrylonitrile membranes). It is necessary to avoid concomitant use Vazolong preparation ®H and such membranes, e.g., for emergency hemodialysis or hemofiltration. In this case it is preferable to use membranes or other exception receiving inhibitors. Similar reactions were observed at low density lipoprotein apheresis using a dextran sulfate. These reactions were avoided by using the temporary cessation of therapy with an ACE inhibitor prior to each subsequent apheresis. Antihistamines are ineffective for removing these reactions.
Hypersensitivity reaction to hydrochlorothiazide does not depend on having a history of asthma or allergies.
Aortic stenosis
Theoretically, patients with aortic stenosis during treatment with vasodilators may be an increased risk of reduced coronary perfusion.
hypotension
After assigning ramipril, usually after the first or second dose or after increasing the dose may develop hypotension, which is most likely in patients with BCC has been lowered as a result of diuretic therapy limited Incoming salt with food, dialysis, diarrhea, vomiting and profuse sweating.
It is usually recommended to dehydration, hypovolemia and hyponatremia corrected before application of the preparation (however, in patients with heart failure bcc replenishment should be made with great care, because there is a risk of decompensation due to an excessive load volume).
In conditions in which there is a hyperstimulation, RAAS and / or kidney function is dependent on its activity, with ACE inhibiting an increased risk of sudden reduction of blood pressure and renal dysfunction. Therefore, in such cases, the beginning of treatment, or at the beginning of the increase initially applied dose required to control blood pressure at the time when no more expected to further decrease blood pressure.
In patients with severe chronic heart failure (including, accompanied by renal failure), treatment with an ACE inhibitor can cause an excessive fall in blood pressure and accompanied by oliguria and (or) progressive azotemia with acute renal failure and / or death. In these patients start treatment with Vazolong ®H or its extension should be carried out only after the adoption of measures against the fall in blood pressure and worsening renal function.
A particular danger is hypotension in patients with ischemic heart disease or cerebral vascular lesions, as in this case it is possible the development of myocardial infarction or stroke. Such patients are subject to strict monitoring and early treatment with increasing doses of the drug.
All patients should be warned that the dehydration due to sweating (including in hot weather or exertion), emesis, diarrhea may lead to excessive decrease of blood pressure and in these cases the question of the dosages Ramipril and hydrochlorothiazide be decided physician.
During treatment with ramipril is not recommended to drink alcohol.
In the case of arterial hypotension need to transfer the patient in a horizontal position raised feet, and start intravenous infusion of 0.9% sodium chloride if necessary.
In the event of syncope, the state should stop taking this medication and tell your doctor.
Transient hypotension is not a contraindication to continue treatment after stabilization of blood pressure. In the case of re-emergence of pronounced hypotension should reduce the dose or stop the drug.
Surgery and general anesthesia
Prior to surgery (including dental) must notify the surgeon / anesthesiologist use of ACE inhibitors. If during general anesthesia hypotension develops, it can be corrected by the BCC. Thiazides may enhance the effects of tubocurarine.
Hematology Control
Before the drug is recommended to control hemoglobin, leukocytes, erythrocytes, platelets, leukocyte formula. More frequent monitoring is recommended in the initial phase of treatment and in patients with impaired renal function, connective tissue diseases (systemic lupus erythematosus, scleroderma) or in patients receiving other medications that can change the picture of peripheral blood.
When the symptoms caused by leukopenia (e.g., fever, lymph node enlargement, tonsillitis), requires urgent picture peripheral blood. If signs of bleeding (smallest petechiae, red-brown lesions on the skin and mucous membranes) also requires control platelets in the peripheral blood.
Monitoring of liver function
It is necessary to conduct a full examination of liver function and other tests for determining whether a patient's symptoms, suspected her defeat: grinpopodobnye symptoms that occur during the first weeks or months of treatment (such as fever, malaise, muscle pain, rash or adenopathy indicating hypersensitivity reactions) , abdominal pain, nausea or vomiting, loss of appetite, jaundice, itching or any other unexplained symptoms. If confirmed, liver function abnormalities should stop taking the drug and appropriate treatment if necessary.
In patients with impaired hepatic function or progressive liver disease the use of thiazides requires caution, as these patients even minimal changes in fluid and electrolyte balance may provoke a hepatic coma.
Controlled clinical trials involving patients with cirrhosis and / or liver dysfunction are absent. With extreme caution should be used drug in patients with pre-existing hepatic impairment, which prior to the start of the drug should determine the status of liver function and it is strictly monitored during treatment.
Monitoring the kidney
due to the suppression activity of the RAAS in predisposed patients possible deterioration of renal function, the risk of which is increased by the simultaneous use of diuretics.
It is recommended to carefully monitor renal function, especially in the first weeks of treatment and in the following patient groups:
- patients with heart failure;
- Patients with renovascular disease, including hemodynamically significant unilateral renal artery stenosis (in these patients, even a slight increase in serum creatinine concentration may be a manifestation of a unilateral reduction of renal function);
- patients with impaired renal function;
- patients after kidney transplantation.
Patients with impaired renal function requires special care in the application preparation Vazolong ® H, and in these cases, use smaller doses of the drug.
Hydrochlorothiazide can promote or enhance azotemia. Cumulative effects of the drug may be in patients with impaired renal function. If amplifying azotemia and oliguria develop during treatment of severe progressive renal disease, diuretic therapy is necessary prek
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