Angiotensin-converting enzyme inhibitor moexipril (Cardiotensin) is used to treat adult patients with hypertension.

Moexipril (Cardiotensin) Uses:

• Hypertension:

  • Moexipril is used in the treatment of patients with hypertension

Guideline recommendations:

• In the absence of comorbidities (such as cerebrovascular disease, persistent kidney disease, diabetes, heart failure, ischemic heart disease, etc.), the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of Hypertension in Adults suggests that thiazide-like diuretics or dihydropyridine calcium channel blockers may be preferable options due to improved cardiovascular endpoints (e.g., avoidance of heart failure and stroke).
• ARBs and ACE inhibitors are both appropriate for monotherapy.
• Combination therapy is usually preferred in patients at high risk (stage 2 hypertension or an atherosclerotic cardiovascular disease [ASCVD] risk of 10%) in order to achieve blood pressure targets.

Off Label Use of Moexipril in Adults:

• Non–ST-elevation acute coronary syndrome
• Stable coronary artery disease
• ST-elevation acute coronary syndrome

Read:

• Ramipril (Tritace)
• Lisinopril (Zestril)
• Enalapril (Epaned, Renitec)

Moexpril Dose in Adults:

Moexipril (Cardiotensin) Dose in the treatment of Hypertension:

• Oral: Initial: 3.75 to 7.5 mg one time every day;
•  

Moexipril Dose in Children:

It is not indicated in children with hypertension.

Pregnancy Risk Factor D

• Up to 30 mg/day in 1 or 2 divided doses, titrate the dose as necessary based on patient response. However, the outcomes may also be affected if the mother has a chronic condition.
• [US Boxed Warning]:
  • An exposure to an ACE inhibitor in the first three months of pregnancy may be linked to an increased risk of foetal abnormalities.
  • Once you are aware that your pregnancy has been detected, discontinue use.
  • Oligohydramnios is a drug that acts on the renin-angiotensin system.
  • A developing foetus may suffer harm or perhaps pass away as a result of medications that influence the renin-angiotensin systems.
  • Oligohydramnios may result in foetal lung hypoplasia or skeletal abnormalities because of the reduced foetal renal function.
  • These medications are also linked to kidney failure, skull hypoplasia, anuria and hypotension in pregnancy, as well as fetal/newborn death.
  • ACE inhibitor exposure in utero should be closely monitored for hyperkalemia, hypotension, or oliguria in the infant.
  • After a permanent fetal trauma, oligohydramnios might not be possible to find.
  • Although it is feasible to correct hypotension and enhance renal function in infants by exchange transfusions and dialysis, there is no information on their efficacy.
  • Negative outcomes for the baby and foetus can also result from high maternal blood pressure.
  • The likelihood of birth abnormalities, low birth weight, stillbirths, premature birth, and neonatal mortality can all be increased by chronic maternal hypertension.
  • The severity and duration of maternal hypertension may have real fetal/newborn consequences.
  • Persistent high blood pressure that is not treated may increase the risk of unfavorable maternal effects such as pre-eclampsia and gestational diabetes.
  • ACE inhibitors should not be used in pregnancy to treat hypertension. They can cause harm to the fetus and must be avoided.
  • Females with reproductive potential should not use contraceptives that contain ACE inhibitors.
  • Women planning to have a baby should avoid ACE inhibitors for hypertension.
  • They should only be used in cases where hypertension is not responding to other medications.

Moexipril use during breastfeeding:

• It isn't known if breast milk contains moexipril.
• Moexipril should not be administered to nursing mothers, according to the manufacturer.

Dose in Kidney Disease:

• CrCl >40 mL/minute/1.73 m²:

  • The manufacturer's labelling does not mention dosage modifications; proceed with caution.

• CrCl ≤40 mL/minute/1.73 m²:

  • Initial: 3.75 mg once daily; maximum dose: 15 mg/day

Dose in Liver disease:

The manufacturer's labelling does not mention dosage modifications. But hepatic dysfunction raises systemic exposure.

Side Effects of Moexipril (Cardiotensin):

• Cardiovascular:

  • Flushing
  • Peripheral Edema
  • Hypotension

• Central Nervous System:

  • Dizziness
  • Fatigue
  • Headache

• Dermatologic:

  • Skin Rash
  • Alopecia

• Endocrine & Metabolic:

  • Hyperkalemia
  • Hyponatremia

• Gastrointestinal:

  • Heartburn
  • Nausea
  • Diarrhea

• Neuromuscular & Skeletal:

  • Myalgia

• Renal:

  • Increased Blood Urea Nitrogen (Reversible)
  • Increased Serum Creatinine (Reversible)
  • Polyuria

• Respiratory:

  • Pharyngitis
  • Sinusitis
  • Cough
  • Upper Respiratory Tract Infection

Contraindications to Moexipril (Cardiotensin):

• Sensitivity of moexipril and any other element of the formulation
• Angioedema brought on by prior ACE medication therapy
• Patients with diabetes mellitus should take aliskiren together.
• Documenting allergic cross-reactivity with ACE inhibitors is not achievable.
• Cross-sensitivity is possible due to chemical similarities and/or pharmacologic reactions.
• However, this cannot be excluded with absolute certainty.

Warnings and precautions

• Angioedema

  • Angioedema can occur at any time, especially after the first dose of ACE inhibitors. It may be a rare occurrence.
  • Patients with idiopathic angioedema or genetic angioedema, as well as African Americans, may be at greater risk.
  • The risk of developing mTOR inhibition (eg everolimus) may be increased.
  • If the tongue, glottis, or larynx are affected, as they may be connected to airway obstruction, frequent monitoring may be necessary.
  • Patients who have had previous airway surgery may be at greater risk for obstruction.
  • It is important to manage belligerents early.
  • Patients with angioedema resulting from ACE inhibitor therapy are not recommended.

• Cholestatic jaundice

  • Cholestatic jaundice is unique toxicity linked to ACE inhibitors.
  • This could result in fulminant liver damage (some fatal).
  • If there is an apparent elevation in hepatic transaminases or jaundice, it will be terminated.

• Cough:

  • A dry, slicing, and unfavourable symptom known as an ACE inhibitor-related cough often appears in the first few months of medication.
  • After stopping the ACE medication, it should normally go away after a month.
  • There may be many causes of coughing (e.g. lung congestion in patients suffering from heart failure).
  • These conditions must also be addressed before discontinuing treatment.

• Hyperkalemia:

  • Patients on ACE inhibitors could develop hyperkalemia, particularly if they also have other risk factors such diabetes, renal impairment, or taking potassium-sparing diuretics or supplements.
  • These agents should be used with caution.

• Hypersensitivity reactions

  • ACE inhibitors can cause anaphylactic reactions.
  • Hemodialysis (CVVHD, for example) and high-flux dialysis membranes (AN69), as well as, sporadically, low-density lipoprotein (LDL) apheresis utilising dextran sulphate cellulose, can both cause anaphylactoid reactions.
  • Patients treated with ACE inhibitors and sensitised with venom from Hymenoptera (bee, wasp) have exhibited remarkable anaphylactoid reactions.

• Hypotension/syncope

  • ACE inhibitors can result in hypotension, syncope, or both. The initial doses are frequently enough.
  • Patients with low volume must accurately measure their volume before initiating treatment.
  • The rate of blood pressure reduction must be appropriate to the patient's clinical situation.
  • Even though it could be required to lower doses, hypotension is not a reason to cease taking ACE inhibitors in the future.
  • This is especially true for heart disease patients whose goal is to lower systolic pressure.

• Neutropenia/agranulocytosis:

  • Another ACE medication, captopril, has been linked to extremely rare instances of neutropenia or agranulocytosis.
  • The likelihood of developing neutropenia is increased in patients with renal damage.
  • Neutropenia is more likely to occur in patients with collagen vascular disease and renal impairment (such systemic lupus erythematosus).
  • Keep an eye out for differences in these patients' CBC readings.

• Renal function deterioration:

  • This may be because patients with limited renal flow (such as those with renal artery stenosis or heart failure) whose GFR depends on angiotensin II experience a decline in renal function or intensifications of BUN and serum creatinine. Oliguria and abrupt renal failure might result from deterioration.
  • Patients with severe or progressive impairment of renal function may experience minor increases in serum creatinine.

• Aortic stenosis

  • Patients with aortic Stenosis should exercise caution as it may decrease coronary perfusion and cause ischemia.

• Ascites:

  • Avoid use in patients suffering from cirrhosis and refractory ascites. If patients are unable to avoid ascites, check blood pressure and kidney function to ensure that they don't develop renal failure.

• Cardiovascular disease

  • Due to the repercussions of dropping blood pressure, patients with ischemic heart disease and cerebrovascular illnesses should be continuously watched (eg stroke, MI).
  • Fluid administration may be used, if necessary, to raise blood pressure. Then, therapy might continue.
  • Patients who develop hypotension after re-initiation of treatment should discontinue the treatment.

• Collagen vascular disease:

  • Patients with collagen vascular disease should use caution since they may be more susceptible to hematologic toxicities, especially if they also have concurrent renal illness.

• Hypertrophic cardiomyopathy with outflow tract obstruction (HCM)

  • Patients with HCM or outflow tract obstruction should be careful as a reduction in afterload could worsen the symptoms.

• Renal artery stenosis

  • In individuals with unilateral or bilateral unstented renal artery stenosis, use with caution.
  • It is advised to prevent use if there is bilateral renal artery stenosis that is untreated.

• Renal impairment

  • Pre-existing renal impairments should be treated with care. Dose modification may be necessary.
  • Avoid rapid dosage increases, which could lead to more renal impairment.

Moexipril: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Monitoring parameters:

• Regularly check CBC with differential if the patient has collagen vascular disease and/or renal impairment.
• serum creatinine
• Blood pressure
• potassium
• BUN

Hypertension: The 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:

• Confirmed hypertension and known CVD or 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥10%:
  • Target blood pressure <130/80 mm Hg is recommended
• Confirmed hypertension without markers of increased ASCVD risk:
  • Target blood pressure <130/80 mm Hg may be reasonable

Diabetes and hypertension: The American Diabetes Association (ADA) guidelines (ADA 2019):

• Patients 18 to 65 years of age, without ASCVD, and 10-year ASCVD risk <15%:
  • Target blood pressure <140/90 mm Hg is recommended.
• Patients 18 to 65 years of age and known ASCVD or 10-year ASCVD risk >15%:
  • Target blood pressure <130/80 mm Hg may be appropriate if it can be safely attained.
• Patients >65 years of age (healthy or complex/intermediate health):
  • Target blood pressure <140/90 mm Hg is recommended.
• Patients >65 years of age (very complex/poor health):
  • Target blood pressure <150/90 mm Hg is recommended.

How to administer Moexipril (Cardiotensin)?

Oral: Administer on an empty stomach 1 hour prior to a meal.

Mechanism of action of Moexipril (Cardiotensin):

• It is an inhibitor of the angiotensin-converting enzyme that is competitive (ACE). It prevents angiotensin II, a potent vasoconstrictor, from converting to angiotensin I. This results in a decrease in the synthesis of aldosterone and an increase in plasma renin activity.

The onset of action:

• Within 2 hours; Peak effect: 3 to 6 hours

Duration:

• 24 hours

Absorption:

• Incomplete

Protein binding, plasma:

• Moexiprilat: ~50%

Metabolism:

• It is a prodrug. It is rapidly converted to moexiprilat; Moexiprilat ~1,000 times more potent

Bioavailability:

• Moexiprilat: ~13%; reduced with food (C and AUC decreased by 70% to 80% and 40% to 50%, respectively)

Half-life elimination:

• Moexipril: 1.3 hours;
• Moexiprilat: 2 to 9.8 hours

Time to peak:

• Moexiprilat: ~1.5 hours

Excretion:

• Moexiprilat: Feces (52%); urine (~7%)

International Brand Names of Moexipril:

• Cardiotensin
• Femipres
• Fempress
• Minotensol
• Moex
• Perdix
• Renoprotect
• Univasc

Moexipril Brand Names in Pakistan:

No Brands Available in Pakistan.