ACCURETIC
Clinical safety rating: caution
Comprehensive clinical and safety monograph for ACCURETIC (ACCURETIC).
ACCURETIC is a combination of quinapril, an angiotensin-converting enzyme (ACE) inhibitor, and hydrochlorothiazide, a thiazide diuretic. Quinapril inhibits ACE, preventing conversion of angiotensin I to angiotensin II, reducing vasoconstriction and aldosterone secretion. Hydrochlorothiazide inhibits sodium reabsorption in the distal convoluted tubule, increasing diuresis and lowering blood pressure.
| Metabolism | Quinapril is hydrolyzed primarily in the liver to its active metabolite quinaprilat. Hydrochlorothiazide is not metabolized; it is excreted unchanged in urine. |
| Excretion | Renal: approximately 90% (60% unchanged, 30% as metabolites). Fecal/biliary: <10%. |
| Half-life | Quinapril: 0.8 hours; Quinaprilat (active): 2 hours in young healthy adults, prolonged to 3-4 hours in elderly or renal impairment. |
| Protein binding | Quinapril: 97% bound to plasma proteins (mainly albumin). Quinaprilat: 95% bound. |
| Volume of Distribution | Quinapril: 1.6 L/kg; Quinaprilat: 1.8 L/kg. Indicates extensive tissue distribution. |
| Bioavailability | Oral: at least 60% for quinapril (rapidly converted to active metabolite quinaprilat). |
| Onset of Action | Oral: 1 hour for antihypertensive effect. |
| Duration of Action | 24 hours with once-daily dosing for blood pressure control. |
One tablet orally once daily. Initial dose is 20 mg quinapril/12.5 mg hydrochlorothiazide, titrated to maximum 20 mg quinapril/25 mg hydrochlorothiazide.
| Dosage form | TABLET |
| Renal impairment | CrCl 30-60 mL/min: initial dose 10 mg quinapril/12.5 mg hydrochlorothiazide once daily; maximum 20 mg quinapril/12.5 mg hydrochlorothiazide. CrCl <30 mL/min: not recommended. |
| Liver impairment | Child-Pugh A or B: use with caution, monitor for hypotension and electrolyte imbalance; no specific dose adjustment guidelines. Child-Pugh C: contraindicated. |
| Pediatric use | Safety and efficacy not established; use not recommended. |
| Geriatric use | Initiate at low end of dosing range, 10 mg quinapril/12.5 mg hydrochlorothiazide once daily; monitor renal function and electrolytes closely due to age-related decreased renal function and increased risk of hypotension. |
| 1st trimester | Consult provider |
| 2nd trimester | Consult provider |
| 3rd trimester | Consult provider |
Clinical note
Comprehensive clinical and safety monograph for ACCURETIC (ACCURETIC).
| Breastfeeding | Excretion into human milk unknown, but risk of serious adverse reactions in nursing infants, including hypotension and renal impairment. M/P ratio not available. Decision to discontinue nursing or drug based on importance of drug to mother. |
| Teratogenic Risk | First trimester: Increased risk of congenital malformations, particularly cardiovascular and central nervous system defects, based on ACE inhibitor class effects. Second and third trimesters: Fetal and neonatal morbidity and mortality, including oligohydramnios, renal dysfunction, skull ossification defects, hypotension, and anuria. |
■ FDA Black Box Warning
Fetal Toxicity: Drugs acting directly on the renin-angiotensin system (including quinapril) can cause injury and death to the developing fetus. Discontinue as soon as pregnancy is detected.
| Serious Effects |
["Pregnancy (absolute)","History of angioedema related to ACE inhibitor therapy","Anuria (due to hydrochlorothiazide)","Hypersensitivity to quinapril, hydrochlorothiazide, or sulfonamide-derived drugs","Concomitant use with aliskiren in patients with diabetes or renal impairment"]
| Precautions | ["Angioedema (risk higher in black patients)","Hypotension especially in volume-depleted patients","Renal impairment (monitor renal function)","Hyperkalemia (monitor serum potassium)","Sulfonamide allergy (due to hydrochlorothiazide component)","Exacerbation of gout","Electrolyte imbalances (hypokalemia, hyponatremia)"] |
| Food/Dietary | Avoid potassium-rich foods (bananas, oranges, leafy greens) and salt substitutes containing potassium. Limit sodium intake for blood pressure control. High-alcohol consumption may increase hypotensive effects. Grapefruit juice may alter drug metabolism; avoid large quantities. |
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| Fetal Monitoring | Monitor maternal blood pressure, renal function (serum creatinine, BUN), and electrolytes (especially potassium). Serial fetal ultrasound for oligohydramnios and fetal growth restriction. Monitor neonatal renal function and blood pressure if exposure in utero. |
| Fertility Effects | No human studies. In animal studies, ACE inhibitors have been associated with decreased fertility and reduced pregnancy rates. Effects attributed to effects on the renin-angiotensin system. |
| Clinical Pearls | ACCURETIC is a fixed-dose combination of quinapril (ACE inhibitor) and hydrochlorothiazide (thiazide diuretic). Monitor serum potassium and renal function within 2 weeks of initiation or dose adjustment due to risk of hyperkalemia from quinapril and hypokalemia from HCTZ. Assess for angioedema (swelling of lips, face, throat) and hypotension, especially in volume-depleted patients. Avoid use in pregnancy (category D); discontinue if pregnancy is detected. Use with caution in renal artery stenosis, patients on NSAIDs or potassium supplements, and those with gout (HCTZ may increase uric acid). |
| Patient Advice | Take exactly as prescribed, usually once daily; do not skip or double doses. · Avoid salt substitutes containing potassium without consulting your doctor. · Report any swelling of the face, lips, or throat, or difficulty breathing immediately. · May cause dizziness or lightheadedness, especially when standing up quickly; avoid driving until you know how this medication affects you. · Use reliable contraception and tell your doctor if you become pregnant or plan to become pregnant. · Limit alcohol intake as it can worsen side effects and increase blood pressure. · Stay hydrated but avoid excessive intake of potassium-rich foods (bananas, oranges) unless instructed. · Notify your doctor if you develop muscle cramps, weakness, irregular heartbeat, or decreased urination. · Do not stop taking this medication abruptly without consulting your doctor. |