Angiotensin-converting enzyme inhibitors (drug interactions)
Angiotensin-converting enzyme (ACE) inhibitors are medications designed to block the conversion of angiotensin, a naturally occurring substance, into a more active form, thereby helping to manage conditions like hypertension and heart failure. However, they can interact with various substances, leading to significant health implications. Noteworthy interactions include L-arginine, which may lower blood pressure excessively when combined with ACE inhibitors, and licorice, which can counteract the effects of these medications by causing sodium retention and raising blood pressure. Additionally, potassium intake must be closely monitored, as ACE inhibitors can lead to elevated potassium levels, a condition known as hyperkalemia, which can be dangerous.
St. John's wort and dong quai may increase sensitivity to the sun, potentially heightening risks when taken alongside ACE inhibitors. Conversely, iron supplements can alleviate common side effects like dry cough but may interfere with the absorption of certain ACE inhibitors if not separated by a few hours. Zinc deficiency is another concern, as ACE inhibitors may deplete zinc levels in the body, leading to side effects. Lastly, the use of non-steroidal anti-inflammatory drugs (NSAIDs) can pose risks, including kidney injury and diminished effectiveness of ACE inhibitors. Understanding these interactions is crucial for safe and effective management of treatments involving ACE inhibitors.
Angiotensin-converting enzyme inhibitors (drug interactions)
DEFINITION: Medications that block the conversion of a naturally occurring substance, angiotensin, to a more active form.
INTERACTIONS: Arginine, dong quai, iron, licorice, potassium, St. John’s wort, zinc, non-steroidal anti-inflammatory drugs (NSAIDs)
DRUGS IN THIS FAMILY: Benazepril hydrochloride (Lotensin, Lotrel), captopril (Capoten), enalapril maleate (Lexxel, Teczem, Vaseretic, Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Prinzide, Zestoretic, Zestril), moexipril hydrochloride (Uniretic, Univasc), quinapril hydrochloride (Accupril), ramipril (Altace), trandolapril (Mavik, Tarka), perindopril erbumine (Aceon)
L-arginine
Effect: Possible Harmful Interaction
L-arginine is an amino acid that has been used to improve immunity in hospitalized persons and many other conditions. Based on experience with intravenous arginine, it is possible that the use of high-dose oral arginine might alter potassium levels in the body, especially in people with severe liver disease. This is a potential concern for persons who take ACE inhibitors. Taking L-arginine with ACE inhibitors may contribute to low blood pressure and increase vasodilation. However, in patients with nephropathy, adding L-arginine to their ACE inhibitor regimens may improve outcomes.
Licorice
Effect: Possible Harmful Interaction
Licorice root, a member of the pea family, has been used since ancient times as both food and medicine. Whole licorice (Glycyrrhiza glabra or G. uralensis) can cause sodium retention and increase blood pressure, thus counteracting the intended effects of ACE inhibitors. The combinations may also increase side effects or lead to a dangerous potassium level, called hyperkalemia. An often unrecognized source of licorice is chewing tobacco. A special form of licorice known as DGL (deglycyrrhizinated licorice) is a deliberately altered form of the herb that should not cause these problems.
Potassium
Effect: Possible Harmful Interaction
ACE inhibitors cause the body to retain more potassium than usual because they limit aldosterone secretion, which causes excess potassium to be excreted in urine. This can raise blood levels of potassium too high, a condition called hyperkalemia, which can be dangerous. The symptoms could include irregular heart rhythm, muscle weakness, nausea, vomiting, irritability, and diarrhea, depending on how high a person's potassium levels are. Persons taking any ACE inhibitors should not take potassium supplements except on medical advice.
Because ingesting more potassium makes the problem worse, it is important to be aware of the various sources of extra potassium. Besides potassium supplements, sources include high-potassium diets, salt substitutes containing potassium, and potassium-sparing diuretics (diuretics that cause the body to retain potassium).
Dong Quai, St. John’s wort
Effect: Possible Harmful Interaction
St. John’s wort (Hypericum perforatum) is primarily used to treat mild to moderate depression. The herb dong quai (Angelica sinensis), sometimes called female ginseng, is often recommended for menstrual disorders such as dysmenorrhea, premenstrual syndrome, and irregular menstruation.
ACE inhibitors have been reported to cause increased sensitivity to the sun, amplifying the risk of sunburn or skin rash. Because St. John’s wort and dong quai may also cause this problem, taking these herbal supplements during treatment with ACE inhibitors might add to this risk. It may be a good idea to wear sunscreen or protective clothing during sun exposure if also taking one of these herbs while using an ACE inhibitor.
Iron
Effect: Possible Benefits and Risks
Persons taking ACE inhibitors frequently develop a dry cough as a side effect. One study suggests that iron supplementation can alleviate this symptom. In this four-week, double-blind, placebo-controlled trial of nineteen persons, using iron as ferrous sulfate significantly reduced cough symptoms compared with placebo.
However, it is unhealthy to get too much iron. For this reason, it is recommended that one seek medical advice before starting iron supplements. However, iron supplements can interfere with the absorption of captopril and perhaps other ACE inhibitors. Iron appears to bind with captopril, resulting in a compound that the body cannot absorb. This also impairs iron absorption. To minimize any potential problems, one should take iron supplements and ACE inhibitors two to three hours apart.
Zinc
Effect: Supplementation Possibly Helpful
ACE inhibitors may cause zinc depletion. The ACE inhibitors captopril and enalapril attach to the trace mineral zinc. Because zinc in this bound form cannot replace the zinc that the body uses to meet its normal needs, a gradual loss of zinc from body tissues may result. Continued drug therapy could lead to zinc deficiency.
It has been suggested, though not proven, that zinc deficiency might account for some of the side effects seen with ACE inhibitors. These side effects include taste disturbances, poor appetite, and skin numbness or tingling.
Whether zinc supplementation will prevent ACE inhibitor-induced zinc deficiency has not been examined, so it seems that taking extra zinc could help. Generally, zinc supplements should also contain copper to prevent zinc-induced copper deficiency.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Effect: Possible Harmful Interaction
NSAIDs are commonly used for headaches, minor injuries, arthritis, cases of cold or flu, and swelling. They include ibuprofen (Advil, Motrin) and naproxen (Aleve), diclofenac (Flector), and celecoxib (Celebrex). When taken with ACE inhibitors, NSAIDs can cause kidney failure, or a drug interaction called a triple whammy (TW). A TW is a life-threatening interaction that may lead to acute kidney injury. In a more minor interaction, NSAIDs may decrease the effectiveness of the ACE inhibitors.
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