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Uses

Hypertension

Management of hypertension (alone or in combination with other classes of antihypertensive agents).

One of several preferred initial therapies in hypertensive patients with heart failure, postmyocardial infarction, high coronary disease risk, diabetes mellitus, chronic renal failure, and/or cerebrovascular disease.

Can be used as monotherapy for initial management of uncomplicated hypertension; however, thiazide diuretics are preferred by JNC 7.

Nephropathy

Stabilization or improvement of effective renal blood flow and glomerular filtration rate and reduction of proteinuria in hypertensive or normotensive patients with moderately impaired renal function, moderate to severe renal disease, or diabetic nephropathy.

CHF

Management of symptomatic CHF, usually in conjunction with cardiac glycosides, diuretics, and β-adrenergic blocking agents.

Left Ventricular Dysfunction after AMI

Treatment of clinically stable patients with left ventricular dysfunction (ejection fraction ≤40%) to improve survival following MI and to reduce the incidence of overt heart failure and subsequent hospitalizations for CHF.

Dosage and Administration

Administration

Oral Administration

Administer orally 1 hour before meals to maximize absorption.

Dosage

Pediatric Patients

Hypertension

Oral

Dosage has been reduced in proportion to body weight; titrate carefully. Some experts recommend an initial dosage of 0.9–1.5 mg/kg daily (given as 0.3–0.5 mg/kg 3 times daily). Increase dosage as necessary to a maximum of 6 mg/kg daily.

Adults

Hypertension

Oral

Initially, 25 mg 2 or 3 times daily. If BP is not adequately controlled after 1–2 weeks, increase dosage to 50 mg 2 or 3 times daily.

Lower initial dosages (e.g., 6.25 mg twice daily to 12.5 mg 3 times daily) may be effective in some patients, particularly those already receiving a diuretic. (See Hypotension under Cautions.)

Usual dosage: Manufacturers recommend 25–150 mg 2 or 3 times daily (usually not necessary to exceed 450 mg daily). JNC 7 recommends 25–100 mg daily given in 2 divided doses; JNC 7 recommends adding another drug, if needed, rather than continuing to increase dosage.

If combination therapy is initiated with captopril/hydrochlorothiazide fixed-combination preparation, captopril 25 mg and hydrochlorothiazide 15 mg daily initially; adjust dosage (generally at 6-week intervals) by administering each drug separately or by advancing the fixed-combination preparation.

Hypertensive Crises

Oral

25 mg 2 or 3 times daily, initiated promptly under close supervision with frequent monitoring of BP. May continue previous diuretic therapy, but discontinue other hypotensive agents. May increase dosage at intervals of ≤24 hours under continuous supervision until optimum BP response is attained or 450 mg daily is given. Adjunctive therapy with other hypotensive agents may be necessary.

Acute therapy (e.g., 12.5–25 mg, repeated once or twice if necessary at intervals of 30–60 minutes or longer) has been effective in adults with hypertensive urgencies† and emergencies†.

Nephropathy

Diabetic Nephropathy

Oral

25 mg 3 times daily.

CHF

Oral

Manufacturers recommend initial dosage of 25 mg 3 times daily; in patients with normal or low BP who may be volume- and/or salt-depleted, initial dosage of 6.25 or 12.5 mg 3 times daily. Increase dosage gradually to 50 mg 3 times daily; delay further dosage increases for ≥2 weeks to assess response.

Some clinicians recommend initial dosage of 6.25 or 12.5 mg 3 times daily, with gradual titration over several weeks to 50 mg 3 times daily, regardless of BP, salt/volume status, or concomitant diuretic therapy. Generally titrate dosage to prespecified target (i.e., ≥150 mg daily) or highest tolerated dosage rather than according to response.

Left Ventricular Dysfunction after AMI

Oral

Manufacturers recommend initiation of therapy ≥3 days post-MI with single dose of 6.25 mg, followed by 12.5 mg 3 times daily. Increase dosage over next several days to 25 mg 3 times daily and then over next several weeks (as tolerated) to 50 mg 3 times daily.

Some clinicians recommend initiation of therapy <24 hours post-MI with initial dose of 6.25 mg, followed by 12.5 mg 2 hours later, 25 mg 10–12 hours later, and then 50 mg twice daily as tolerated. Recommended maintenance dosage: 50 mg 3 times daily.

Prescribing Limits

Pediatric Patients

Hypertension

Oral

Maximum 6 mg/kg daily.

Adults

Hypertension

Oral

Maximum 450 mg daily.

Dosage of captopril/hydrochlorothiazide fixed-combination generally should not exceed captopril 150 mg and hydrochlorothiazide 50 mg daily.

CHF

Oral

Maximum dosage recommended by manufacturer and some experts is 450 mg daily. Other experts suggest maximum dosage of 50 mg 3 times daily.

Special Populations

Dosage in Renal Impairment

Manufacturers recommend initial dosage of <75 mg daily; increase dosage in small increments at 1- to 2-week intervals. After desired therapeutic effect has been attained, slowly reduce dosage to minimum effective level.

Patients with Cl_cr 10–50 mL/minute: 75% of usual captopril dosage or administration of usual dose every 12–18 hours suggested by some clinicians.

Cl_cr <10 mL/minute: 50% of usual dosage or administration of usual dose every 24 hours suggested by some clinicians.

Patients undergoing hemodialysis may require supplemental dose after dialysis.

Fixed-combination captopril/hydrochlorothiazide tablets usually are not recommended for patients with severe renal impairment.

Geriatric Patients

Hypertension

Usual adult dosages generally have been used; dosages of 6.25–12.5 mg 1–4 times daily used occasionally.

Volume-and/or Salt-Depleted Patients

Correct volume and/or salt depletion prior to initiation of therapy or initiate therapy under close medical supervision using lower initial dosage. (See Dosage: CHF, under Dosage and Administration.)