What medications and supplements interact with Angiotensin-Converting Enzyme (ACE) inhibitors, particularly in geriatric patients with hypertension, heart failure, or diabetes?

ACE Inhibitor Drug and Supplement Interactions

Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients taking ACE inhibitors, as they block the favorable effects and enhance adverse effects, particularly increasing the risk of acute renal failure and attenuating antihypertensive efficacy. 1

Critical Interactions to Avoid

Potassium-Elevating Agents (Highest Risk)

• Potassium-sparing diuretics (spironolactone, eplerenone, amiloride, triamterene) combined with ACE inhibitors create substantial hyperkalemia risk, especially in patients with renal insufficiency (GFR <45 mL/min). 1, 2 Spironolactone doses should not exceed 25 mg daily when combined with ACE inhibitors, and the combination requires serum potassium monitoring within 1 week of initiation, then at 1,4,8, and 12 weeks. 1, 2

• Potassium supplements and salt substitutes (including those used in DASH diets) create additive hyperkalemia risk and should be discontinued when starting ACE inhibitors unless there is documented refractory hypokalemia. 2, 3 ACE inhibitors typically eliminate the need for long-term potassium supplementation. 1

• Angiotensin receptor blockers (ARBs) should never be combined with ACE inhibitors, as this dual RAAS blockade substantially increases hyperkalemia and hypotension risk without additional cardiovascular benefit. 2, 4

• Direct renin inhibitors (aliskiren) must be avoided with ACE inhibitors due to excessive hyperkalemia risk, particularly in patients with chronic kidney disease. 2

NSAIDs and Related Agents

• All NSAIDs (ibuprofen, naproxen, indomethacin, COX-2 inhibitors) block the favorable effects of ACE inhibitors by inhibiting prostaglandin synthesis, attenuate antihypertensive efficacy, and increase the risk of acute renal failure when renal function becomes dependent on angiotensin II and prostaglandins. 1, 2, 3 This interaction is particularly dangerous in volume-depleted patients or those with pre-existing renal insufficiency. 3

• Interestingly, indomethacin attenuates the antihypertensive effects of captopril, but this interaction has not been consistently demonstrated with enalapril or lisinopril. 5

Diuretic Interactions

• Thiazide and loop diuretics in sodium/volume-depleted patients can cause excessive hypotension when ACE inhibitors are added. 3, 6 However, fluid retention can minimize the symptomatic benefits of ACE inhibition, requiring careful balance of diuretic dosing. 1

• The hypotensive effects of ACE inhibition may attenuate the natriuretic response to diuretics in hemodynamically unstable patients, potentially requiring temporary interruption of the ACE inhibitor until clinical status stabilizes. 1

Controversial Interaction: Aspirin

The aspirin-ACE inhibitor interaction remains controversial, with conflicting evidence about whether aspirin diminishes ACE inhibitor benefits in heart failure patients. 1

• Retrospective analyses suggest aspirin might interfere with ACE inhibitor benefits by inhibiting kinin-mediated prostaglandin synthesis, with composite risk reduction of 20% for patients taking aspirin versus 29% for those not taking aspirin (difference not statistically significant). 1

• Short-term hemodynamic studies show aspirin can attenuate the hemodynamic actions of ACE inhibitors in heart failure, an effect not seen with clopidogrel. 1

• Despite theoretical concerns, large systematic overviews of 22,060 patients from 6 randomized trials showed ACE inhibitors remained significantly beneficial in patients with and without aspirin therapy. 1

• Clinical approach: Many physicians prescribe aspirin and ACE inhibitors together when there is a clear indication for aspirin. 1 Alternative physicians consider clopidogrel instead, which does not interact with ACE inhibitors, though clopidogrel lacks indication for primary prevention of ischemic events. 1

Other Significant Interactions

Medications Requiring Monitoring

• Lithium: ACE inhibitors may induce lithium toxicity by decreasing lithium clearance, requiring close monitoring of lithium levels. 3, 7

• Digoxin: Captopril specifically decreases digoxin clearance from plasma in patients with heart failure, though this interaction is not universal to all ACE inhibitors. 5

• Oral hypoglycemic agents: ACE inhibitors may enhance the effects of oral hypoglycemic agents, requiring glucose monitoring. 6

Supplements and Herbal Products

• Herbal supplements including alfalfa, dandelion, and hawthorn berry can increase hyperkalemia risk when combined with ACE inhibitors. 2

• Amino acids (aminocaproic acid, arginine, lysine) in high doses can cause hyperkalemia, especially when combined with ACE inhibitors. 2

Monitoring Requirements for High-Risk Combinations

When ACE inhibitors must be combined with interacting medications, check serum potassium and creatinine within 1-2 weeks of initiation, then periodically thereafter, especially in patients with pre-existing hypotension, hyponatremia, diabetes mellitus, or azotemia. 1, 2

• Potassium >5.5 mEq/L should trigger discontinuation or dose reduction of the offending agent. 2

• An increase in serum creatinine of 10-20% is acceptable and does not require ACE inhibitor suspension. 4

• Creatinine rises >20% warrant immediate discontinuation. 4

Special Populations

In geriatric patients, polypharmacy is common (39% take ≥5 medications), making drug-drug interactions more likely. 1 The prescribing cascade—where adverse effects of one medication are treated as new conditions requiring additional medications—is particularly problematic with ACE inhibitors. 1 For example, NSAID-induced hypertension may lead to inappropriate ACE inhibitor escalation rather than NSAID discontinuation. 1