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Carace plus (Lisinopril, hydrochlorothiazide)

How does it work?

Carace plus tablets contain two active ingredients, lisinopril and hydrochlorothiazide. Lisinopril is a type of medicine called an ACE inhibitor. Hydrochlorothiazide is a type of medicine called a thiazide diuretic. These are both medicines used to lower high blood pressure.

ACE inhibitors such as lisinopril work by blocking the action of a compound in the body called angiotensin converting enzyme (ACE). Normally ACE produces another compound called angiotensin II, as part of the body's natural control of blood pressure. Angiotensin II causes blood vessels to constrict and narrow, which increases the pressure within the blood vessels.

As lisinopril blocks the action of ACE, it reduces the production of angiotensin II. This means that the blood vessels are allowed to relax and widen. The overall effect of this is a drop in blood pressure, hence lisinopril can be used to lower high blood pressure.

Diuretics such as hydrochlorothiazide are sometimes referred to as ‘water tablets’. They remove excess fluid from the body by increasing the production of urine.

Diuretics act in the kidneys. They work by causing the kidneys to increase the amount of salts, such as potassium and sodium, that are filtered out of the blood and into the urine. When these salts are filtered out of the blood by the kidneys, they draw water alongside them. As diuretics increase the removal of salts from the blood, they also cause more water to be drawn out of the blood and into the urine.

Removing water from the blood decreases the volume of fluid circulating through the blood vessels. This subsequently decreases the pressure within the blood vessels. Diuretics can therefore be used to lower high blood pressure.

The combination of lisinopril with hydrochlorothiazide is used when blood pressure has not been lowered sufficiently using lisinopril on its own.

What is it used for?

  • Mild to moderate high blood pressure (hypertension).

Warning!

  • Diuretics cause your kidneys to produce more urine, so you may prefer to take this medicine in the morning rather than before going to bed. This will avoid disturbing your sleep with the need to get up in the night to visit the toilet. Seek further advice from your doctor or pharmacist.
  • This medicine may make you feel dizzy as a result of the drop in your blood pressure. If you feel dizzy this can usually be relieved by lying down until the symptoms pass. If affected you should avoid performing potentially hazardous tasks such as driving or operating machinary. If you frequently feel dizzy you should let your doctor know, as your dose of this medicine may need reducing.
  • Alcohol may enhance the blood pressure lowering effect of this medicine, which can increase dizziness and may increase the risk of fainting.
  • ACE inhibitors can sometimes cause an allergic reaction called angioedema. Stop taking this medicine and consult your doctor immediately if you experience difficulty breathing or swallowing, or swelling of your face, lips, tongue, throat, hands, feet or ankles while taking this medicine. This type of allergic reaction has been reported more frequently in people of Afro-Caribbean origin.
  • Your blood pressure, kidney function and the amount of potassium in your blood should be regularly monitored while you are taking this medicine.
  • If you need a test to assess the functioning of your parathyroid gland your doctor may ask you to stop taking this medicine beforehand, as it may interfere with the test results.

Use with caution in

  • Elderly people.
  • Decreased liver function.
  • Decreased kidney function.
  • Narrowing of the arteries that supply blood to the kidneys (renal artery stenosis).
  • People with low fluid volume or salt levels in the body, eg due to diuretic therapy, low-sodium diet, diarrhoea or vomiting.
  • People taking other medicines for high blood pressure, particularly diuretics (see end of factsheet).
  • People with hardening of the arteries (athersclerosis), eg in the heart (cardiovascular disease), brain (cerebrovascular disease) or legs (peripheral vascular disease).
  • Heart failure.
  • Narrowing of the main artery of the body (aortic stenosis).
  • Heart disease characterised by thickening of the internal heart muscle and a blockage inside the heart (hypertrophic obstructive cardiomyopathy).
  • Diabetes.
  • History of gout.
  • Diseases affecting connective tissue, eg scleroderma, systemic lupus erythematosus or rheumatoid arthritis (collagen vascular diseases).
  • People receiving therapy to remove certain types of fat from the blood using a machine (LDL apheresis).
  • People undergoing therapy to decrease allergy to bee or wasp stings (desensitisation).

Not to be used in

  • Allergy to medicines from the sulphonamide group, eg the antibiotic sulfamethoxazole.
  • History of swelling of the lips, face or tongue (angioedema) with no known cause, or caused by previous use of an ACE inhibitor medicine.
  • Hereditary angioedema (angioneurotic oedema).
  • People whose kidneys are not producing urine (anuria).
  • People with kidney failure who need dialysis.
  • Pregnancy.
  • Breastfeeding.
  • This medicine is not recommended for children.

This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy.If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.

Pregnancy and breastfeeding

Certain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safely used in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine.

  • This medicine should not be used in pregnancy, particularly in the second and third trimesters, as it may be harmful to the unborn baby. Seek further medical advice from your doctor. If you get pregnant while taking this medicine, stop taking it and consult your doctor immediately.
  • It is not known if lisinopril passes into breast milk, however hydrochlorothiazide does pass into breast milk. As it could have harmful effects on a nursing infant, this medicine should not be used during breastfeeding. You may be advised to bottlefeed your baby if you need to take this medicine. Seek medical advice from your doctor.

Side effects

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Just because a side effect is stated here does not mean that all people using this medicine will experience that or any side effect.

  • Dizziness.
  • Headache.
  • Fatigue.
  • Dry cough.
  • Low blood pressure (hypotension).
  • Disturbances of the gut such as diarrhoea, constipation, nausea, vomiting or abdominal pain.
  • Inflammation of the pancreas (pancreatitis).
  • Feeling of weakness (asthenia).
  • Rash.
  • Dry mouth.
  • Chest pain (angina).
  • Awareness of your heart beat (palpitations).
  • Pins and needles sensations (paraesthesia).
  • Impotence.
  • Alteration in taste.
  • Increased or decreased level of potassium in the blood (hyperkalaemia or hypokalaemia).
  • Increased level of uric acid in the blood (hyperuricaemia), this may cause kidney problems or gout.
  • Severe swelling of lips, face, tongue or throat (angioedema - see warning above) .
  • Problems with kidney function.
  • Disturbances in the normal levels of blood cells in the blood (tell you doctor if you get a sore throat, mouth ulcers, high temperature (fever), or feel tired or generally unwell while taking this medicine).
  • Problems with liver function, including jaundice or hepatitis (consult your doctor promptly if you develop unexplained itching, yellowing of the skin or eyes, unusually dark urine, nausea and vomiting, abdominal pains, loss of appetite or flu-like symptoms while taking this medicine).

The side effects listed above may not include all of the side effects reported by the medicine's manufacturer.For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist.

How can this medicine affect other medicines?

It is important to tell your doctor or pharmacist what medicines you are already taking, including those bought without a prescription and herbal medicines, before you start treatment with this medicine. Similarly, check with your doctor or pharmacist before taking any new medicines while taking this one, to ensure that the combination is safe.

This medicine will have an additive effect with other medicines that decrease blood pressure, particularly other medicines used to treat high blood pressure (antihypertensives). In people taking antihypertensive medicines it may cause a large drop in blood pressure with the first dose or after any dose increases, particularly in people taking diuretic medicines such as furosemide. This may cause dizziness, which can usually be relieved by lying down until the symptoms pass. If you frequently feel dizzy while taking this medicine in combination with other blood pressure lowering medicines you should let your doctor know, as your doses may need adjusting. Other medicines that decrease blood pressure include the following:

  • other ACE inhibitors, eg enalapril
  • aldesleukin
  • alpha-blockers such as prazosin
  • alprostadil
  • angiotensin II receptor antagonists such as losartan
  • antipsychotics
  • benzodiazepines, eg temazepam, diazepam
  • baclofen
  • beta-blockers such as propranolol
  • calcium-channel blockers such as verapamil, nifedipine
  • clonidine
  • diazoxide
  • diuretics, eg furosemide, bendroflumethiazide
  • dopamine agonists, eg bromocriptine, apomorphine
  • hydralazine
  • levodopa
  • MAOI antidepressants, eg phenelzine
  • methyldopa
  • minoxidil
  • moxonidine
  • moxisylyte
  • nicorandil
  • nitrates, eg glyceryl trinitrate
  • tizanidine.

Non-steroidal anti-inflammatory drugs (NSAIDs, eg indometacin, aspirin, diclofenac, ibuprofen) may reduce the blood pressure lowering effect of this medicine, and may increase the risk of a decline in kidney function. You should avoid taking this type of painkiller unless recommended by your doctor.

There may be a risk of raised potassium levels in the blood (hyperkalaemia) if any of the following medicines are taken with lisinopril, hence these are not normally recommended for use in combination with this medicine. If you are taking any of the following with this medicine you should have regular blood tests to monitor the amount of potassium in your blood:

  • angiotensin II receptor antagonists, eg losartan
  • ciclosporin
  • drospirenone
  • epoetin (this may also oppose the blood pressure lowering effect of lisinopril)
  • heparin
  • potassium-containing salt substitutes (eg Lo-Salt)
  • potassium salts, eg potassium citrate for cystitis
  • potassium-sparing diuretics (eg spironolactone, triamterene, amiloride)
  • potassium supplements.

There may be a risk that the amount of potassium in the blood could fall too low (hypokalaemia) if any of the following medicines are taken in combination with this medicine:

  • amphotericin
  • corticosteroids
  • carbenoxolone
  • beta-agonist bronchodilators such as salbutamol
  • stimulant laxatives, eg bisacodyl.

This medicine may increase the blood level of the medicine lithium and for this reason, it is not normally recommended for people taking lithium. People taking this medicine in combination with lithium should have the level of lithium in their blood closely monitored.

Lisinopril may possibly enhance the blood sugar lowering effect of insulin and oral antidiabetic medicines, and so could increase the risk of low blood sugar (hypoglycaemia). On the other hand, hydrochlorothiazide may increase blood sugar levels. People with diabetes should therefore carefully monitor their blood sugar while taking this medicine, particularly in the first few weeks of treatment.

There may be an increased risk of a drop in the normal numbers of white blood cells in the blood if this medicine is taken in combination with any of the following medicines:

  • allopurinol
  • azathioprine
  • immunosuppressant therapy
  • procainamide.

If you are taking any of these in combination with this medicine, you should have regular blood tests to monitor the levels of your blood cells, particularly if you also have any kidney problems or diseases affecting connective tissue, eg scleroderma, systemic lupus erythematosus or rheumatoid arthritis (collagen vascular diseases). Tell your doctor if you experience any signs of infection, such as fever, sore throat or mouth ulcers, as these could be signs of problems with your white blood cells.

Other medicines containing the same active ingredients

Zestoretic