Tomlinson B
Department of Clinical Pharmacology, Chinese University of Hong Kong, Shatin, Hong Kong.
Drugs Aging. 1996 Oct;9(4):262-73. doi: 10.2165/00002512-199609040-00004.
Despite having lower levels of plasma renin activity than younger individuals, elderly patients with hypertension respond well to ACE inhibitors and the drugs have few adverse effects. Plasma concentrations of the active ACE inhibitor are generally higher in the elderly because of decreased renal clearance. These altered pharmacokinetics, combined with impairment of cardiovascular reflexes and the increasing prevalence of heart failure and renal impairment with age, render elderly patients more susceptible to first-dose hypotension. Although many studies have shown that standard dosages are well tolerated it is safer to use lower initial dosages of ACE inhibitors in elderly hypertensive patients because hypotensive reactions are not always predictable. The maintenance dosage may be determined more by the presence of renal disease or heart failure than by age per se. In elderly patients with heart failure, ACE inhibitors should be introduced even more cautiously, using low dosages and preferably under supervision. It may also be necessary to interrupt diuretic treatment for a few days to prevent severe hypotension. The ACE inhibitor dosage should then be titrated up to the maximum that is well tolerated, as this appears to offer the greatest benefit.
尽管老年高血压患者的血浆肾素活性水平低于年轻人，但他们对ACE抑制剂反应良好，且这些药物几乎没有不良反应。由于肾脏清除率降低，老年患者体内活性ACE抑制剂的血浆浓度通常较高。这些改变的药代动力学，加上心血管反射功能受损以及心力衰竭和肾功能损害的患病率随年龄增加，使老年患者更容易发生首剂低血压。尽管许多研究表明标准剂量耐受性良好，但在老年高血压患者中使用较低的ACE抑制剂初始剂量更安全，因为低血压反应并不总是可预测的。维持剂量可能更多地取决于肾脏疾病或心力衰竭的存在，而不是年龄本身。对于老年心力衰竭患者，应更谨慎地使用ACE抑制剂，采用低剂量，最好在监护下使用。可能还需要中断利尿治疗几天以防止严重低血压。然后应将ACE抑制剂剂量滴定至最大耐受剂量，因为这似乎能带来最大益处。
