Ace%252525252520inhibitors

# ACE Inhibitors ## Overview Angiotensin-Converting Enzyme (ACE) inhibitors block the conversion of angiotensin I to angiotensin II, leading to decreased systemic vascular resistance and reduced aldosterone secretion. They are primarily used for cardiovascular and renal protection. Common agents include Lisinopril, Enalapril, and Ramipril. ## Primary Indications * Hypertension * Heart failure (HFrEF) * Post-myocardial infarction * Diabetic nephropathy (proteinuria reduction) * Chronic Kidney Disease (CKD) ## Adult Dosing * **Lisinopril:** Hypertension: 10 mg once daily; max 40 mg/day. Heart failure: 2.5–5 mg once daily; target 20–40 mg/day. * **Enalapril:** Hypertension: 5 mg twice daily; max 40 mg/day. Heart failure: 2.5 mg twice daily; target 10–20 mg twice daily. * **Ramipril:** Hypertension: 2.5 mg once daily; max 20 mg/day. Heart failure/Post-MI: 1.25–2.5 mg twice daily; target 5 mg twice daily. * *Note: Specific initiation and titration schedules depend on institutional protocols and clinical stability.* ## Pediatric Dosing * **Lisinopril:** Hypertension (>6 years): 0.07 mg/kg once daily; max 0.61 mg/kg or 40 mg daily. * **Enalapril:** Hypertension (1 month–16 years): 0.08 mg/kg once daily; max 5 mg daily, titrated up to 0.58 mg/kg (max 40 mg). * *Note: Pediatric dosing requires weight-based calculations and expert consultation; use lower starting doses in neonates.* ## Dose Adjustments * **Renal Impairment:** Reduce initial doses and frequency for CrCl <30 mL/min. Monitor serum creatinine and potassium closely. * **Hepatic Impairment:** Use caution; may require lower starting doses for agents requiring bioactivation (e.g., Enalapril). * **Volume Deplecion:** Reduce or hold diuretics 2–3 days before therapy initiation to prevent profound hypotension. ## Contraindications * History of angioedema (hereditary or ACE-inhibitor induced). * Pregnancy (Category D: causes fetal morbidity/mortality; discontinue immediately if pregnancy is detected). * Use with aliskiren in patients with diabetes. * Concomitant use with neprilysin inhibitors (e.g., sacubitril) within 36 hours. ## Adverse Effects * **Common:** Dry cough (due to bradykinin accumulation), hyperkalemia, headache, dizziness, fatigue. * **Serious:** Angioedema (highest risk in Black patients), acute kidney injury, severe hypotension, agranulocytosis (rare). ## Key Drug Interactions * **Potassium-sparing diuretics/Supplements:** Increased risk of severe hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of acute renal failure. * **Lithium:** May decrease lithium excretion, increasing toxicity risk. * **Sacubitril:** Absolute contraindication due to risk of angioedema. ## Monitoring * **Baseline:** Serum creatinine, BUN, potassium, baseline blood pressure. * **Follow-up:** Check electrolytes and renal function 1–2 weeks after initiation or dose changes. * **Long-term:** Persistent cough, blood pressure, and renal function every 3–6 months. ## Clinical Pearls * The dry cough associated with ACE inhibitors generally resolves within 1–4 weeks of discontinuation. If intolerable, switch to an Angiotensin II Receptor Blocker (ARB). * An acute rise in serum creatinine (up to 30%) is often acceptable upon initiation; monitor to ensure it plateaus and does not continue to rise. * Always assess for bilateral renal artery stenosis before initiating, as ACE inhibitors can precipitate renal failure in these patients. *** **Disclaimer:** This information is for educational purposes only. Clinical protocols may vary by institution. Always verify current prescribing information, contraindications, and patient-specific factors (including weight and renal function) using official drug monographs or clinical decision support tools before prescribing or administering medication.