Ace%2525252525252520inhibitors

# ACE Inhibitors ## Overview Angiotensin-Converting Enzyme (ACE) inhibitors (e.g., lisinopril, enalapril, ramipril) block the conversion of angiotensin I to angiotensin II, leading to decreased systemic vascular resistance and reduced aldosterone secretion. ## Primary Indications * Hypertension * Heart failure (reduced ejection fraction) * Post-myocardial infarction * Chronic kidney disease (diabetic nephropathy/proteinuria management) ## Adult Dosing * **Lisinopril:** Hypertension start 10 mg daily (max 40 mg). Heart failure start 2.5–5 mg daily (max 40 mg). * **Enalapril:** Hypertension start 5 mg daily (max 40 mg). Heart failure start 2.5 mg twice daily (max 20 mg twice daily). * **Ramipril:** Hypertension start 2.5 mg daily (max 20 mg). Post-MI/High cardiovascular risk start 2.5 mg twice daily (max 5 mg twice daily). * *Note: Dosing varies significantly by agent; always verify the specific molecule’s package insert.* ## Pediatric Dosing * **Lisinopril:** ≥6 years: 0.07 mg/kg once daily (max 5 mg). Titrate based on BP response (max 0.61 mg/kg or 40 mg/day). * **Enalapril:** Neonates/infants: 0.01 mg/kg once daily. Children: 0.08 mg/kg once daily (max 5 mg). * *Note: Pediatric dosing is highly weight-based and specific to indication; consult specialized resources (e.g., Harriet Lane Handbook).* ## Dose Adjustments * **Renal Impairment:** Reduce initial dose and monitor creatinine closely if CrCl <30 mL/min. * **Hepatic Impairment:** Use caution with prodrugs (e.g., enalapril, ramipril) that require hepatic esterification unless otherwise indicated. * **Volume Depleted Patients:** Start at lower doses to prevent profound hypotension. ## Contraindications * History of angioedema (hereditary or ACE-inhibitor induced). * Pregnancy (Category D: fetal toxicity/teratogenicity). * Concomitant use with aliskiren in patients with diabetes mellitus. * Concomitant use with or within 36 hours of sacubitril/valsartan (risk of angioedema). ## Adverse Effects * **Common:** Dry, persistent cough (due to bradykinin accumulation), hyperkalemia, headache, dizziness. * **Serious:** Angioedema (life-threatening, can occur years after initiation), acute kidney injury, hypotension, neutropenia (rare). ## Key Drug Interactions * **Potassium-sparing diuretics/K+ supplements:** High risk of severe hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of acute renal failure by inhibiting vasodilatory prostaglandins. * **Lithium:** May reduce lithium excretion, leading to toxicity. ## Monitoring * **Baseline/Follow-up:** Serum creatinine, blood urea nitrogen (BUN), and potassium 1–2 weeks after initiation or dosage change. * **Blood Pressure:** Monitor regularly for efficacy and symptomatic hypotension. * **Angioedema:** Educate patient to seek immediate care if swelling of the face, tongue, or lips occurs. ## Clinical Pearls * **Cough:** If a patient is intolerant of ACE inhibitors due to cough, switch to an Angiotensin II Receptor Blocker (ARB). * **First-Dose Hypotension:** Common in heart failure or volume-depleted patients; start low and administer first dose or titrations at bedtime if possible. * **Renal Protection:** ACE inhibitors are standard of care for proteinuric renal disease, despite an initial expected rise in creatinine (up to 30% is generally acceptable). *** **Disclaimer:** This information is for educational purposes. Dosing and clinical guidelines may vary based on institutional protocols and individual patient factors. Always consult the most recent FDA-approved package insert or a verified clinical database (e.g., Lexicomp/UpToDate) before prescribing.