Ace%25252525252525252520inhibitors

# ACE Inhibitors ## Overview Angiotensin-Converting Enzyme (ACE) inhibitors block the conversion of angiotensin I to angiotensin II, leading to decreased systemic vascular resistance and suppressed aldosterone secretion. They are foundational in managing hypertension, heart failure, and diabetic nephropathy. ## Primary Indications * Hypertension * Heart failure (HFrEF) * Post-myocardial infarction (MI) * Chronic kidney disease (CKD) with proteinuria (e.g., diabetic nephropathy) ## Adult Dosing *Dosing varies by specific agent (e.g., Lisinopril, Ramipril, Enalapril). Example: Lisinopril (Prinivil, Zestril).* * **Hypertension:** Start 10 mg QD; usual maintenance 20–40 mg QD (Max 80 mg). * **Heart Failure:** Start 2.5–5 mg QD; titrate to target 20–40 mg QD. * **Post-MI:** Start 5 mg within 24 hours; target 10 mg QD. ## Pediatric Dosing *Dosing requires pediatric-specific references (e.g., Harriet Lane Handbook) and varies by weight/age.* * **Lisinopril:** Recommended for children ≥6 years. Initial dose 0.07 mg/kg (up to 5 mg) QD; max 0.6 mg/kg (up to 40 mg) QD. * **Enalapril:** Initial dose 0.08 mg/kg QD; may titrate up to 0.58 mg/kg QD. ## Dose Adjustments * **Renal Impairment:** Reduce initial dose or increase dosing interval if eGFR <30 mL/min/1.73m². * **Hepatic Impairment:** Use caution; dosage reduction may be necessary for agents requiring hepatic conversion (e.g., Enalapril converted to Enalaprilat). ## Contraindications * History of angioedema (hereditary or ACE-inhibitor induced). * Concurrent use with aliskiren in patients with diabetes. * Pregnancy (Category D: causes fetal injury and death). * Bilateral renal artery stenosis. ## Adverse Effects * **Common:** Dry, hacking cough (due to bradykinin accumulation). * **Serious:** Angioedema, hyperkalemia, acute kidney injury (AKI), symptomatic hypotension. ## Key Drug Interactions * **Potassium-sparing diuretics/supplements:** High risk of severe hyperkalemia. * **NSAIDs:** Increased risk of renal failure and reduced antihypertensive efficacy. * **Lithium:** May increase lithium levels via reduced renal excretion. * **ARBs/Direct Renin Inhibitors:** Dual RAAS blockade increases risks of AKI and hyperkalemia without significant mortality benefit. ## Monitoring * **Baseline/Follow-up:** Serum creatinine and electrolytes (potassium) should be checked 1–2 weeks after initiation or dose escalation. * **Blood Pressure:** Monitor for orthostasis and hypotension. * **Physical Exam:** Assess for signs of angioedema. ## Clinical Pearls * The characteristic "ACE inhibitor cough" usually resolves within 1–4 weeks of discontinuation. * Patients with African descent have a higher risk of angioedema and may show a reduced antihypertensive response to ACE inhibitors compared to other classes (e.g., CCBs or Thiazides). * Always pause ACE inhibitors during acute dehydration or illness to prevent precipitous decline in renal function. *** **Educational Disclaimer:** This information is for educational purposes only. Clinical practice is subject to change. Always verify current prescribing information, institutional protocols, and specific patient contraindications via official sources (e.g., Lexicomp, UpToDate, or the FDA label) before prescribing or administering medication.