Ace%252525252525252525252520inhibitors

# ACE Inhibitors ## Overview Angiotensin-Converting Enzyme (ACE) inhibitors (e.g., lisinopril, ramipril, enalapril) block the conversion of angiotensin I to angiotensin II, leading to systemic vasodilation and reduced aldosterone secretion. ## Primary Indications * Hypertension * Heart Failure with reduced ejection fraction (HFrEF) * Post-myocardial infarction * Chronic Kidney Disease (CKD) with proteinuria/diabetic nephropathy ## Adult Dosing * **Lisinopril:** HTN: 10 mg daily (max 40 mg); HF: 5 mg daily (target 20–40 mg). * **Ramipril:** HTN: 2.5 mg daily (max 20 mg); HF/Post-MI: 1.25–2.5 mg BID (target 5 mg BID). * **Enalapril:** HTN: 5 mg daily (max 40 mg); HF: 2.5 mg BID (target 10–20 mg BID). * *Note: Specific titration targets vary by institutional protocol; start low and titrate based on blood pressure and renal tolerance.* ## Pediatric Dosing * **Enalapril:** 0.08 mg/kg once daily (max 5 mg). * **Lisinopril:** 0.07 mg/kg once daily (max 5 mg). * *Consult current pediatric dosing references (e.g., Harriet Lane) as dosing is highly weight-dependent and age-specific.* ## Dose Adjustments * **Renal Impairment:** Reduce starting doses and monitor serum creatinine (SCr) trends closely. Generally avoided if CrCl <30 mL/min or in significant bilateral renal artery stenosis. * **Hepatic Impairment:** Dose adjustments may be required for prodrugs (e.g., enalapril conversion to enalaprilat). ## Contraindications * History of angioedema (hereditary or ACE-inhibitor induced). * Pregnancy (Category D: fetal toxicity and death). * Concomitant use with aliskiren in patients with diabetes. * Concomitant use with sacubitril/valsartan (requires 36-hour washout period). ## Adverse Effects * **Common:** Dry, productive cough (bradykinin-mediated). * **Serious:** Angioedema (life-threatening, can occur years after therapy initiation), hyperkalemia, acute kidney injury (AKI), hypotension. ## Key Drug Interactions * **Potassium-sparing diuretics/K+ supplements:** Risk of severe hyperkalemia. * **NSAIDs:** Increased risk of AKI due to loss of renal afferent arteriolar vasodilation. * **Lithium:** May increase lithium levels (monitor closely). ## Monitoring * **Baseline/Follow-up:** Potassium, SCr, BUN, and blood pressure 1–2 weeks after initiation or dose escalation. * **Symptoms:** Monitor for tongue swelling, throat tightness, or persistent cough. ## Clinical Pearls * The dry cough does not occur with Angiotensin II Receptor Blockers (ARBs). * Serum creatinine increases of up to 30% are considered "expected" and acceptable upon initiation; increases beyond that mandate caution. * African American populations are at higher risk for ACE-inhibitor-induced angioedema. *** *Educational Disclaimer: This information is for educational purposes only. Always verify dosing, contraindications, and drug interactions with current clinical resources (e.g., Lexicomp, UpToDate) and local institutional guidelines before prescribing or administering medication.*