Ace%2525252525252525252525252520inhibitors

# ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors) ## Overview ACE inhibitors (e.g., lisinopril, enalapril, ramipril) block the conversion of angiotensin I to angiotensin II, leading to vasodilation, decreased aldosterone secretion, and reduction in blood pressure and cardiac remodeling. ## Primary Indications * Hypertension * Heart failure (HFrEF) * Post-myocardial infarction * Chronic kidney disease (diabetic nephropathy/proteinuria) ## Adult Dosing * **Lisinopril:** HTN: 10 mg daily (max 40 mg); HF: 5 mg daily (target 20-40 mg). * **Enalapril:** HTN: 5 mg daily (max 40 mg); HF: 2.5 mg BID (target 10-20 mg BID). * **Ramipril:** HTN: 2.5–5 mg daily (max 20 mg); Post-MI: 2.5 mg BID (target 5 mg BID). * *Note: Dosing depends on indication; start low and titrate based on hemodynamic response.* ## Pediatric Dosing * **Lisinopril:** >6 years: 0.07 mg/kg once daily (max 5 mg initially, max 0.6 mg/kg or 40 mg). * **Enalapril:** >1 month: 0.08 mg/kg daily (max 5 mg initially, max 0.5 mg/kg or 40 mg). * *Safety Note: Pediatric dosing is highly variable; consult weight-based institutional protocols.* ## Dose Adjustments * **Renal Impairment:** Reduce starting dose and titration frequency if CrCl <30 mL/min. * **Hepatic Impairment:** Generally safe, but monitor closely, especially with prodrugs (e.g., enalapril). ## Contraindications * History of angioedema. * Concomitant use with aliskiren in patients with diabetes. * Use within 36 hours of sacubitril/valsartan (Entresto). * Pregnancy (Category D/X: causes fetal injury/death). ## Adverse Effects * **Common:** Dry, hacking cough (due to bradykinin accumulation), hyperkalemia, headache, dizziness. * **Serious:** Angioedema (life-threatening airway obstruction), acute renal failure (especially in bilateral renal artery stenosis), orthostatic hypotension. ## Key Drug Interactions * **Potassium-sparing diuretics/K+ supplements:** Risk of hyperkalemia. * **NSAIDs:** Increased risk of acute kidney injury and reduced antihypertensive efficacy. * **Lithium:** May increase lithium toxicity. * **ARBs/Direct Renin Inhibitors:** Combined blockade significantly increases risk of hyperkalemia and renal dysfunction without clear mortality benefit. ## Monitoring * **Baseline/Follow-up:** Serum potassium and creatinine within 1–2 weeks of initiation or dose increase. * **Blood Pressure:** Monitor for orthostasis during initial titration. * **Symptoms:** Monitor for dry cough and signs of angioedema. ## Clinical Pearls * **The "Cough":** If a patient develops a persistent dry, non-productive cough, it is a class effect; consider switching to an ARB. * **Renal Protection:** Initial creatinine increases of up to 30% are common and acceptable; if >30%, investigate for renal artery stenosis or dehydration. * **First-dose hypotension:** Start at bedtime if the patient is volume-depleted or on heavy diuretic therapy. *** **Educational Disclaimer:** This information is for educational purposes only. Always consult current FDA-approved labeling, local institutional guidelines, and clinical drug databases before prescribing or administering medication.