Ace%2525252525252525252525252525252520inhibitors

# ACE Inhibitors ## Overview Angiotensin-Converting Enzyme (ACE) inhibitors block the conversion of angiotensin I to angiotensin II, preventing vasoconstriction and aldosterone secretion. They are cornerstone therapies for hypertension, heart failure, and chronic kidney disease. ## Primary Indications * Hypertension * Heart failure (reduced ejection fraction) * Post-myocardial infarction * Diabetic nephropathy/Proteinuria ## Adult Dosing * **Lisinopril:** Hypertension: 10 mg once daily (range 10–40 mg); Heart Failure: 5 mg once daily (target 20–40 mg/day). * **Enalapril:** Hypertension: 5 mg once daily (up to 40 mg/day); Heart Failure: 2.5 mg twice daily (target 10–20 mg twice daily). * **Ramipril:** Hypertension: 2.5 mg once daily (range 2.5–20 mg/day); Heart Failure: 1.25–2.5 mg once daily (target 10 mg/day). * *Note: Dosing varies significantly by agent; consult current package inserts for specific titration schedules.* ## Pediatric Dosing * **Lisinopril:** (≥6 years) 0.07 mg/kg/dose once daily, increased up to 0.6 mg/kg (max 40 mg). * **Enalapril:** (1 month–16 years) 0.08 mg/kg/dose once daily, titrated to max 0.6 mg/kg/day (max 40 mg). * *Dosing in pediatrics is highly weight-based and specific to age; verify exact protocols through institutional guidelines or pediatric pharmacology references (e.g., Harriet Lane).* ## Dose Adjustments * **Renal Impairment:** Reduce starting dose and titrate cautiously if eGFR <30 mL/min/1.73m². * **Hepatic Impairment:** Generally safe, though some (e.g., enalapril) are prodrugs requiring hepatic conversion; monitor for reduced efficacy in severe failure. ## Contraindications * History of angioedema (hereditary or ACE-inhibitor induced). * Pregnancy (Category D: causes fetal morbidity/mortality in 2nd and 3rd trimesters). * Concomitant use with aliskiren in patients with diabetes. * Concomitant use with sacubitril/valsartan (36-hour washout period required for ACE inhibitor before starting ARNIs). ## Adverse Effects * **Common:** Dry, hacking cough (due to bradykinin accumulation). * **Serious:** Angioedema (rare but life-threatening; higher risk in Black patients), hyperkalemia, acute kidney injury (in patients with bilateral renal artery stenosis), orthostatic hypotension. ## Key Drug Interactions * **Potassium-sparing diuretics/supplements:** Increased risk of severe hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of acute kidney injury. * **Lithium:** May increase serum lithium levels, increasing toxicity risk. ## Monitoring * **Baseline:** Serum potassium, blood pressure, renal function (SCr/BUN). * **Follow-up:** Check electrolytes and renal function 1–2 weeks after initiation or dose escalation. * **Ongoing:** Monitor for signs of persistent dry cough or angioedema. ## Clinical Pearls * ACE inhibitors are preferred first-line agents in patients with diabetes to delay the progression of chronic kidney disease. * If a patient develops a persistent dry cough, consider switching to an Angiotensin II Receptor Blocker (ARB). * In African American populations, ACE inhibitors are less effective as monotherapy for blood pressure control compared to CCBs or thiazides and carry a higher risk of angioedema. *** *Disclaimer: This information is for educational purposes only. Always verify current prescribing information, institutional protocols, and patient-specific factors via reliable clinical databases (e.g., Lexicomp, UpToDate) before prescribing or administering medication.*