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# ACE Inhibitors ## Overview Angiotensin-Converting Enzyme (ACE) inhibitors block the conversion of angiotensin I to angiotensin II, leading to systemic vasodilation, reduction in aldosterone secretion, and inhibition of cardiac/vascular remodeling. ## Primary Indications Hypertension, Heart Failure (HFrEF), Post-Myocardial Infarction, Chronic Kidney Disease (proteinuria/diabetic nephropathy). ## Adult Dosing *Note: Dosages vary by agent (e.g., Lisinopril, Enalapril, Ramipril). Below are frequent examples:* * **Lisinopril:** Hypertension start 10 mg daily; Target 20–40 mg daily. Heart Failure start 2.5–5 mg daily; Target 20–40 mg daily. * **Enalapril:** Hypertension start 5 mg daily; Target 10–40 mg daily. Heart Failure start 2.5 mg BID; Target 10–20 mg BID. * **Ramipril:** Hypertension start 2.5 mg daily; Target 10 mg daily. ## Pediatric Dosing *Note: Use is often off-label; dosing depends on local institutional protocols.* * **Lisinopril:** Initial 0.07 mg/kg once daily (max 5 mg); Titrate up to 0.6 mg/kg daily (max 40 mg). * **Enalapril:** Initial 0.08 mg/kg once daily (max 5 mg); Titrate based on desired BP response. ## Dose Adjustments * **Renal Impairment:** Reduce starting dose and titration speed in patients with CrCl <30 mL/min. * **Hepatic Impairment:** Generally safe, though caution is advised with prodrugs (e.g., Enalapril) that require hepatic conversion. ## Contraindications History of angioedema (hereditary, idiopathic, or ACE-inhibitor induced), concomitant use with aliskiren in patients with diabetes, pregnancy (Category D: fetal toxicity in 2nd/3rd trimester), and bilateral renal artery stenosis. ## Adverse Effects Dry cough (common, due to bradykinin accumulation), hyperkalemia, serum creatinine increase (up to 30% is typically acceptable), hypotension, headache, and rare but life-threatening angioedema. ## Key Drug Interactions * **Potassium-sparing diuretics/K+ supplements:** High risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of acute kidney injury (AKI). * **ARBs/Direct Renin Inhibitors:** Dual blockade increases risk of AKI and hyperkalemia. * **Lithium:** May increase lithium levels/toxicity. ## Monitoring * **Baseline:** Serum potassium, creatinine, BUN, and blood pressure. * **Follow-up:** Re-check potassium and renal function 1–2 weeks after initiation or dose escalation. ## Clinical Pearls * If a patient develops an ACE-inhibitor-induced cough, suggest switching to an Angiotensin II Receptor Blocker (ARB), as ARBs do not affect bradykinin metabolism. * ACE inhibitors are considered superior to other antihypertensives in patients with proteinuria or HFrEF due to their mortality benefits and renal protection. * Washout period: A 36-hour washout period is required when switching between an ACE inhibitor and an Angiotensin Receptor-Neprilysin Inhibitor (ARNI/Sacubitril/Valsartan) to mitigate angioedema risk. *** **Disclaimer:** This information is for educational purposes only. Always consult the official package insert and your facility's evidence-based clinical guidelines before prescribing or administering medication. Dosage, contraindications, and drug interactions are subject to change.