Ace%25252525252525252525252525252525252525252520inhibitors

# ACE Inhibitors ## Overview Angiotensin-Converting Enzyme (ACE) inhibitors (e.g., lisinopril, enalapril, ramipril) block the conversion of angiotensin I to angiotensin II, leading to decreased systemic vascular resistance and reduced aldosterone secretion. They are cornerstone therapies in cardiovascular and renal disease. ## Primary Indications * Hypertension * Heart failure (HFrEF) * Post-myocardial infarction * Diabetic nephropathy/Proteinuria ## Adult Dosing *Examples provided for common agents:* * **Lisinopril:** Hypertension: Start 10 mg PO daily; target 20–40 mg daily. CHF: Start 2.5–5 mg PO daily; target 20–40 mg daily. Max: 40–80 mg/day (varies by indication). * **Enalapril:** Hypertension: Start 5 mg PO daily; max 40 mg/day. CHF: Start 2.5 mg PO twice daily; target 10–20 mg twice daily. * **Ramipril:** Hypertension: Start 2.5 mg PO daily; max 20 mg/day. ## Pediatric Dosing * **Lisinopril:** Hypertension (≥6 years): 0.07 mg/kg/dose once daily, up to 5 mg; titrate up to 0.6 mg/kg (max 40 mg). * **Enalapril:** Hypertension (≥1 month): 0.08 mg/kg once daily (max 5 mg). *Note: Pediatric dosing depends heavily on local institutional protocols and weight-based titration; always consult pediatric-specific references (e.g., Harriet Lane).* ## Dose Adjustments * **Renal Impairment:** Reduce starting dose and titration speed if eGFR <30 mL/min/1.73m². * **Hepatic Impairment:** Generally no specific adjustment, but use caution with pro-drugs (e.g., enalapril, ramipril) which require hepatic conversion. ## Contraindications * History of angioedema (hereditary or ACE-inhibitor induced). * Concurrent use with aliskiren in patients with diabetes. * Pregnancy (Category D: causes fetal injury/death); discontinue immediately if pregnancy is detected. * Bilateral renal artery stenosis (relative/guarded contraindication). ## Adverse Effects * **Common:** Dry, persistent cough (due to bradykinin accumulation). * **Serious:** Angioedema (rare but emergent), hyperkalemia, acute kidney injury (AKI), hypotension, and dysgeusia. ## Key Drug Interactions * **Potassium-sparing diuretics/Potassium supplements:** Increased risk of severe hyperkalemia. * **NSAIDs:** Reduced antihypertensive effect and increased risk of AKI by inhibiting prostaglandins. * **Lithium:** ACE inhibitors may decrease lithium excretion, increasing toxicity risk. * **Aliskiren:** Do not combine due to increased risk of hyperkalemia/hypotension. ## Monitoring * **Baseline/Follow-up:** Serum creatinine and potassium (within 1–2 weeks of initiation or dose increase). * **Blood Pressure:** Monitor for orthostasis and hypotension. * **Physical:** Monitor for signs of angioedema (swelling of face, lips, tongue, glottis). ## Clinical Pearls * **Cough Management:** If a patient develops a persistent dry cough, switch to an Angiotensin II Receptor Blocker (ARB). * **First-Dose Phenomenon:** Risk of severe hypotension exists, especially in volume-depleted patients or those on high-dose diuretics. * **Race-based efficacy:** ACE inhibitors may be less effective as monotherapy in Black populations; calcium channel blockers are often preferred. * **Washout:** Ensure a 36-hour washout period when switching between an ACE inhibitor and an ARNI (sacubitril/valsartan) to mitigate angioedema risk. *** **Disclaimer:** This information is for educational purposes only. Clinical practice and therapeutic guidelines evolve. Please verify all dosing, contraindications, and drug interactions using official local prescribing information, institutional protocols, or current drug compendia (e.g., Lexicomp, UpToDate) before prescribing.