Ace%252525252525252525252525252525252525252525252520inhibitors

## Overview Angiotensin-converting enzyme (ACE) inhibitors are a class of drugs used to treat hypertension and heart failure. They work by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, leading to vasodilation and reduced blood pressure. ## Primary Indications * Hypertension * Heart failure (reduced ejection fraction) * Post-myocardial infarction (left ventricular dysfunction) * Diabetic nephropathy (proteinuria) ## Adult Dosing Dosing varies significantly by specific ACE inhibitor and indication. A common starting dose for lisinopril in hypertension is 10 mg orally once daily, with a typical maintenance dose of 20-40 mg daily. For heart failure, enalapril may be initiated at 2.5 mg orally twice daily, titrated up to 10 mg twice daily. Maximum doses are specific to each agent and indication; consult prescribing information. ## Pediatric Dosing Established pediatric dosing exists for some ACE inhibitors, such as enalapril. For hypertension, a typical starting dose is 0.08 mg/kg orally once daily, with a maximum of 40 mg/day. Pediatric dosing should be guided by specific drug guidelines and patient factors. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary in patients with renal insufficiency. Specific recommendations depend on the degree of impairment and the individual ACE inhibitor. * **Hepatic Impairment:** Generally, no dose adjustment is needed, but caution is advised. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment * Hereditary or idiopathic angioedema * Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment * Pregnancy (especially second and third trimesters) ## Adverse Effects * **Angioedema:** A rare but serious adverse effect, characterized by swelling of the face, lips, tongue, or larynx. * **Cough:** A dry, persistent cough is a common side effect. * **Hyperkalemia:** Especially in patients with renal impairment or those taking potassium-sparing diuretics or potassium supplements. * **Hypotension:** Particularly with the first dose or in volume-depleted patients. * **Renal impairment:** Can occur, especially in patients with pre-existing renal disease. * **Dizziness, fatigue.** ## Key Drug Interactions * **Potassium-sparing diuretics (e.g., spironolactone), potassium supplements, salt substitutes:** Increased risk of hyperkalemia. * **NSAIDs (including aspirin):** May decrease antihypertensive effect and increase risk of renal impairment. * **Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal impairment. Avoid concomitant use in specific populations. * **Diuretics:** Increased risk of symptomatic hypotension, especially with initial doses of ACE inhibitors. * **Lithium:** ACE inhibitors may reduce lithium clearance, leading to increased lithium levels and toxicity. ## Monitoring * **Blood pressure:** Regular monitoring is essential. * **Renal function (serum creatinine, BUN):** Baseline and periodically thereafter. * **Serum potassium:** Baseline and periodically thereafter, especially in high-risk patients. * **Signs and symptoms of angioedema or cough.** ## Clinical Pearls * ACE inhibitors are generally safe and effective but require careful monitoring for adverse effects, particularly angioedema and hyperkalemia. * Initiate at a low dose and titrate slowly, especially in elderly patients, those with heart failure, or renal impairment. * Consider switching to an angiotensin II receptor blocker (ARB) if cough is problematic. * Avoid use in pregnancy due to the risk of fetal harm. *** *Disclaimer: This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information for specific drugs and individual patient factors before making any treatment decisions.*