Ace%25252525252525252525252525252525252525252525252520inhibitors

# Angiotensin-Converting Enzyme (ACE) Inhibitors ## Overview ACE inhibitors are a class of medications primarily used to treat cardiovascular conditions, including hypertension and heart failure. They work by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, leading to vasodilation and reduced aldosterone secretion. ## Primary Indications * Hypertension * Heart failure (systolic dysfunction) * Myocardial infarction (post-MI management) * Diabetic nephropathy * Chronic kidney disease (proteinuric) ## Adult Dosing Dosing varies significantly by specific ACE inhibitor. Titration is usually based on patient response and tolerance. Local protocols often dictate initial and titration regimens. * **Benazepril:** Start 5-10 mg once daily, titrate up to 20-40 mg once daily. * **Captopril:** Start 6.25-12.5 mg TID, titrate up to 25-50 mg TID. * **Enalapril:** Start 2.5-5 mg once daily (oral), titrate up to 10-40 mg once daily. IV: 0.625-1.25 mg every 6 hours. * **Fosinopril:** Start 10 mg once daily, titrate up to 20-40 mg once daily. * **Lisinopril:** Start 5-10 mg once daily, titrate up to 20-40 mg once daily. * **Moexipril:** Start 7.5 mg once daily, titrate up to 15-30 mg once daily. * **Perindopril:** Start 2.5-5 mg once daily, titrate up to 10 mg once daily. * **Quinapril:** Start 5-10 mg BID, titrate up to 20-80 mg BID. * **Ramipril:** Start 2.5 mg once daily, titrate up to 5-10 mg once daily. * **Trandolapril:** Start 0.5-1 mg once daily, titrate up to 2-4 mg once daily. ## Pediatric Dosing Dosing is weight-based and should be initiated and titrated cautiously. Consult specific product monographs or pediatric guidelines. * **Enalapril:** 0.07 mg/kg/day to 0.5 mg/kg/day divided BID. * **Lisinopril:** 0.07 mg/kg/day to 0.42 mg/kg/day once daily. * **Captopril:** 0.3 mg/kg/dose to 1 mg/kg/dose TID. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially in moderate to severe renal impairment. Monitor serum creatinine and potassium. * **Hepatic Impairment:** Cautious initiation and titration; metabolic pathways vary. ## Contraindications * History of angioedema related to prior ACE inhibitor treatment. * Concomitant use with aliskiren in patients with diabetes or renal impairment. * Pregnancy (especially second and third trimesters). * Hypersensitivity to ACE inhibitors. ## Adverse Effects * **Common:** Dry cough, dizziness, headache, fatigue, hyperkalemia. * **Serious:** Angioedema (potentially life-threatening), acute kidney injury (especially in those with bilateral renal artery stenosis), hypotension, neutropenia, hepatotoxicity. ## Key Drug Interactions * **Potassium-sparing diuretics/Potassium supplements/ARBs/Aliskiren/Heparin/NSAIDs:** Increased risk of hyperkalemia. * **Diuretics:** Increased risk of hypotension, especially with first-dose therapy. * **Lithium:** Increased serum lithium levels, risk of lithium toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. * **NSAIDS:** Can attenuate antihypertensive effect and increase risk of renal dysfunction. ## Monitoring * Blood pressure * Serum creatinine and electrolytes (especially potassium) * Renal function * Signs and symptoms of angioedema and infection ## Clinical Pearls * Cough is a common, dose-limiting side effect but is generally reversible upon discontinuation. * Angioedema can occur at any time and is a medical emergency. Patients should be instructed to discontinue the drug immediately and seek medical attention if swelling of the face, lips, tongue, or throat occurs. * First-dose hypotension is more common in patients who are volume-depleted or on diuretic therapy. * ACE inhibitors should be used with caution in patients with bilateral renal artery stenosis due to the risk of acute kidney injury. * Discontinuation is recommended prior to pregnancy. *** **Disclaimer:** This information is intended for educational purposes only and does not constitute prescribing advice. Always consult the most current prescribing information and relevant clinical guidelines for specific drug use.