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## Overview Angiotensin-Converting Enzyme (ACE) inhibitors are a class of medications primarily used to treat cardiovascular conditions like hypertension, heart failure, and following myocardial infarction. They work by inhibiting the angiotensin-converting enzyme, which leads to vasodilation and reduced sodium and water retention. ## Primary Indications * Hypertension * Heart failure (systolic dysfunction) * Left ventricular dysfunction post-myocardial infarction * Diabetic nephropathy (proteinuria) ## Adult Dosing Dosing is highly individualized and depends on the specific ACE inhibitor, indication, and patient response. Titration is generally required to achieve target blood pressure or symptom control. * **Benazepril:** Start 5-10 mg once daily. Max 40 mg/day. * **Captopril:** Start 25 mg twice daily. Max 150 mg three times daily. * **Enalapril:** Start 5 mg once daily. Max 40 mg/day. * **Fosinopril:** Start 10 mg once daily. Max 80 mg/day. * **Lisinopril:** Start 10 mg once daily. Max 80 mg/day. * **Moexipril:** Start 7.5 mg once daily. Max 30 mg/day. * **Perindopril:** Start 2.5-5 mg once daily. Max 10 mg/day. * **Quinapril:** Start 10-20 mg once daily. Max 80 mg/day. * **Ramipril:** Start 2.5 mg once daily. Max 10 mg/day. * **Trandolapril:** Start 1 mg once daily. Max 4 mg/day. *Note: Initial doses for patients with heart failure or on diuretics may be lower. Specific target doses are often determined by local guidelines and clinical assessment.* ## Pediatric Dosing ACE inhibitors are used in pediatric patients for hypertension, heart failure, and post-Kawasaki disease. Dosing is typically based on weight and the specific agent. * **Enalapril:** 0.07 mg/kg to 0.57 mg/kg per day divided once or twice daily. Max 40 mg/day. * **Lisinopril:** 0.07 mg/kg to 0.4 mg/kg per day once daily. Max 40 mg/day. * **Captopril:** 0.3 mg/kg to 0.5 mg/kg per dose given every 8 hours. Max 6 mg/kg/day. *Refer to specific pediatric dosing guidelines for other ACE inhibitors, as availability and established pediatric data may vary.* ## Dose Adjustments * **Renal Impairment:** Reduce initial dose and titrate cautiously. Monitoring of renal function and potassium is essential. Specific dose adjustments vary by agent and degree of renal impairment. * **Hepatic Impairment:** Captopril and Enalapril may require dose reduction. Other ACE inhibitors are generally less affected. * **Volume Depletion/Hyponatremia:** Start with a lower dose and titrate slowly. ## Contraindications * History of angioedema related to ACE inhibitor therapy. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment. * Pregnancy (Category D in 2nd and 3rd trimesters). ## Adverse Effects * **Common:** Dry cough, dizziness, hypotension, hyperkalemia, fatigue. * **Less Common/Serious:** Angioedema (potentially life-threatening), acute kidney injury (especially in patients with bilateral renal artery stenosis), neutropenia/agranulocytosis (rare), hepatotoxicity. ## Key Drug Interactions * **Potassium-sparing diuretics and potassium supplements:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Diuretics:** Increased risk of hypotension, especially with the first dose. * **Lithium:** ACE inhibitors can increase lithium levels, leading to toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus), DPP-4 inhibitors (e.g., vildagliptin):** Increased risk of angioedema. * **Sacubitril/Valsartan:** Increased risk of angioedema; do not initiate sacubitril/valsartan within 36 hours of stopping an ACE inhibitor. ## Monitoring * Blood pressure * Serum potassium * Renal function (BUN, creatinine) * Signs/symptoms of angioedema or hypersensitivity * Baseline and periodic complete blood count (CBC) if risk factors are present. ## Clinical Pearls * The characteristic dry cough is thought to be due to bradykinin accumulation and typically resolves within 1-4 weeks of discontinuation. * Initiate at a low dose and titrate slowly, particularly in patients with heart failure, renal impairment, or those on diuretics, to minimize the risk of hypotension and acute kidney injury. * Monitor potassium closely, especially in patients with renal impairment or those taking potassium-sparing agents. * Advise patients to report any swelling of the face, lips, tongue, or throat immediately. *** **Disclaimer:** This information is for educational purposes only and does not substitute for professional medical advice. Always consult with a qualified healthcare provider for any questions regarding a medical condition or treatment. Please verify current prescribing information with the drug's official labeling.