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# ACE Inhibitors ## Overview Angiotensin-Converting Enzyme (ACE) inhibitors are a class of medications primarily used to treat hypertension and heart failure. They work by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. ## Primary Indications * Hypertension * Congestive Heart Failure (CHF) * Left Ventricular Dysfunction post-Myocardial Infarction (MI) * Diabetic Nephropathy * Certain kidney diseases ## Adult Dosing Dosing varies significantly by specific ACE inhibitor, indication, and patient factors. Doses should be titrated upwards based on clinical response and tolerability. * **Benazepril:** Hypertension: 10-40 mg once daily. CHF: 5-40 mg once daily. * **Captopril:** Hypertension: 25-150 mg twice daily. CHF: 6.25-12.5 mg three times daily, may increase to 50 mg three times daily. Post-MI: 6.25 mg three times daily, increase as tolerated. * **Enalapril:** Hypertension: 10-40 mg once or twice daily. CHF: 2.5-20 mg twice daily. Post-MI: 5 mg twice daily, increase as tolerated. * **Fosinopril:** Hypertension: 10-40 mg once daily. CHF: 10-40 mg once daily. * **Lisinopril:** Hypertension: 10-40 mg once daily. CHF: 5-40 mg once daily. Post-MI: 5 mg once daily, increase as tolerated. * **Moexipril:** Hypertension: 7.5-30 mg once daily. * **Perindopril:** Hypertension: 2.5-10 mg once daily. CHF: 2.5-10 mg once daily. Post-MI: 2.5-10 mg once daily. * **Ramipril:** Hypertension: 2.5-20 mg once daily. CHF: 2.5-10 mg once daily. Post-MI: 5 mg once daily, increase as tolerated. * **Trandolapril:** Hypertension: 1-4 mg once daily. CHF: 1-4 mg once daily. ## Pediatric Dosing Established pediatric dosing varies by agent and indication. Always consult specific pediatric guidelines. * **Enalapril:** Hypertension: 6 months to 16 years: 0.07 mg/kg/day to 0.5 mg/kg/day divided once or twice daily. * **Lisinopril:** Hypertension: 6 years to 16 years: 0.07 mg/kg/day to 0.61 mg/kg/day divided once daily. * **Ramipril:** Hypertension: 10 years to 16 years: 1.25 mg to 5 mg once daily. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, particularly for captopril and enalapril. Use of lower starting doses and slower titration is recommended. * **Hepatic Impairment:** Caution is advised; monitor closely. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes. * Pregnancy (especially in the second and third trimesters). ## Adverse Effects * **Common:** Dry cough, dizziness, hypotension, hyperkalemia, headache, fatigue. * **Less Common/Serious:** Angioedema (face, lips, tongue, throat, extremities, intestines), renal impairment (especially in patients with bilateral renal artery stenosis), rash, taste disturbances, neutropenia, agranulocytosis. ## Key Drug Interactions * **Potassium-sparing diuretics, potassium supplements, aliskiren, ARBs, heparin, salt substitutes:** Increased risk of hyperkalemia. * **NSAIDs, COX-2 inhibitors:** May decrease antihypertensive effect and increase risk of renal impairment. * **Diuretics (especially loop and thiazide):** Increased risk of symptomatic hypotension, especially upon initiation. * **Lithium:** Increased lithium levels and toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus, temsirolimus):** Increased risk of angioedema. * **Racecadotril and other NEP inhibitors:** Increased risk of angioedema. ## Monitoring * **Blood Pressure:** Regularly, especially after dose initiation or changes. * **Renal Function:** Serum creatinine and BUN, particularly in patients with pre-existing renal disease or risk factors. * **Electrolytes:** Serum potassium, especially in patients with renal impairment or those taking potassium-sparing agents. * **Complete Blood Count (CBC):** Less frequent, but consider if neutropenia is suspected. * **Signs and Symptoms of Angioedema:** Educate patients to report immediately. ## Clinical Pearls * The characteristic dry cough is a common side effect and often leads to discontinuation. It is generally reversible upon cessation of the drug. * Initiate at low doses and titrate slowly, especially in patients with heart failure, renal impairment, or those taking diuretics. * First-dose hypotension can occur, particularly in volume-depleted patients. Consider withholding diuretics or administering a lower initial dose. * ACE inhibitors are generally contraindicated in pregnancy due to risks to the fetus. * Monitor for hyperkalemia, especially in patients with renal dysfunction or those receiving potassium-sparing agents. *** *Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult current prescribing information and guidelines, and exercise your professional judgment when making clinical decisions. Dosing and management may vary based on individual patient needs and local protocols.*