Ace%2525252525252525252525252525252525252525252525252525252525252525252525252520inhibitors

# ACE Inhibitors ## Overview Angiotensin-converting enzyme (ACE) inhibitors are a class of medications that block the production of angiotensin II, a potent vasoconstrictor. This leads to vasodilation, reduced aldosterone secretion, and decreased sympathetic nervous system activity, ultimately lowering blood pressure and reducing cardiac workload. ## Primary Indications * Hypertension * Heart failure (reduced ejection fraction) * Myocardial infarction (post-MI management) * Diabetic nephropathy * Chronic kidney disease with proteinuria ## Adult Dosing Dosing varies significantly by specific ACE inhibitor and indication. Typical starting doses and maximum daily doses (for common indications like hypertension) are provided below for representative agents. **Actual dosing regimens are often guided by local protocols and patient response.** * **Benazepril:** Start 10 mg daily, max 40 mg daily. * **Captopril:** Start 25 mg twice daily, max 150 mg twice daily. * **Enalapril:** Start 5 mg daily or twice daily, max 40 mg daily. * **Lisinopril:** Start 10 mg daily, max 40 mg daily. * **Ramipril:** Start 2.5 mg daily, max 10 mg daily. * **Trandolapril:** Start 1 mg daily, max 4 mg daily. **Note:** For heart failure, initiation is often at lower doses and titrated more slowly. ## Pediatric Dosing ACE inhibitors are used in pediatric populations, but dosing is highly individualized and often guided by specialist recommendations. * **Enalapril:** Hypertension: 0.07-0.1 mg/kg/day divided every 12-24 hours, max 0.5 mg/kg/day. * **Lisinopril:** Hypertension: 0.07-0.2 mg/kg/day once daily, max 20 mg/day. **Uncertainty:** Dosing for other ACE inhibitors and indications in pediatrics is less well-established and requires careful consideration and monitoring. ## Dose Adjustments * **Renal Impairment:** Initial doses should be reduced, and titration should be slower. Specific reductions depend on the agent and creatinine clearance. * **Hepatic Impairment:** Generally, no dose adjustment is required for liver impairment, 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. * Pregnancy (especially in the second and third trimesters). * Known hypersensitivity to the drug. ## Adverse Effects * **Common:** Cough (dry, persistent), dizziness, fatigue, headache, hyperkalemia. * **Serious:** Angioedema (lips, face, tongue, throat, intestines), acute kidney injury, hypotension, syncope, neutropenia/agranulocytosis (rare). ## Key Drug Interactions * **Potassium-sparing diuretics, potassium supplements, spironolactone, eplerenone:** Increased risk of hyperkalemia. * **NSAIDs (including COX-2 inhibitors):** May blunt antihypertensive effect and increase risk of renal impairment. * **Diuretics (especially thiazides and loop diuretics):** Increased risk of symptomatic hypotension, particularly upon initiation. * **Lithium:** ACE inhibitors can decrease lithium clearance, leading to lithium toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus), DPP-4 inhibitors (e.g., vildagliptin):** Increased risk of angioedema. * **Sacubitril/valsartan:** Concomitant use is contraindicated within 36 hours of the last dose of an ACE inhibitor due to increased risk of angioedema. ## Monitoring * **Blood Pressure:** Regularly assess for efficacy and hypotension. * **Renal Function:** Monitor serum creatinine and BUN, especially at initiation and with dose changes. * **Potassium Levels:** Monitor serum potassium, particularly in patients with renal impairment, diabetes, or those on potassium-sparing agents. * **Angioedema:** Educate patients to report any signs immediately. ## Clinical Pearls * The characteristic dry cough is thought to be due to bradykinin accumulation and typically resolves upon discontinuation. * Angioedema is a medical emergency and requires immediate discontinuation of the ACE inhibitor. * Initiation in patients who are volume-depleted or on high-dose diuretics may require a lower starting dose or temporary discontinuation of the diuretic. * ACE inhibitors are generally not first-line agents for hypertension in Black patients unless they have specific compelling indications like heart failure or chronic kidney disease. * For patients with symptomatic bradycardia, cardiogenic shock, or severe hypotension, ACE inhibitors are generally contraindicated. *** **Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and professional guidelines for definitive dosing, indications, contraindications, and safety information. Local formularies and protocols may also influence drug selection and dosing.