Ace%252525252525252525252525252525252525252525252525252525252525252525252525252520inhibitors

# ACE Inhibitors ## Overview ACE inhibitors (e.g., lisinopril, enalapril, ramipril) are a class of medications that block the action of angiotensin-converting enzyme, leading to vasodilation and reduced sodium and water retention. This mechanism lowers blood pressure and reduces cardiac workload. ## Primary Indications * Hypertension * Heart failure (reduced ejection fraction) * Post-myocardial infarction (in select patients) * Diabetic nephropathy (in patients with proteinuria) ## Adult Dosing Dosing varies significantly by agent and indication. Titration is typically required to achieve target blood pressure or clinical response. * **Hypertension:** * Lisinopril: Starting dose 10 mg once daily. Usual range 10-40 mg once daily. Maximum 40 mg daily. * Enalapril: Starting dose 5 mg once or twice daily. Usual range 10-40 mg once or twice daily. Maximum 40 mg daily. * Ramipril: Starting dose 2.5 mg once daily. Usual range 2.5-20 mg once daily. Maximum 20 mg daily. * **Heart Failure:** * Enalapril: Starting dose 2.5 mg twice daily. Usual range 10-20 mg twice daily. Maximum 20 mg twice daily. * Lisinopril: Starting dose 5 mg once daily. Usual range 10-40 mg once daily. Maximum 40 mg daily. * Ramipril: Starting dose 1.25 mg once daily. Usual range 2.5-10 mg once daily. Maximum 10 mg daily. * **Post-MI:** Often initiated as part of a comprehensive regimen. Dosing depends on the specific agent and patient tolerance, typically guided by clinical trials or local protocols. ## Pediatric Dosing Dosing in pediatric patients is typically based on weight and indication and should be determined by a healthcare professional experienced in pediatric pharmacotherapy. * **Hypertension:** * Enalapril: 0.07 mg/kg/dose to 0.2 mg/kg/dose once daily or divided twice daily. Maximum 0.61 mg/kg/day or 40 mg/day. * Lisinopril: 0.07 mg/kg/dose once daily. Maximum 40 mg/day. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially in patients with significant renal dysfunction. Specific guidelines vary by agent and degree of renal impairment; consult product information. * **Hepatic Impairment:** Use with caution. Dose adjustments may be needed, though typically less pronounced than with renal impairment. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes. * Pregnancy (especially second and third trimesters). ## Adverse Effects * **Common:** Cough (dry, persistent), dizziness, fatigue, headache, hyperkalemia, hypotension. * **Serious:** Angioedema (including laryngeal edema), acute kidney injury, severe hypotension, hyperkalemia, hepatotoxicity. ## Key Drug Interactions * **Potassium-Sparing Diuretics & Potassium Supplements:** Increased risk of hyperkalemia. * **NSAIDs:** May blunt antihypertensive effect and increase risk of renal impairment. * **Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction. Avoid concomitant use, especially in patients with diabetes. * **ARBs:** Increased risk of hyperkalemia, hypotension, and renal dysfunction. * **Lithium:** ACE inhibitors can reduce lithium clearance, increasing lithium toxicity risk. * **mTOR Inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. ## Monitoring * **Blood Pressure:** Regularly to assess efficacy and titrate dose. * **Renal Function:** Serum creatinine and BUN, especially at initiation, with dose increases, and in patients with risk factors. * **Potassium:** Serum electrolytes, particularly at initiation, with dose increases, and in patients with renal impairment or on potassium-sparing agents. * **Angioedema:** Patients should be educated to report any swelling, especially of the face, lips, tongue, or throat, immediately. ## Clinical Pearls * The characteristic dry cough is a common reason for discontinuation but is not an angioedema. * ACE inhibitors should be initiated at low doses and titrated slowly, especially in patients who are volume-depleted, salt-depleted, or have heart failure. * First-dose hypotension can occur, particularly in patients with significant volume depletion. * Angioedema is a rare but life-threatening adverse effect. Patients should be advised to seek immediate medical attention if symptoms occur. * Discontinuation of ACE inhibitors during pregnancy is strongly recommended. *** **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 your healthcare provider for any questions regarding drug therapy.