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# ACE Inhibitors ## Overview ACE inhibitors (Angiotensin-Converting Enzyme inhibitors) are a class of medications primarily used to treat cardiovascular conditions, including hypertension, heart failure, and post-myocardial infarction. They work by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, leading to vasodilation and reduced blood pressure. ## Primary Indications * Hypertension * Heart Failure (reduced ejection fraction) * Post-Myocardial Infarction (to improve survival) * Diabetic Nephropathy (in select patients with proteinuria) ## Adult Dosing Dosing is highly individualized and depends on the specific ACE inhibitor, indication, and patient response. Titration is common. * **Benazepril:** Hypertension 10 mg PO daily, titrate to 20-40 mg/day. * **Captopril:** Hypertension 25 mg PO BID-TID, titrate to 50 mg TID. Heart failure 6.25 mg PO TID, titrate to 50 mg TID. Max 150 mg TID. * **Enalapril:** Hypertension 5 mg PO daily, titrate to 10-40 mg/day. Heart failure 2.5 mg PO BID, titrate to 10 mg BID. Max 20 mg BID. * **Fosinopril:** Hypertension 10 mg PO daily, titrate to 20-40 mg/day. * **Lisinopril:** Hypertension 10 mg PO daily, titrate to 20-40 mg/day. Max 80 mg/day. Heart failure 5 mg PO daily, titrate to 10-35 mg/day. * **Moexipril:** Hypertension 7.5 mg PO daily, titrate to 15-30 mg/day. * **Perindopril:** Hypertension 5 mg PO daily, titrate to 10 mg/day. Max 20 mg/day. Heart failure 2.5-5 mg PO daily, titrate to 10 mg/day. * **Ramipril:** Hypertension 2.5 mg PO daily, titrate to 5-10 mg/day. Heart failure 1.25 mg PO daily, titrate to 10 mg/day. * **Trandolapril:** Hypertension 1 mg PO daily, titrate to 2-4 mg/day. * **Quinapril:** Hypertension 10 mg PO daily, titrate to 20-40 mg/day BID. * **Ramipril:** Hypertension 2.5 mg PO daily, titrate to 5-10 mg/day. Heart failure 1.25 mg PO daily, titrate to 10 mg/day. ## Pediatric Dosing * **Captopril:** Hypertension: 0.3 mg/kg/dose PO every 8-12 hours, may titrate up to 2 mg/kg/day in divided doses. * **Enalapril:** Hypertension: 0.07 mg/kg/dose PO once daily, may titrate up to 0.57 mg/kg/day (or adult max) in divided doses. * **Lisinopril:** Hypertension: 0.07 mg/kg/dose PO once daily, may titrate up to 0.61 mg/kg/day (or adult max) in divided doses. *Note: Pediatric dosing can vary based on formulation availability and specific clinical guidelines. Always consult current pediatric dosing references.* ## Dose Adjustments * **Renal Impairment:** Dose reduction is often required, especially in moderate to severe renal impairment. Specific recommendations vary by agent. * **Hepatic Impairment:** Use with caution; dose adjustments may be needed. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment. * Pregnancy (especially second and third trimesters). ## Adverse Effects * **Common:** Dry cough, dizziness, hypotension, hyperkalemia, fatigue, headache. * **Serious:** Angioedema (potentially life-threatening), acute kidney injury, hyperkalemia, neutropenia, elevated liver enzymes. ## Key Drug Interactions * **Potassium-sparing diuretics (e.g., spironolactone, amiloride) & Potassium supplements:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal impairment. * **Lithium:** ACE inhibitors can reduce lithium clearance, increasing lithium toxicity risk. * **Aliskiren:** Increased risk of adverse effects, particularly hyperkalemia and hypotension. Avoid in patients with diabetes or renal impairment. * **ARBs (Angiotensin II Receptor Blockers):** Increased risk of hypotension, hyperkalemia, and renal dysfunction. Generally avoided unless specific indications and close monitoring. * **Diuretics:** Increased risk of hypotension, especially with initial doses. ## Monitoring * **Blood Pressure:** Regularly monitor BP, especially after initiating or titrating therapy. * **Renal Function:** Monitor serum creatinine and BUN. * **Potassium:** Monitor serum potassium levels, especially in patients with renal impairment or those taking potassium supplements or potassium-sparing diuretics. * **Angioedema:** Educate patients on symptoms and to discontinue medication immediately if they occur. ## Clinical Pearls * Cough is a common and often dose-limiting side effect, occurring in up to 20% of patients. If cough is bothersome, consider switching to an ARB. * First-dose hypotension can occur, particularly in volume-depleted patients or those on diuretics. Start with a low dose, preferably at bedtime, and monitor closely. * Angioedema is a rare but serious adverse effect that can occur at any time during treatment and requires immediate discontinuation of the ACE inhibitor. * ACE inhibitors are generally considered safe and effective for long-term use in many cardiovascular conditions. *** *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 relevant guidelines for complete and up-to-date details on drug indications, contraindications, warnings, precautions, adverse reactions, and dosing before making any clinical decisions.*