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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, leading to vasodilation and reduced blood pressure. ## Primary Indications * Hypertension * Heart failure (systolic dysfunction) * Myocardial infarction (post-MI) * Diabetic nephropathy * Renal protection in patients with certain chronic kidney diseases ## Adult Dosing * **Benazepril:** Start at 5-10 mg orally once daily. Usual maintenance: 20-40 mg once daily. Max: 80 mg once daily. * **Captopril:** Start at 6.25-12.5 mg orally 2-3 times daily. Usual maintenance: 25-50 mg 2-3 times daily. Max: 150 mg 3 times daily. * **Enalapril:** Start at 2.5-5 mg orally once or twice daily. Usual maintenance: 10-40 mg once or twice daily. Max: 40 mg twice daily. * **Fosinopril:** Start at 10 mg orally once daily. Usual maintenance: 20-40 mg once daily. Max: 80 mg once daily. * **Lisinopril:** Start at 10 mg orally once daily. Usual maintenance: 20-40 mg once daily. Max: 80 mg once daily. * **Moexipril:** Start at 7.5 mg orally once daily. Usual maintenance: 15 mg once daily. Max: 30 mg once daily. * **Perindopril:** Start at 2.5-5 mg orally once daily. Usual maintenance: 5-10 mg once daily. Max: 10 mg once daily. * **Quinapril:** Start at 5-10 mg orally once or twice daily. Usual maintenance: 20-80 mg once or twice daily. Max: 80 mg twice daily. * **Ramipril:** Start at 2.5-5 mg orally once daily. Usual maintenance: 10 mg once daily. Max: 10 mg once daily. * **Trandolapril:** Start at 1 mg orally once daily. Usual maintenance: 2-4 mg once daily. Max: 8 mg once daily. Dosing for specific indications (e.g., heart failure, post-MI) may vary. Consult specific guidelines. ## Pediatric Dosing Dosing in pediatric patients is highly variable and often requires careful titration based on patient weight and response. Specific doses should be guided by weight-based protocols and clinical judgment. * **Enalapril:** 0.07-0.1 mg/kg/day in 1-2 divided doses. Max: 0.61 mg/kg/day. * **Lisinopril:** 0.07-0.2 mg/kg/day once daily. Max: 20 mg/day. * **Ramipril:** 0.07-0.14 mg/kg/day once daily. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially in severe renal impairment (CrCl < 30 mL/min). Captopril and enalapril are renally excreted and may require more significant adjustments. Fosinopril is not significantly affected by renal impairment. * **Hepatic Impairment:** Use with caution. Captopril and enalapril generally do not require dose adjustment unless hepatic insufficiency is severe. * **Volume Depletion:** Initiate at lower doses and titrate cautiously. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes or renal impairment. * Pregnancy (teratogenic). ## Adverse Effects * **Common:** Dry cough, dizziness, headache, fatigue, hyperkalemia, hypotension. * **Serious:** Angioedema (lips, face, tongue, larynx), renal failure, severe hypotension, rash, hepatotoxicity. ## Key Drug Interactions * **Potassium-Sparing Diuretics/Potassium Supplements/Salt Substitutes:** Increased risk of hyperkalemia. * **Diuretics (Thiazide/Loop):** Increased risk of hypotension, especially with initial doses. Consider withholding diuretic or starting ACE inhibitor at lower dose. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal impairment. * **Lithium:** ACE inhibitors can increase lithium levels. Monitor lithium levels. * **mTOR Inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. * **Aliskiren:** Contraindicated in patients with diabetes or renal impairment; increased risk of hyperkalemia and hypotension. * **ARBs:** Increased risk of hyperkalemia, hypotension, and renal dysfunction; generally avoid combination. ## Monitoring * Blood pressure (at baseline and regularly during treatment). * Serum potassium (baseline and periodically). * Renal function (serum creatinine, BUN) (baseline and periodically). * Signs and symptoms of angioedema or hypersensitivity. * For heart failure: signs and symptoms of fluid overload, exercise tolerance. ## Clinical Pearls * The characteristic dry cough is thought to be due to increased bradykinin levels. If cough is bothersome, consider switching to an ARB. * Initiate at lower doses, especially in patients who are elderly, volume-depleted, or on concomitant diuretics, to minimize risk of hypotension and renal dysfunction. * ACE inhibitors are generally renoprotective in patients with diabetes and proteinuria. * Angioedema is a medical emergency and requires immediate discontinuation of the ACE inhibitor and prompt treatment. *** *Disclaimer: This information is intended for educational purposes and should not be considered a substitute for professional medical advice. Always consult the most current prescribing information and professional guidelines for complete details and to ensure patient-specific appropriateness.*