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# ACE Inhibitors ## Overview Angiotensin-converting enzyme (ACE) inhibitors are a class of drugs 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) * Post-myocardial infarction (MI) * Diabetic nephropathy * Certain chronic kidney diseases ## Adult Dosing Dosing is highly individualized and depends on the specific ACE inhibitor, indication, and patient response. Typical starting doses are low and titrated upwards. * **Benazepril:** Hypertension: 10-40 mg daily. Heart Failure: 10 mg daily, titrate to 40 mg daily. * **Captopril:** Hypertension: 25 mg twice daily, titrate to 50 mg twice or three times daily (max 150 mg twice daily). Heart Failure: 6.25-12.5 mg three times daily, titrate to 50 mg three times daily. * **Enalapril:** Hypertension: 5 mg once or twice daily, titrate to 10-40 mg daily (max 40 mg daily). Heart Failure: 2.5 mg once or twice daily, titrate to 10-20 mg twice daily (max 40 mg daily). * **Fosinopril:** Hypertension: 10-40 mg daily (max 80 mg daily). Heart Failure: 10 mg daily, titrate to 40 mg daily. * **Lisinopril:** Hypertension: 10 mg once daily, titrate to 40 mg daily (max 80 mg daily). Heart Failure: 5 mg once daily, titrate to 10-40 mg once daily. * **Moexipril:** Hypertension: 7.5-15 mg once daily, titrate to 30 mg daily. * **Perindopril:** Hypertension: 2.5-10 mg once daily (max 10 mg daily). Heart Failure: 2.5-5 mg once daily, titrate to 10 mg once daily. * **Quinapril:** Hypertension: 10-40 mg twice daily (max 80 mg daily). Heart Failure: 5 mg twice daily, titrate to 10-40 mg twice daily. * **Ramipril:** Hypertension: 2.5-5 mg once daily, titrate to 10 mg once daily. Heart Failure: 2.5 mg twice daily, titrate to 10 mg twice daily. * **Trandolapril:** Hypertension: 1-4 mg once daily (max 8 mg daily). Heart Failure: 1 mg once daily, titrate to 4 mg once daily. ## Pediatric Dosing Pediatric dosing is less established and often requires consultation with pediatric specialists. Doses are generally weight-based. * **Enalapril:** Hypertension: 0.07 mg/kg/day once daily, titrate to 0.21 mg/kg/day (max 40 mg/day). * **Lisinopril:** Hypertension: 0.07 mg/kg/day once daily, titrate to 0.21 mg/kg/day (max 40 mg/day). * **Captopril:** Hypertension: 0.3 mg/kg/dose three times daily, titrate based on response. ## Dose Adjustments * **Renal Impairment:** Reduce initial dose and titrate cautiously. Specific reductions vary by agent and degree of renal impairment. * **Hepatic Impairment:** Captopril and enalapril are less affected. Other agents may require dose adjustment. * **Concomitant Diuretics:** May require lower initial doses of ACE inhibitors. ## Contraindications * History of angioedema related to ACE inhibitor therapy. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes mellitus. * Pregnancy (especially second and third trimesters). * Hypersensitivity to the specific ACE inhibitor. ## Adverse Effects * Dry cough (most common) * Hypotension * Hyperkalemia * Angioedema (rare but serious, can be life-threatening) * Dizziness * Fatigue * Renal insufficiency (especially in patients with bilateral renal artery stenosis) * Taste disturbances (captopril) ## Key Drug Interactions * **Potassium-sparing diuretics (e.g., spironolactone, amiloride) and potassium supplements:** Increased risk of hyperkalemia. * **NSAIDs:** May blunt antihypertensive effect and increase risk of renal dysfunction. * **Lithium:** Increased lithium levels and toxicity. * **Diuretics:** Additive hypotensive effect; increased risk of first-dose hypotension. * **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. * **ARBs and Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction. Avoid concomitant use, especially in patients with diabetes. ## Monitoring * Blood pressure (regularly) * Serum potassium (baseline and periodically) * Renal function (creatinine, BUN) (baseline and periodically) * Signs and symptoms of angioedema and cough ## Clinical Pearls * Initiate at low doses and titrate slowly to assess tolerability and efficacy. * Advise patients about the potential for dry cough and angioedema. * Angioedema is a medical emergency and requires immediate discontinuation of the ACE inhibitor. * Monitor electrolytes and renal function closely, especially in patients with pre-existing renal disease or those taking other nephrotoxic agents. * ACE inhibitors are generally safe and effective in diabetic patients for both hypertension and nephroprotection. *** *Disclaimer: This information is for educational purposes and does not substitute professional medical advice. Always consult the most current prescribing information and your healthcare provider for definitive guidance.*