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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) * Post-myocardial infarction (for specific agents) * Diabetic nephropathy (proteinuric kidney disease) ## Adult Dosing Dosing varies by specific agent. Typical starting doses and maximums include: * **Benazepril:** Start 10 mg once daily, max 40 mg once daily. * **Captopril:** Start 25 mg twice daily, max 150 mg three times daily. (Requires more frequent dosing) * **Enalapril:** Start 5 mg once or twice daily, max 40 mg once or twice daily. * **Fosinopril:** Start 10 mg once daily, max 80 mg once daily. * **Lisinopril:** Start 10 mg once daily, max 40 mg once daily. * **Moexipril:** Start 7.5 mg once daily, max 30 mg once daily. * **Perindopril:** Start 2.5-5 mg once daily, max 10 mg once daily. * **Ramipril:** Start 2.5 mg once daily, max 10 mg once daily. * **Trandolapril:** Start 1 mg once daily, max 8 mg once daily. * **Quinapril:** Start 10 mg once or twice daily, max 80 mg once or twice daily. Dose titration is guided by blood pressure response and tolerability. ## Pediatric Dosing * **Hypertension:** Dosing is highly variable and often weight-based. * **Captopril:** 0.3-0.5 mg/kg/dose every 8-12 hours. Max 3 mg/kg/day. * **Enalapril:** 0.1 mg/kg/dose once daily. Max 0.5 mg/kg/day. * **Lisinopril:** 0.07-0.2 mg/kg/dose once daily. Max 20 mg/day. * Consult specific pediatric guidelines for precise dosing and indications. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially in moderate to severe renal impairment. Specific guidelines vary by agent. * **Hepatic Impairment:** Generally no dose adjustment is needed, but caution is advised. ## Contraindications * History of angioedema related to ACE inhibitor therapy. * Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment. * Pregnancy (second and third trimesters). ## Adverse Effects * **Cough:** Dry, persistent cough is common. * **Hypotension:** Especially with the first dose or in volume-depleted patients. * **Hyperkalemia:** Risk increases with renal impairment and potassium-sparing diuretics. * **Angioedema:** Rare but potentially life-threatening. Risk is higher in African Americans. * **Renal dysfunction:** Can occur, particularly in patients with bilateral renal artery stenosis or severe heart failure. * **Other:** Dizziness, fatigue, rash, dysgeusia, elevated liver enzymes. ## Key Drug Interactions * **Diuretics (especially potassium-sparing):** Increased risk of hyperkalemia. * **Potassium supplements:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction; contraindicated in diabetes and renal impairment. * **ARBs:** Increased risk of angioedema and hyperkalemia; generally avoided, especially in high-risk patients. * **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, especially after initiation or dose changes. * **Renal Function:** Serum creatinine and BUN, particularly in patients with pre-existing renal disease or risk factors. * **Potassium:** Serum potassium levels, especially with renal impairment, concurrent diuretic use, or potassium supplementation. * **Angioedema:** Patient education on signs and symptoms is crucial. ## Clinical Pearls * Initiate at a low dose and titrate slowly to minimize side effects like hypotension and cough. * ACE inhibitors are generally considered renoprotective in patients with diabetes and proteinuria. * Discontinue ACE inhibitors immediately if angioedema occurs. * Consider alternative antihypertensive agents in patients who develop a persistent cough. * First-dose hypotension can be significant; advise patients to take the first dose at bedtime and avoid activities requiring alertness. *** *Disclaimer: This information is for educational purposes only and does not substitute for professional medical advice. Always consult with a qualified healthcare provider to determine the best course of treatment for your specific condition and to ensure you have the most current prescribing information.*