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# ACE Inhibitors ## Overview Angiotensin-converting enzyme (ACE) inhibitors are a class of medications 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 (left ventricular dysfunction) * Diabetic nephropathy (in certain patients with proteinuria) * Chronic kidney disease (in certain patients with proteinuria) ## Adult Dosing Dosing is highly individualized and depends on the specific ACE inhibitor, indication, and patient response. Titration is crucial. * **Benazepril:** Start 5-10 mg once daily. Max 40 mg once daily. * **Captopril:** Start 12.5-25 mg twice daily. Max 150 mg three times daily. * **Enalapril:** Start 2.5-5 mg once or twice daily. Max 40 mg once or twice daily. * **Fosinopril:** Start 5-10 mg once daily. Max 40 mg once daily. * **Lisinopril:** Start 5-10 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. * **Quinapril:** Start 5-10 mg twice daily. Max 80 mg twice daily. * **Ramipril:** Start 2.5-5 mg once daily. Max 10 mg once daily. * **Trandolapril:** Start 0.5-1 mg once daily. Max 4 mg once daily. Dose adjustments for specific indications (e.g., heart failure) may differ. Refer to institutional protocols or specific drug monographs. ## Pediatric Dosing Established pediatric dosing varies by age and indication. Consult specific pediatric guidelines. * **Enalapril:** 0.07 mg/kg/day divided twice daily for hypertension. Max 0.61 mg/kg/day or 40 mg/day. * **Lisinopril:** 0.07 mg/kg/day once daily for hypertension. Max 0.61 mg/kg/day or 40 mg/day. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially with lower GFRs. Captopril and enalapril are renally eliminated. Lisinopril is also renally eliminated. Consult specific drug monographs for recommended adjustments based on creatinine clearance. * **Hepatic Impairment:** Generally no dose adjustment required for most ACE inhibitors, but caution is advised. ## Contraindications * History of angioedema related to prior ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes. * Second and third trimesters of pregnancy. ## Adverse Effects * **Hypotension:** Especially with the first dose or in volume-depleted patients. * **Cough:** Dry, persistent cough (most common). * **Hyperkalemia:** Particularly in patients with renal impairment or on potassium-sparing diuretics. * **Angioedema:** Rare but potentially life-threatening. * **Renal dysfunction:** Can worsen pre-existing renal impairment. * **Dizziness, fatigue, headache.** * **Rash.** * **Dysgeusia (altered taste).** ## Key Drug Interactions * **Diuretics:** Increased risk of hypotension and hyperkalemia. * **Potassium Supplements and Potassium-Sparing Diuretics (e.g., spironolactone, amiloride):** Increased risk of severe hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Lithium:** ACE inhibitors can increase lithium levels, increasing risk of toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus) and DPP-4 inhibitors (e.g., vildagliptin):** Increased risk of angioedema. * **Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction. Avoid concomitant use, especially in diabetic patients. ## Monitoring * **Blood Pressure:** Regularly, especially after initiation or dose changes. * **Serum Potassium:** Prior to therapy, within the first month, and periodically thereafter. * **Renal Function (BUN, Creatinine):** Prior to therapy, within the first month, and periodically thereafter, especially in high-risk patients. * **Signs and Symptoms of Angioedema:** Educate patients to report immediately. ## Clinical Pearls * ACE inhibitors are generally considered first-line agents for hypertension and heart failure. * The characteristic dry cough is thought to be due to bradykinin accumulation. If cough is bothersome, consider switching to an angiotensin II receptor blocker (ARB). * Initiate at a low dose and titrate slowly to minimize hypotension and other side effects. * Monitor renal function and potassium closely, especially in patients with pre-existing renal disease or those on concomitant medications affecting potassium. * Advise patients to report any signs of angioedema (swelling of the face, lips, tongue, or throat) immediately. * ACE inhibitors are contraindicated in pregnancy. *** *Disclaimer: This information is for educational purposes only and does not substitute for professional medical advice. Always verify current prescribing information with the official drug product labeling or a reliable drug information resource before making any clinical decisions.*