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# ACE Inhibitors
## Overview
ACE inhibitors (e.g., lisinopril, enalapril, ramipril) are a class of medications that block the action of angiotensin-converting enzyme, leading to vasodilation and reduced aldosterone secretion. This results in decreased blood pressure and workload on the heart.
## Primary Indications
* Hypertension
* Heart failure (systolic dysfunction)
* Post-myocardial infarction (LV dysfunction)
* Diabetic nephropathy (proteinuria)
* Chronic kidney disease (proteinuria)
## Adult Dosing
Dosing is highly individualized and depends on the specific ACE inhibitor and indication. Typical starting doses for hypertension:
* **Benazepril:** 10 mg orally once daily
* **Captopril:** 12.5-25 mg orally twice daily
* **Enalapril:** 5 mg orally once or twice daily
* **Lisinopril:** 10 mg orally once daily
* **Ramipril:** 2.5 mg orally once daily
Maximum doses vary by indication and agent. For hypertension, common maximums range from 40 mg (enalapril) to 80 mg (benazepril) daily. For heart failure, specific maximums apply (e.g., lisinopril 35 mg daily).
## Pediatric Dosing
Established for some agents:
* **Enalapril:** 0.07 mg/kg/day orally once daily, increased to a maximum of 0.5 mg/kg/day or 20 mg/day.
* **Lisinopril:** 0.07 mg/kg/day orally once daily, increased to a maximum of 0.61 mg/kg/day or 20 mg/day.
## Dose Adjustments
* **Renal Impairment:** Dose reductions are often necessary, particularly in patients with significant renal dysfunction. Specific guidelines vary by agent.
* **Hepatic Impairment:** Cautious initiation and dose titration are recommended.
* **Volume Depletion:** Correct before initiating or start at a lower dose.
## Contraindications
* History of angioedema related to ACE inhibitor therapy
* Concomitant use with aliskiren in patients with diabetes mellitus or moderate to severe renal impairment
* Pregnancy (especially second and third trimesters)
* Hypersensitivity to the specific ACE inhibitor
## Adverse Effects
* **Common:** Cough (dry, persistent), dizziness, headache, fatigue, hyperkalemia.
* **Serious:** Angioedema (facial, laryngeal), acute kidney injury (especially in renal artery stenosis), hypotension, neutropenia/agranulocytosis (rare).
## Key Drug Interactions
* **Potassium-sparing diuretics & Potassium supplements:** Increased risk of hyperkalemia.
* **NSAIDs:** May reduce antihypertensive effect and increase risk of renal impairment.
* **ARBs & Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal impairment. Avoid combination.
* **Lithium:** ACE inhibitors can increase lithium levels.
## Monitoring
* **Baseline:** Serum creatinine, BUN, electrolytes (especially potassium).
* **During therapy:** Serum creatinine, BUN, electrolytes (potassium) within 1-2 weeks of initiation or dose increase, and periodically thereafter. Blood pressure.
## Clinical Pearls
* The characteristic dry cough is often dose-limiting and may resolve upon discontinuation.
* Monitor for signs of angioedema, which can be life-threatening and requires immediate discontinuation.
* Use with caution in patients with bilateral renal artery stenosis or solitary kidney due to risk of acute kidney injury.
* Initiate at a lower dose in elderly patients, those who are volume-depleted, or those with significant renal impairment.
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*This information is intended for clinical use and does not substitute for a comprehensive review of the current prescribing information for the specific agent being used. Always verify current drug information with reliable sources.*
