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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 (reduced ejection fraction) * Post-Myocardial Infarction (in select patients) * Diabetic Nephropathy (in select patients) ## Adult Dosing Dosing varies significantly by agent. Common starting doses and maximum doses are listed below for frequently used agents. Titration is typically based on blood pressure response and patient tolerance. * **Benazepril:** Start 10 mg once daily. Max 80 mg once daily. * **Captopril:** Start 25 mg twice daily. Max 150 mg three times daily. * **Enalapril (oral):** Start 5 mg once daily. Max 40 mg once daily. * **Enalaprilat (IV):** Start 0.625 mg every 6 hours. Max 5 mg every 6 hours. * **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. ## Pediatric Dosing Established pediatric dosing is available for some ACE inhibitors, but often requires careful titration and monitoring. Specific dosing should be guided by evidence-based guidelines or local institutional protocols. * **Enalapril:** * Hypertension: 0.07 mg/kg/day to 0.5 mg/kg/day divided once or twice daily. Max 40 mg/day. * **Lisinopril:** * Hypertension: 0.07 mg/kg/day to 0.31 mg/kg/day once daily. Max 40 mg/day. ## Dose Adjustments * **Renal Impairment:** Dose reduction is generally recommended, particularly for agents cleared renally. Specific recommendations vary by agent and degree of renal impairment. * **Hepatic Impairment:** Use with caution. Some agents may require dose adjustment. ## Contraindications * History of angioedema related to prior ACE inhibitor treatment. * Concomitant use with aliskiren in patients with diabetes mellitus. * Pregnancy (Category D in 2nd and 3rd trimesters; generally avoided in 1st trimester). * Known hypersensitivity to the specific ACE inhibitor. ## Adverse Effects * **Common:** Dry cough, dizziness, fatigue, headache, hyperkalemia, hypotension. * **Serious:** Angioedema (can be life-threatening), acute kidney injury, hyperkalemia, hepatotoxicity. ## Key Drug Interactions * **Potassium-Sparing Diuretics/Potassium Supplements/ARBs/Aliskiren:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal impairment. * **Diuretics (Thiazide/Loop):** Increased risk of symptomatic hypotension, especially upon initiation. * **Lithium:** ACE inhibitors can reduce lithium clearance, leading to increased lithium levels and toxicity. * **mTOR Inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. ## Monitoring * **Blood Pressure:** Regularly monitor for hypotension and efficacy. * **Renal Function:** Baseline and periodic monitoring of serum creatinine and BUN. * **Electrolytes:** Baseline and periodic monitoring of serum potassium. * **Angioedema:** Educate patients on signs and symptoms and to seek immediate medical attention. ## Clinical Pearls * The characteristic dry cough is often dose-related and may resolve upon discontinuation or switching to an ARB. * First-dose hypotension can occur, especially in volume-depleted patients or those on diuretics. Consider a lower starting dose and administer the first dose at bedtime. * ACE inhibitors are generally considered renoprotective in patients with diabetic nephropathy and proteinuria. * Discontinue immediately if angioedema occurs. *** *This information is for educational purposes only and does not constitute medical advice. Always verify current prescribing information with official drug references and consider individual patient factors.*