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# ACE Inhibitors ## Overview ACE inhibitors (e.g., lisinopril, enalapril, ramipril) block the conversion of angiotensin I to angiotensin II, leading to vasodilation and reduced aldosterone secretion. ## Primary Indications * Hypertension * Heart Failure (HF) * Post-Myocardial Infarction (MI) * Diabetic Nephropathy * Proteinuric Kidney Disease ## Adult Dosing Dosing is highly individualized and depends on the specific agent and indication. Titration is crucial. * **Hypertension:** Initial doses vary by agent. Common starting doses: Lisinopril 10 mg once daily, Enalapril 5 mg once or twice daily, Ramipril 2.5 mg once daily. Maximum doses vary, e.g., Lisinopril up to 40 mg once daily. * **Heart Failure:** Initial doses are typically lower than for hypertension. Common starting doses: Lisinopril 2.5-5 mg once daily, Enalapril 2.5 mg twice daily. Target doses are often higher, e.g., Lisinopril 30-40 mg once daily, Enalapril 10-20 mg twice daily. * **Post-MI:** Dosing varies. For Lisinopril, often initiated at 5 mg daily, with titration to 10 mg daily. * **Diabetic Nephropathy/Proteinuric Kidney Disease:** Dosing typically mirrors hypertension guidelines, with titration guided by blood pressure and proteinuria. ## Pediatric Dosing * **Hypertension:** Established for specific agents. * Enalapril: 0.07-0.1 mg/kg/dose once daily, maximum 0.61 mg/kg/day or 40 mg/day. * Lisinopril: 0.07-0.2 mg/kg/dose once daily, maximum 20 mg/day. * Benzapril: 0.1-0.2 mg/kg/dose once daily, maximum 20 mg/day. * Dosing should be guided by renal function and blood pressure response. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially in severe impairment. Specific recommendations vary by agent and CrCl. Monitor potassium closely. * **Hepatic Impairment:** Caution is advised; dose adjustments may be needed for prodrugs like enalapril. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment. * Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment. * Pregnancy (typically Category D in the second and third trimesters). ## Adverse Effects * **Angioedema:** Rare but potentially life-threatening. * **Cough:** Dry, persistent cough is common. * **Hyperkalemia:** Especially in patients with renal impairment or on potassium-sparing diuretics. * **Hypotension:** Particularly with the first dose or in volume-depleted patients. * **Renal Dysfunction:** Can cause acute kidney injury, especially in susceptible individuals. * Dizziness, fatigue, rash. ## Key Drug Interactions * **Potassium-Sparing Diuretics (e.g., Spironolactone, Amiloride) & Potassium Supplements:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal impairment. * **Lithium:** ACE inhibitors can increase lithium levels. * **Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal impairment. Contraindicated in patients with diabetes. * **ARBs:** Increased risk of angioedema and hyperkalemia. ## Monitoring * **Blood Pressure:** Regularly, especially after initiation or dose changes. * **Serum Potassium:** Before initiation, during the first month, and periodically thereafter, especially in patients with risk factors for hyperkalemia. * **Renal Function (Serum Creatinine, BUN):** Before initiation, during the first month, and periodically. * **Signs/Symptoms of Angioedema:** Educate patients to report immediately. ## Clinical Pearls * Initiate at low doses and titrate slowly to minimize adverse effects, particularly hypotension and cough. * Angioedema can occur at any time during therapy and requires immediate discontinuation. * Contraindicated in pregnancy due to risk of fetal injury or death. * Cough is a common reason for discontinuation, but not a contraindication to trying an ARB. * Consider careful monitoring of renal function and potassium when used with diuretics or in patients with pre-existing renal disease. *** **Disclaimer:** This information is intended for healthcare professionals and does not substitute for complete prescribing information. Always consult the most current drug monographs and institutional protocols for definitive guidance.