Ace%252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252520inhibitors

# ACE Inhibitors ## Overview Angiotensin-Converting Enzyme (ACE) inhibitors are a class of drugs used primarily to treat hypertension and heart failure. They work by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. ## Primary Indications * Hypertension * Heart failure (systolic dysfunction) * Post-myocardial infarction (to improve survival) * Diabetic nephropathy (proteinuria reduction) * Chronic kidney disease (proteinuria reduction) ## Adult Dosing Dosing is highly individualized and depends on the specific ACE inhibitor, indication, and patient response. Titration is common. * **Benzapril:** Hypertension: 10 mg once daily, titrate to 20-40 mg/day. * **Captopril:** Hypertension: 25 mg BID-TID, titrate to 50 mg BID-TID (max 450 mg/day). Heart failure: 6.25 mg TID, titrate to 50 mg TID. * **Enalapril:** Hypertension: 5 mg once daily, titrate to 10-40 mg/day. Heart failure: 2.5 mg BID, titrate to 10 mg BID. * **Fosinopril:** Hypertension: 10 mg once daily, titrate to 20-40 mg/day. Heart failure: 5 mg once daily, titrate to 10-40 mg/day. * **Lisinopril:** Hypertension: 10 mg once daily, titrate to 20-40 mg/day (max 80 mg/day). Heart failure: 2.5 mg once daily, titrate to 5-35 mg/day. * **Moexipril:** Hypertension: 7.5-15 mg once daily, titrate to 30 mg/day. * **Perindopril:** Hypertension: 2.5-5 mg once daily, titrate to 10 mg/day. Heart failure: 2.5 mg once daily, titrate to 10 mg/day. * **Ramipril:** Hypertension: 2.5 mg once daily, titrate to 5-20 mg/day. Heart failure: 1.25 mg once daily, titrate to 10 mg/day. * **Trandolapril:** Hypertension: 1 mg once daily, titrate to 4 mg/day. Heart failure: 0.5 mg once daily, titrate to 4 mg/day. ## Pediatric Dosing * **Enalapril:** Hypertension: 0.07 mg/kg once daily (max 40 mg/day). * **Lisinopril:** Hypertension: 0.07 mg/kg once daily (max 40 mg/day). * **Ramipril:** Hypertension: Generally not recommended due to lack of established dosing. Dosing for other ACE inhibitors in pediatrics is generally not well-established or recommended. ## Dose Adjustments * **Renal Impairment:** Initial doses should be reduced, especially for enalapril, lisinopril, and ramipril. Monitor renal function and potassium. * Captopril: ClCr < 30 mL/min: Start with 12.5 mg TID. * Enalapril: ClCr < 30 mL/min: Start with 2.5 mg/day. * Lisinopril: ClCr < 30 mL/min: Start with 2.5-5 mg/day. * Ramipril: ClCr < 40 mL/min: Start with 1.25 mg/day. * **Hepatic Impairment:** Use with caution. Captopril and enalapril may require lower doses. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment. * Hereditary angioedema. * Concomitant use with aliskiren in patients with diabetes. * Pregnancy (especially 2nd and 3rd trimesters). ## Adverse Effects * **Common:** Dry cough, dizziness, fatigue, headache, hyperkalemia. * **Serious:** Angioedema (facial, laryngeal), hypotension, renal dysfunction/failure, hyperkalemia, neutropenia, hepatotoxicity. ## Key Drug Interactions * **Potassium-sparing diuretics (e.g., spironolactone, amiloride), potassium supplements, salt substitutes:** Increased risk of hyperkalemia. * **NSAIDs, COX-2 inhibitors:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Diuretics (especially thiazides, loop diuretics):** Increased risk of hypotension and azotemia. * **Lithium:** Increased lithium levels and toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus), DPP-4 inhibitors (e.g., saxagliptin, linagliptin):** Increased risk of angioedema. * **Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction. Avoid in diabetics. ## Monitoring * **Blood Pressure:** Regularly. * **Renal Function:** Serum creatinine and BUN, especially at initiation and with dose changes. * **Electrolytes:** Serum potassium, especially with renal impairment or concomitant use of potassium-sparing agents. * **Angioedema:** Educate patients on signs and symptoms. ## Clinical Pearls * Cough is a common side effect, often dose-limiting. If cough is bothersome and not due to other causes, consider switching to an Angiotensin II Receptor Blocker (ARB). * Initiate at low doses and titrate gradually, especially in patients with volume depletion, heart failure, or renal impairment. * The risk of angioedema is higher in Black patients. * ACE inhibitors can be teratogenic; discontinue immediately if pregnancy is detected. * First-dose hypotension can occur, particularly in patients on diuretics or with significant sodium depletion. *** **Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines for specific patient management decisions.