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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 (systolic dysfunction) * Post-myocardial infarction (MI) * Diabetic nephropathy * Proteinuric chronic kidney disease ## Adult Dosing Dosing is highly individualized and depends on the specific ACE inhibitor and indication. Common starting doses are typically low and titrated upwards. * **Hypertension:** * Benazepril: Start 10 mg PO daily, max 40 mg/day. * Captopril: Start 25 mg PO BID, max 150 mg TID. * Enalapril: Start 5 mg PO daily or BID, max 40 mg/day. * Lisinopril: Start 10 mg PO daily, max 40 mg/day. * Ramipril: Start 2.5 mg PO daily, max 20 mg/day. * **Heart Failure:** * Enalapril: Start 2.5 mg PO BID, max 20 mg BID. * Lisinopril: Start 5 mg PO daily, max 40 mg/day. * Ramipril: Start 1.25 mg PO daily, max 10 mg BID. *Note: Exact starting doses and titration schedules may vary based on local protocols and patient factors.* ## Pediatric Dosing * **Hypertension:** Dosing is often weight-based and may vary by specific agent. Consult specialized pediatric guidelines or product monographs. * Enalapril: 0.07 mg/kg/day PO divided BID, max 0.61 mg/kg/day or 40 mg/day. * Lisinopril: 0.07 mg/kg/day PO once daily, max 20 mg/day. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially in moderate to severe renal impairment. Monitor serum creatinine and potassium. * **Hepatic Impairment:** Cautious use; no specific dose adjustments for most, but monitor for adverse effects. ## Contraindications * History of angioedema related to prior ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes mellitus or moderate to severe renal impairment. * Pregnancy (especially second and third trimesters) due to risk of fetal injury and death. * Hypersensitivity to the drug. ## Adverse Effects * **Common:** Cough (dry, persistent), dizziness, fatigue, headache, hypotension. * **Serious:** Angioedema (facial, lip, tongue, throat, or intestinal), hyperkalemia, acute kidney injury (especially in those with bilateral renal artery stenosis or severe heart failure), rash, hepatic failure. ## Key Drug Interactions * **Potassium-sparing diuretics, potassium supplements, salt substitutes:** Increased risk of hyperkalemia. * **NSAIDs, COX-2 inhibitors:** May reduce antihypertensive effect and increase risk of renal impairment. * **Diuretics (especially potassium-depleting):** Increased risk of hypotension, especially with initial doses. * **ARBs, Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction. Avoid combination in most patients. * **Lithium:** ACE inhibitors can decrease lithium clearance, increasing the risk of lithium toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus), DPP-4 inhibitors (e.g., saxagliptin, linagliptin):** Increased risk of angioedema. ## Monitoring * **Baseline:** Serum creatinine, electrolytes (especially potassium), blood pressure. * **During therapy:** Serum creatinine, electrolytes (especially potassium), blood pressure, assess for cough and angioedema. Frequency of monitoring depends on indication and patient stability. ## Clinical Pearls * The characteristic dry cough is often dose-limiting and typically resolves after discontinuation. * Angioedema is a medical emergency and requires immediate discontinuation of the ACE inhibitor. * Initiate at low doses and titrate slowly, especially in patients with heart failure, renal impairment, or those taking diuretics. * Monitor renal function and potassium closely, particularly in at-risk populations (e.g., elderly, patients with renal artery stenosis, severe heart failure). * Avoid in pregnancy. *** *Disclaimer: This information is intended for clinical use and is not a substitute for professional medical advice. Always consult the most current prescribing information for specific drug details and local institutional protocols.*