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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 (proteinuria) * Chronic kidney disease (proteinuria) ## Adult Dosing Dosing varies significantly by agent. Titration is typically guided by blood pressure response and patient tolerance. * **Hypertension:** * Benazepril: Start 10 mg once daily, may increase to 20-40 mg once daily. * Captopril: Start 25 mg twice daily, may increase to 50 mg thrice daily. * Enalapril: Start 5 mg once or twice daily, may increase to 10-40 mg once or twice daily. * Fosinopril: Start 10 mg once daily, may increase to 20-40 mg once daily. * Lisinopril: Start 10 mg once daily, may increase to 20-40 mg once daily. * Moexipril: Start 7.5 mg once daily, may increase to 15 mg twice daily. * Perindopril: Start 5 mg once daily, may increase to 10 mg once daily. * Quinapril: Start 10 mg once or twice daily, may increase to 20-80 mg once or twice daily. * Ramipril: Start 2.5 mg once daily, may increase to 5-10 mg once daily. * Trandolapril: Start 1 mg once daily, may increase to 4 mg once daily. * **Heart Failure:** * Enalapril: Start 2.5 mg twice daily, titrate up to 10 mg twice daily. * Lisinopril: Start 5 mg once daily, titrate up to 10 mg once daily. * Ramipril: Start 2.5 mg twice daily, titrate up to 5 mg twice daily. * *Specific dosing for other ACE inhibitors in heart failure may be established and should be followed per local protocol.* * **Post-MI:** * Captopril: Start 6.25 mg thrice daily, titrate up to 12.5 mg thrice daily, then 25 mg thrice daily. * Enalapril: Start 5 mg once daily, titrate up to 10 mg twice daily, then 20 mg twice daily. * Lisinopril: Start 5 mg once daily, titrate up to 10 mg once daily, then 20 mg once daily. * Ramipril: Start 2.5 mg twice daily, titrate up to 5 mg twice daily, then 10 mg twice daily. * **Diabetic Nephropathy/CKD with Proteinuria:** * Dosing similar to hypertension, with titration aiming to reduce proteinuria. Max doses may be limited by side effects. ## Pediatric Dosing * **Hypertension:** Dosing is weight-based and varies by agent and age. * Enalapril: 0.07 mg/kg/dose orally once daily (max 5 mg/day in infants/children <6 years; max 20 mg/day in children >6 years). * Lisinopril: 0.07 mg/kg/dose orally once daily (max 5 mg/day). * *Refer to specific pediatric guidelines for other ACE inhibitors.* ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, particularly with severe renal impairment. Monitor serum creatinine and potassium. * **Hepatic Impairment:** Use with caution; dose adjustments may be needed. ## Contraindications * History of angioedema related to ACE inhibitor therapy. * Concomitant use of aliskiren in patients with diabetes. * Pregnancy (teratogenic risk). * Hypersensitivity to ACE inhibitors. ## Adverse Effects * **Common:** Dry cough, dizziness, hyperkalemia, fatigue, hypotension. * **Serious:** Angioedema (potentially life-threatening), acute kidney injury, severe hypotension, hyperkalemia, rash, elevated liver enzymes. ## Key Drug Interactions * **Potassium-sparing diuretics, potassium supplements, aliskiren, ARBs:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Lithium:** Increased lithium levels and risk of toxicity. * **Diuretics (especially thiazides):** Increased risk of symptomatic hypotension, particularly with the first dose. * **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. ## Monitoring * Blood pressure regularly. * Serum electrolytes (potassium) and renal function (creatinine, BUN) at baseline, during titration, and periodically thereafter. * Signs and symptoms of angioedema. * Signs and symptoms of infection (neutropenia is rare but possible). ## Clinical Pearls * Cough is a common side effect, typically dry and bothersome, and resolves upon discontinuation. * Angioedema is a serious, idiosyncratic reaction and a contraindication to further use. * First-dose hypotension can occur, especially in volume-depleted patients or those on diuretics. * ACE inhibitors are generally considered renoprotective in patients with diabetes and proteinuria. * Discontinue ACE inhibitors in pregnancy due to teratogenicity. *** *This information is for educational purposes only and does not constitute medical advice. Always consult the most current prescribing information and a healthcare professional for accurate and individualized medical guidance.*