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# ACE Inhibitors ## Overview ACE inhibitors are a class of medications that block the action of angiotensin-converting enzyme, leading to vasodilation and reduced aldosterone secretion. This results in decreased blood pressure and reduced workload on the heart. ## Primary Indications * Hypertension * Heart failure (systolic dysfunction) * Post-myocardial infarction (MI) (left ventricular dysfunction) * Diabetic nephropathy * Proteinuric chronic kidney disease ## Adult Dosing Dosing is highly variable by specific agent, indication, and patient factors. Titration is generally required. * **Hypertension:** * Benazepril: Start 10 mg once daily, titrate up to 40 mg once daily. * Captopril: Start 25 mg twice daily, titrate up to 150 mg twice daily. * Enalapril: Start 5 mg once or twice daily, titrate up to 40 mg once or twice daily. * Fosinopril: Start 10 mg once daily, titrate up to 40 mg once daily. * Lisinopril: Start 10 mg once daily, titrate up to 40 mg once daily. * Moexipril: Start 7.5 mg once daily, titrate up to 30 mg once daily. * Perindopril: Start 5 mg once daily, titrate up to 10 mg once daily. * Quinapril: Start 10 mg once or twice daily, titrate up to 80 mg once or twice daily. * Ramipril: Start 2.5 mg once daily, titrate up to 10 mg once daily. * Trandolapril: Start 1 mg once daily, titrate up to 8 mg once daily. * **Heart Failure:** Dosing varies significantly. Generally started at a lower dose and titrated upwards as tolerated. * **Post-MI:** Generally started within 24 hours of MI if hemodynamically stable. Specific doses vary by agent. ## Pediatric Dosing ACE inhibitors are used in pediatrics for hypertension and sometimes heart failure. Dosing is weight-based and requires careful titration. Exact dosing depends on local protocol and specific agent. * **Captopril:** 0.3 mg/kg/dose to 0.5 mg/kg/dose every 8 to 12 hours. Maximum dose varies by indication. * **Enalapril:** 0.07 mg/kg/dose once daily to 0.21 mg/kg/dose twice daily. Maximum dose varies by indication. * **Lisinopril:** 0.07 mg/kg/dose once daily. Maximum dose varies by indication. ## Dose Adjustments * **Renal Impairment:** Dose reduction is usually necessary, particularly in severe renal impairment. Specific guidelines vary by agent. Monitor serum creatinine and potassium. * **Hepatic Impairment:** Use with caution. Dose adjustments may be needed, especially for prodrugs like enalapril and ramipril. ## Contraindications * History of angioedema related to ACE inhibitor therapy. * Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment. * Pregnancy (Category D in 2nd and 3rd trimesters; contraindicated). ## Adverse Effects * Cough (dry, persistent) * Hypotension, dizziness * Hyperkalemia * Angioedema (rare but life-threatening, particularly affecting face, lips, tongue, glottis, and intestines) * Renal insufficiency (especially in patients with bilateral renal artery stenosis) * Fatigue, headache * Rash ## Key Drug Interactions * **Potassium-sparing diuretics, potassium supplements, salt substitutes:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Diuretics (especially thiazide diuretics):** Increased risk of hypotension, particularly with initial doses. * **Lithium:** ACE inhibitors can increase lithium levels, leading to toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. * **ARBs and Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction. Avoid concomitant use in high-risk patients. ## Monitoring * Blood pressure (before and during therapy) * Serum potassium (baseline and periodically) * Serum creatinine and BUN (baseline and periodically) * Signs and symptoms of angioedema * For patients with heart failure, monitor for worsening symptoms, volume status, and electrolytes. ## Clinical Pearls * Cough is a common adverse effect and is usually dose-dependent and reversible upon discontinuation. * Angioedema is a medical emergency. Patients should be instructed to discontinue the medication immediately and seek emergency care if it occurs. * Initiate therapy at a low dose and titrate slowly, especially in patients with heart failure, the elderly, or those on diuretics. * Monitor renal function and potassium closely, particularly in patients with pre-existing renal disease or other risk factors. * ACE inhibitors are generally safe and effective in diabetic patients, and can help prevent or slow the progression of diabetic nephropathy. *** *This information is intended for educational purposes and does not substitute for professional medical advice. Always consult with a qualified healthcare provider to confirm the accuracy and applicability of this information to your specific situation. Prescribing information can change; always verify with the most current official drug labeling.*