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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. This results in decreased blood pressure and reduced cardiac workload. ## Primary Indications * Hypertension * Heart failure (systolic dysfunction) * Post-myocardial infarction (left ventricular dysfunction) * Diabetic nephropathy * Proteinuric kidney disease ## Adult Dosing Dosing varies by agent and indication. Common starting doses and maximums (unless otherwise specified): * **Hypertension:** * Lisinopril: Start 10 mg PO daily, max 40 mg daily. * Enalapril: Start 5 mg PO daily or BID, max 40 mg daily. * Ramipril: Start 2.5 mg PO daily, max 10 mg daily. * **Heart Failure:** * Enalapril: Start 2.5 mg PO BID, max 20 mg daily. * Lisinopril: Start 5 mg PO daily, max 40 mg daily. * Ramipril: Start 1.25 mg PO daily, max 10 mg daily. * **Post-MI:** * Lisinopril: Start 5 mg PO daily, titrate to 10 mg PO daily. * Ramipril: Start 1.25 mg PO daily, titrate to 5 mg PO BID. ## Pediatric Dosing Dosing in children is less established and requires careful titration based on weight and response. Consult pediatric-specific guidelines. * **Hypertension:** * Enalapril: 0.07 to 0.1 mg/kg/dose PO BID. Max 0.61 mg/kg/day. * Lisinopril: 0.07 mg/kg/dose PO daily. Max 10 mg daily for children < 20 kg, max 20 mg daily for children ≥ 20 kg. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary. Consult specific agent guidelines for recommended reductions based on creatinine clearance. * **Hepatic Impairment:** Use with caution; dose may need adjustment, especially for prodrugs like enalapril. ## Contraindications * History of angioedema related to ACE inhibitor therapy. * Concomitant use with aliskiren in patients with diabetes or moderate to severe renal impairment. * Pregnancy (risk of fetal injury or death). * Known hypersensitivity to the drug. ## Adverse Effects * **Angioedema:** Potentially life-threatening; seek immediate medical attention. * **Hyperkalemia:** Especially in patients with renal impairment or those taking potassium supplements/sparing diuretics. * **Hypotension:** Particularly with the first dose or in volume-depleted patients. * **Cough:** Dry, persistent cough is common. * **Renal dysfunction:** Can worsen pre-existing renal impairment. * **Dizziness, fatigue, headache.** * **Rash.** ## Key Drug Interactions * **Potassium-sparing diuretics (e.g., spironolactone, amiloride), potassium supplements, trimethoprim:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Diuretics (thiazide and loop):** Increased risk of hypotension, especially with initial doses. * **Lithium:** ACE inhibitors can decrease lithium clearance, increasing lithium toxicity risk. * **ARBs and Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction. Avoid concomitant use in specific populations. ## Monitoring * **Blood pressure:** Regularly, especially after initiation or dose changes. * **Renal function (serum creatinine, BUN):** Before initiating therapy and periodically thereafter. * **Potassium levels:** Before initiating therapy and periodically thereafter, especially in patients with renal impairment or hyperkalemia risk factors. * **Signs and symptoms of angioedema.** ## Clinical Pearls * Initiate at a low dose and titrate slowly, especially in patients with heart failure, renal impairment, or those taking diuretics. * Monitor for the first-dose hypotensive effect. Consider withholding diuretics or administering a lower initial ACE inhibitor dose in volume-depleted patients. * Discontinue immediately if angioedema occurs. * A persistent dry cough is a common side effect; consider switching to an ARB if bothersome. * ACE inhibitors are generally safe and effective in proteinuric kidney disease, but renal function and potassium should be monitored closely. *** **Disclaimer:** This information is intended for clinical use and does not replace comprehensive drug compendia. Always verify current prescribing information and consult with a qualified healthcare professional before making any clinical decisions.