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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, thereby leading to vasodilation and reduced blood pressure. ## Primary Indications * Hypertension * Heart Failure (systolic dysfunction) * Post-Myocardial Infarction (in patients with clinical signs of heart failure or left ventricular dysfunction) * Diabetic Nephropathy (in patients with type 1 diabetes and hypertension) ## Adult Dosing Dosing varies by specific agent. Initial doses are typically low and titrated upwards. * **Benazepril:** Start at 10 mg once daily. Usual range: 10-40 mg/day. Max: 80 mg/day. * **Captopril:** Start at 25 mg twice daily. Usual range: 25-150 mg twice daily. Max: 450 mg/day. * **Enalapril:** Start at 5 mg once daily (oral). Usual range: 10-40 mg/day. Max: 40 mg/day. For IV use: 1.25 mg every 6 hours. * **Fosinopril:** Start at 10 mg once daily. Usual range: 10-40 mg/day. Max: 80 mg/day. * **Lisinopril:** Start at 10 mg once daily. Usual range: 10-40 mg/day. Max: 80 mg/day. * **Moexipril:** Start at 7.5 mg once daily. Usual range: 7.5-30 mg/day. Max: 30 mg/day. * **Perindopril:** Start at 5 mg once daily. Usual range: 5-10 mg/day. Max: 20 mg/day. * **Quinapril:** Start at 5 mg twice daily. Usual range: 10-40 mg twice daily. Max: 80 mg/day. * **Ramipril:** Start at 2.5 mg once daily. Usual range: 2.5-10 mg/day. Max: 10 mg/day. * **Trandolapril:** Start at 1 mg once daily. Usual range: 1-4 mg/day. Max: 8 mg/day. ## Pediatric Dosing ACE inhibitor use in children is less common and generally reserved for specific indications. Dosing is often weight-based and requires careful monitoring. * **Captopril:** Hypertension: 0.3 mg/kg/dose every 8-12 hours. Max: 1.5 mg/kg/dose or 50 mg/dose. * **Enalapril:** Hypertension: 0.1 mg/kg/dose once daily. Max: 0.5 mg/kg/dose or 20 mg/dose. * **Lisinopril:** Hypertension: 0.07 mg/kg/dose once daily. Max: 0.61 mg/kg/dose or 20 mg/dose. *Dosing for other agents and specific indications may vary and should be determined by local protocol or specialist guidance.* ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially in patients with significant renal impairment (creatinine clearance < 30 mL/min). Specific adjustments vary by agent and are usually guided by renal function tests. * **Hepatic Impairment:** Generally, no dose adjustment is needed for mild to moderate hepatic impairment, but caution is advised. * **Volume Depletion:** Initiate at lower doses and titrate cautiously. ## Contraindications * History of angioedema related to prior ACE inhibitor treatment. * Concomitant use with aliskiren in patients with diabetes. * Pregnancy (especially second and third trimesters). ## Adverse Effects * **Common:** Dry cough, hyperkalemia, dizziness, fatigue, headache, hypotension. * **Serious:** Angioedema (potentially life-threatening), acute kidney injury, severe hypotension, hepatotoxicity. ## 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 impairment. * **Lithium:** ACE inhibitors can decrease lithium clearance, leading to increased lithium levels and toxicity. * **Diuretics:** Increased risk of hypotension, especially with concurrent diuretic use. * **ARBs (Angiotensin II Receptor Blockers):** Avoid concomitant use due to increased risk of adverse events without clear benefit. * **mTOR Inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. ## Monitoring * **Blood Pressure:** Regularly monitor for therapeutic response and hypotension. * **Serum Potassium:** Monitor at baseline and periodically, especially in patients with renal impairment or taking potassium supplements/sparing diuretics. * **Renal Function (BUN, Creatinine):** Monitor at baseline and periodically, especially in patients with renal impairment or risk factors for kidney disease. * **Signs of Angioedema:** Educate patients to report any swelling of the face, lips, tongue, or throat immediately. ## Clinical Pearls * The characteristic dry cough is thought to be due to bradykinin accumulation and typically resolves upon discontinuation. * Hypotension is more likely with initial doses, volume depletion, or concomitant diuretic use. Patients should be advised to stand up slowly. * Angioedema is a rare but serious adverse effect and requires immediate discontinuation of the ACE inhibitor. * ACE inhibitors are generally considered safe and effective in diabetic patients, offering renal protection. * Renal function and potassium levels should be monitored closely, especially in high-risk patients. *** *This information is intended for educational purposes only and does not substitute for professional medical advice. Always consult with a qualified healthcare provider for any health concerns or before making any decisions related to your health or treatment. Verify current prescribing information and guidelines before use.*