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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 * Congestive Heart Failure (CHF) * Post-Myocardial Infarction (MI) to improve survival * Diabetic Nephropathy (proteinuria reduction) ## Adult Dosing Dosing varies significantly by agent and indication. Titration is common. * **Hypertension:** * Benazepril: Start 10 mg once daily, titrate to 20-40 mg once daily. * Captopril: Start 25 mg twice daily, titrate to 50 mg three times daily. * Enalapril: Start 5 mg once daily, titrate to 10-40 mg once or twice daily. * Fosinopril: Start 10 mg once daily, titrate to 20-40 mg once daily. * Lisinopril: Start 10 mg once daily, titrate to 20-40 mg once daily. * Moexipril: Start 7.5 mg once daily, titrate to 15-30 mg once daily. * Perindopril: Start 2.5-5 mg once daily, titrate to 10 mg once daily. * Quinapril: Start 10 mg once or twice daily, titrate to 20-80 mg once or twice daily. * Ramipril: Start 2.5 mg once daily, titrate to 10 mg once daily. * Trandolapril: Start 1 mg once daily, titrate to 4 mg once daily. * **Congestive Heart Failure:** * Enalapril: Start 2.5 mg twice daily, titrate to 10-20 mg twice daily. * Captopril: Start 6.25 mg three times daily, titrate to 50 mg three times daily. * Lisinopril: Start 5 mg once daily, titrate to 10-40 mg once daily. * Ramipril: Start 1.25 mg once daily, titrate to 10 mg once daily. * **Post-MI:** * Ramipril: Start 1.25 mg once daily, titrate to 5 mg twice daily. * **Diabetic Nephropathy:** * Ramipril: Start 1.25 mg once daily, titrate to 10 mg once daily. * Lisinopril: Start 10 mg once daily, titrate to 20 mg once daily. ## Pediatric Dosing Dosing for pediatric patients is often weight-based and may vary by indication. Consult specific pediatric guidelines or drug monographs. * **Hypertension:** * Enalapril: 0.07-0.1 mg/kg/dose once daily or twice daily, maximum 40 mg/day. * Lisinopril: 0.07-0.2 mg/kg/day once daily, maximum 40 mg/day. ## Dose Adjustments * **Renal Impairment:** Dose reduction and slower titration are necessary in patients with renal insufficiency. Specific recommendations depend on the agent and creatinine clearance. * **Hepatic Impairment:** Use with caution. Some agents (e.g., enalapril, lisinopril) may require dose reduction. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment. * Second and third trimesters of pregnancy. ## Adverse Effects * **Common:** Dry cough, dizziness, fatigue, headache, hypotension. * **Serious:** Angioedema (facial, laryngeal), hyperkalemia, acute kidney injury, neutropenia, hepatotoxicity. ## Key Drug Interactions * **Potassium-Sparing Diuretics & Potassium Supplements:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Lithium:** ACE inhibitors can increase serum lithium levels, leading to toxicity. * **mTOR Inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. * **ARBs & Aliskiren:** Increased risk of adverse events including hyperkalemia and renal dysfunction. ## Monitoring * **Baseline:** Renal function (serum creatinine, BUN), serum electrolytes (potassium). * **During Therapy:** * Blood pressure. * Renal function and electrolytes within 1-2 weeks of initiation or dose increase, and periodically thereafter. * Signs and symptoms of angioedema. ## Clinical Pearls * The characteristic dry cough is thought to be due to increased bradykinin levels and is usually reversible upon discontinuation. * Angioedema is a rare but life-threatening side effect; patients should be instructed to seek immediate medical attention if swelling of the face, lips, tongue, or throat occurs. * ACE inhibitors should be initiated at low doses and titrated gradually to minimize the risk of hypotension, especially in volume-depleted patients or those with heart failure. * Monitor renal function closely, especially in patients with pre-existing renal disease, heart failure, or bilateral renal artery stenosis. *** *Disclaimer: This information is intended for educational purposes only and does not constitute medical advice. Always consult the most current prescribing information, relevant clinical guidelines, and a healthcare professional for specific patient care decisions.*