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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
* Chronic kidney disease (CKD) with proteinuria
## Adult Dosing
Dosing varies significantly between individual ACE inhibitors. Generally, treatment is initiated at a low dose and titrated upwards based on patient response and tolerability.
* **Benazepril:** Start 5-10 mg once daily, titrate up to 40 mg/day.
* **Captopril:** Start 6.25-12.5 mg every 8-12 hours, titrate up to 50 mg every 8 hours.
* **Enalapril:** Start 2.5-5 mg once or twice daily, titrate up to 10-40 mg/day (once or twice daily).
* **Fosinopril:** Start 5-10 mg once daily, titrate up to 40 mg/day.
* **Lisinopril:** Start 5-10 mg once daily, titrate up to 40 mg/day.
* **Moexipril:** Start 7.5 mg once daily, titrate up to 30 mg/day.
* **Perindopril:** Start 2.5-5 mg once daily, titrate up to 10 mg/day.
* **Ramipril:** Start 2.5-5 mg once daily, titrate up to 10 mg/day.
* **Trandolapril:** Start 0.5-1 mg once daily, titrate up to 4 mg/day.
## Pediatric Dosing
* **Hypertension:** Dosing is highly variable and often guided by nomograms or specific protocols.
* **Enalapril:** 0.07 mg/kg/day (maximum 5 mg/day) for children aged 1 month to 16 years.
* **Lisinopril:** 0.07 mg/kg/day (maximum 5 mg/day) for children aged 6 to 16 years.
* Other ACE inhibitors may have established pediatric dosing, but requires specific reference.
## Dose Adjustments
* **Renal Impairment:** Dose reduction is typically required in patients with significant renal impairment (creatinine clearance < 30 mL/min). Specific recommendations vary by drug and degree of impairment.
* **Hepatic Impairment:** Generally, dose adjustments are not necessary unless hepatic dysfunction is severe.
## 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.
* Pregnancy (especially in the second and third trimesters).
## Adverse Effects
* **Common:** Dry cough, dizziness, hyperkalemia, hypotension, fatigue, headache.
* **Less Common:** Angioedema (potentially life-threatening), rash, renal dysfunction, taste disturbances.
## Key Drug Interactions
* **Potassium-sparing diuretics/Potassium supplements/ARBs/Aliskiren:** Increased risk of hyperkalemia.
* **NSAIDs/COX-2 inhibitors:** May reduce antihypertensive effect and increase risk of renal dysfunction.
* **Lithium:** Increased serum lithium levels and toxicity.
* **Diuretics:** Increased risk of hypotension, especially in volume-depleted patients.
* **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema.
## Monitoring
* Blood pressure
* Serum creatinine and electrolytes (especially potassium)
* Renal function (baseline and periodically)
* Signs and symptoms of angioedema and hypersensitivity
## Clinical Pearls
* Dry cough is a common, dose-related side effect and may necessitate discontinuation or switching to an angiotensin II receptor blocker (ARB).
* First-dose hypotension can occur, especially in patients taking diuretics or who are volume-depleted. Administer the first dose cautiously and monitor closely.
* Hyperkalemia is a significant concern, particularly in patients with renal impairment or those taking potassium-sparing agents.
* ACE inhibitors are generally contraindicated in pregnancy due to the risk of fetal harm.
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**Disclaimer:** This information is intended for healthcare professionals and should not be used as a substitute for professional medical advice. Always consult the most current prescribing information and relevant clinical guidelines before making any treatment decisions.
