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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
* Chronic kidney disease (CKD) with proteinuria
## Adult Dosing
Dosing varies significantly by specific ACE inhibitor and indication. Common starting doses (once daily unless otherwise noted):
* **Benazepril:** Hypertension 10 mg, CHF 5 mg. Max: Hypertension 80 mg, CHF 40 mg.
* **Captopril:** Hypertension 12.5-25 mg BID-TID, CHF 6.25-12.5 mg TID. Max: Hypertension 150 mg TID, CHF 150 mg TID.
* **Enalapril:** Hypertension 5-10 mg, CHF 2.5-5 mg BID. Max: Hypertension 40 mg, CHF 40 mg BID.
* **Fosinopril:** Hypertension 10-20 mg, CHF 5 mg. Max: Hypertension 80 mg, CHF 40 mg.
* **Lisinopril:** Hypertension 10 mg, CHF 5 mg. Max: Hypertension 40 mg, CHF 40 mg.
* **Moexipril:** Hypertension 7.5 mg, CHF 3.75 mg. Max: Hypertension 30 mg, CHF 15 mg.
* **Perindopril:** Hypertension 2.5-5 mg, CHF 2.5 mg. Max: Hypertension 10 mg, CHF 10 mg.
* **Ramipril:** Hypertension 2.5-5 mg, CHF 1.25-2.5 mg. Max: Hypertension 10 mg, CHF 10 mg.
* **Trandolapril:** Hypertension 1-4 mg, CHF 0.5-1 mg. Max: Hypertension 16 mg, CHF 4 mg.
Dose initiation and titration should be guided by patient response and tolerance.
## Pediatric Dosing
Dosing in pediatric patients is weight-based and should be determined by specific drug monographs or local protocols.
* **Enalapril:** Hypertension 0.07 mg/kg/day (max 40 mg/day), CHF 0.1 mg/kg/dose BID (max 40 mg/day).
* **Lisinopril:** Hypertension 0.07 mg/kg/day (max 40 mg/day).
* **Ramipril:** Hypertension 0.07 mg/kg/day (max 5 mg/day).
## Dose Adjustments
* **Renal Impairment:** Dose reduction is often necessary. Specific adjustments depend on the degree of renal impairment and the individual ACE inhibitor.
* **Hepatic Impairment:** Use with caution; dose adjustments may be needed for some agents (e.g., captopril, enalapril).
## Contraindications
* History of angioedema related to prior ACE inhibitor treatment.
* Concomitant use with aliskiren in patients with diabetes or renal impairment.
* Pregnancy (especially second and third trimesters).
* Known hypersensitivity to ACE inhibitors.
## Adverse Effects
* **Common:** Cough (dry, persistent), dizziness, headache, fatigue, hyperkalemia.
* **Serious:** Angioedema (potentially life-threatening), hypotension, acute kidney injury (especially in susceptible individuals), rash, hepatotoxicity (rare).
## Key Drug Interactions
* **Potassium-sparing diuretics, potassium supplements, spironolactone, eplerenone, aliskiren:** Increased risk of hyperkalemia.
* **NSAIDs, aspirin:** May decrease antihypertensive effect and increase risk of renal impairment.
* **Diuretics (especially loop and thiazide):** Increased risk of symptomatic hypotension, especially after initiating ACE inhibitor therapy.
* **Lithium:** ACE inhibitors can decrease lithium clearance, increasing lithium toxicity risk.
* **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema.
## Monitoring
* **Blood pressure:** Regularly, especially after initiation or dose changes.
* **Serum potassium:** Baseline and periodically, especially in patients with renal impairment or those on potassium-sparing agents.
* **Renal function (serum creatinine, BUN):** Baseline and periodically.
* **Angioedema symptoms:** Educate patients to report immediately.
## Clinical Pearls
* Cough is a common side effect and may necessitate discontinuation or switching to an ARB.
* Initiate with low doses and titrate slowly, especially in patients with heart failure, renal impairment, or volume depletion.
* ACE inhibitors are generally renoprotective in patients with proteinuria.
* Discontinue ACE inhibitors promptly if angioedema occurs.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines for the specific drug and patient situation.*
