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# ACE Inhibitors ## Overview ACE inhibitors (e.g., captopril, enalapril, lisinopril, ramipril) are a class of medications primarily used to treat hypertension and heart failure by blocking the conversion of angiotensin I to angiotensin II, leading to vasodilation and reduced aldosterone secretion. ## Primary Indications * Hypertension * Heart failure (systolic dysfunction) * Post-myocardial infarction (to improve survival) * Diabetic nephropathy (proteinuria reduction) ## Adult Dosing Dosing is highly individualized and depends on the specific ACE inhibitor, indication, and patient tolerance. Doses are typically started low and titrated upwards. * **Hypertension:** * Captopril: Initial 50 mg PO TID, titrate to 150 mg PO TID. * Enalapril: Initial 5 mg PO QD, titrate to 10-40 mg PO QD. * Lisinopril: Initial 10 mg PO QD, titrate to 20-40 mg PO QD. * Ramipril: Initial 2.5 mg PO QD, titrate to 5-10 mg PO QD. * **Heart Failure:** * Enalapril: Initial 2.5 mg PO BID, titrate to 10 mg PO BID. * Lisinopril: Initial 5 mg PO QD, titrate to 10-20 mg PO QD. * Ramipril: Initial 2.5 mg PO BID, titrate to 5 mg PO BID. * **Post-MI:** * Lisinopril: Initial 5 mg PO QD, followed by 5 mg PO QD after 24 hours, then 10 mg PO QD. Continue for at least 6 weeks. * **Diabetic Nephropathy:** * Enalapril: 10-20 mg PO QD. * Lisinopril: 20 mg PO QD. * Ramipril: 5 mg PO QD. ## Pediatric Dosing ACE inhibitor use in pediatrics is generally limited to specific situations and requires careful monitoring. Dosing varies significantly by age and indication. Consult specific pediatric guidelines for established dosing ranges. * **Hypertension:** * Enalapril: 0.08 mg/kg/day to 0.58 mg/kg/day divided BID. Max dose: 40 mg/day. * Lisinopril: 0.07 mg/kg/day to 0.61 mg/kg/day divided QD. Max dose: 40 mg/day. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially in severe renal impairment. Specific guidance depends on the individual ACE inhibitor and creatinine clearance. * **Hepatic Impairment:** Generally not a primary reason for dose adjustment, but caution is advised. * **Volume Depletion:** Initiate at lower doses. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes mellitus or moderate to severe renal impairment. * Pregnancy (especially second and third trimesters). ## Adverse Effects * **Common:** Cough (dry, persistent), dizziness, hypotension, hyperkalemia, headache, fatigue. * **Serious:** Angioedema (potentially life-threatening), acute kidney injury, hepatotoxicity, neutropenia, hyperkalemia. ## Key Drug Interactions * **Potassium-sparing diuretics (e.g., spironolactone) and potassium supplements:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Diuretics:** Increased risk of hypotension, especially with loop diuretics. * **Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction; avoid concomitant use in certain populations. * **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. ## Monitoring * **Renal function (serum creatinine, BUN):** Baseline and periodically thereafter, especially with dose changes or in patients with risk factors for renal dysfunction. * **Serum potassium:** Baseline and periodically, especially with renal impairment or concomitant use of potassium-altering drugs. * **Blood pressure:** Regularly to assess efficacy and adjust dose. * **Signs/symptoms of angioedema:** Patient education is crucial. ## Clinical Pearls * Cough is a common side effect, often dose-related, and may necessitate discontinuation. * Risk of angioedema is higher in African Americans. * First-dose hypotension can occur, particularly in volume-depleted patients or those on diuretics. * Consider switching to an angiotensin II receptor blocker (ARB) if angioedema occurs, but cross-reactivity is possible. * Use with caution in patients with bilateral renal artery stenosis. *** *Disclaimer: This information is intended for healthcare professionals. Always verify the most current prescribing information with official drug references and institutional protocols.*