Ace%2525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252520inhibitors

# 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) * Diabetic nephropathy * Proteinuric chronic kidney disease ## Adult Dosing Dosing is highly individualized and depends on the specific agent and indication. Common starting doses are low and titrated upwards based on patient response and tolerability. * **Hypertension:** * Benazepril: Start 10 mg once daily, max 80 mg daily. * Captopril: Start 12.5 mg to 25 mg twice daily, max 150 mg twice daily. * Enalapril: Start 5 mg once daily, max 40 mg daily (once or twice daily). * Fosinopril: Start 10 mg once daily, max 80 mg daily. * Lisinopril: Start 10 mg once daily, max 80 mg daily. * Moexipril: Start 7.5 mg once daily, max 30 mg daily. * Perindopril: Start 2.5 mg to 5 mg once daily, max 10 mg daily. * Quinapril: Start 10 mg once or twice daily, max 80 mg daily. * Ramipril: Start 2.5 mg to 5 mg once daily, max 20 mg daily. * Trandolapril: Start 1 mg once daily, max 8 mg daily. * **Heart Failure:** Dosing is typically initiated at lower doses than for hypertension and titrated more slowly. Consult specific guidelines for initiation and titration protocols (e.g., ACC/AHA guidelines). * **Post-MI:** Typically started within 24 hours, e.g., Ramipril 2.5 mg twice daily, titrating to 5 mg twice daily. ## Pediatric Dosing * **Hypertension:** * Enalapril: 0.07 mg/kg to 0.2 mg/kg (max 40 mg) once daily. * Lisinopril: 0.07 mg/kg (max 10 mg) once daily, may increase to 0.2 mg/kg (max 20 mg) once daily. * Captopril: 0.3 mg/kg to 0.5 mg/kg (max 50 mg) three times daily. Dosing in neonates and infants for these indications is less established and requires careful consideration and monitoring. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially for captopril and enalapril. For others, monitor renal function closely. * Captopril: If CrCl < 30 mL/min, 25% to 50% of standard dose. * Enalapril: If CrCl < 30 mL/min, 5 mg daily, may increase. * **Hepatic Impairment:** May require dose reduction due to decreased metabolism; particularly for prodrugs like enalapril and benazepril. ## Contraindications * History of angioedema related to prior ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment. * Pregnancy (especially second and third trimesters). ## Adverse Effects * **Common:** Cough (dry, persistent), dizziness, fatigue, headache, hypotension, hyperkalemia. * **Serious:** Angioedema (rare but life-threatening, can occur at any time), acute kidney injury (especially in patients with bilateral renal artery stenosis or severe heart failure), rash, neutropenia, agranulocytosis (rare). ## Key Drug Interactions * **Potassium-sparing diuretics & Potassium supplements:** Increased risk of hyperkalemia. * **NSAIDs & COX-2 inhibitors:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Diuretics (especially loop and thiazide):** Increased risk of symptomatic hypotension, especially upon initiation. * **Lithium:** ACE inhibitors can reduce lithium clearance, leading to lithium toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. * **ARBs & Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal impairment; avoid concomitant use, especially in high-risk populations. ## Monitoring * Blood pressure (before and after initiation/titration). * Serum potassium (especially at initiation, dose increases, and in renal impairment). * Renal function (BUN, creatinine) at baseline and periodically. * Signs and symptoms of angioedema. * Complete blood count (CBC) if concerns for hematologic effects. ## Clinical Pearls * ACE inhibitors are often considered first-line therapy for hypertension, particularly in patients with certain comorbidities like diabetes or chronic kidney disease. * The characteristic dry cough is typically not dose-limiting and may resolve with discontinuation. * Angioedema is a medical emergency; discontinue ACE inhibitor immediately and manage airway. * Start low and go slow, especially in elderly, volume-depleted, or renally impaired patients. * Monitor for first-dose hypotension, particularly if the patient is also on diuretics. *** *This information is intended for clinical professionals and is not a substitute for current prescribing information. Always consult the official drug labeling and relevant clinical guidelines for complete and up-to-date details.*