Please check your internet connection and try again.
# ACE Inhibitors
## Overview
Angiotensin-Converting Enzyme (ACE) inhibitors block the conversion of angiotensin I to angiotensin II, leading to vasodilation and reduced aldosterone secretion. This results in decreased blood pressure and reduced cardiac workload.
## Primary Indications
* Hypertension
* Heart Failure (Systolic Dysfunction)
* Post-Myocardial Infarction (MI) (in patients with evidence of heart failure or LV dysfunction)
* Diabetic Nephropathy (in patients with type 2 diabetes and hypertension)
* Chronic Kidney Disease (CKD) (in select patients to slow progression)
## Adult Dosing
Dosing varies significantly by specific agent, indication, and patient factors. Titration is common.
* **Hypertension:** Typical starting doses:
* Benazepril: 10 mg once daily
* Captopril: 25 mg twice daily
* Enalapril: 5 mg once daily
* Fosinopril: 10 mg once daily
* Lisinopril: 10 mg once daily
* Moexipril: 7.5 mg once daily
* Perindopril: 5 mg once daily
* Quinapril: 10 mg twice daily
* Ramipril: 2.5 mg once daily
* Trandolapril: 1 mg once daily
* *Maximum doses vary by agent and indication.*
* **Heart Failure:** Typical starting doses:
* Captopril: 6.25 mg three times daily
* Enalapril: 2.5 mg once or twice daily
* Lisinopril: 5 mg once daily
* Ramipril: 1.25 mg once daily
* *Titrate upward as tolerated based on BP and clinical response. Maximum doses vary by agent.*
* **Post-MI:** Typically initiated within 24 hours if no contraindications.
* Captopril: 6.25 mg three times daily, then titrate.
* Enalapril: 2.5 mg twice daily, then titrate.
* *Consult specific guidelines for timing and titration.*
* **Diabetic Nephropathy/CKD:** Dosing similar to hypertension, with a goal of proteinuria reduction.
## Pediatric Dosing
Dosing is weight-based and varies by agent. Consult specific pediatric dosing resources.
* **Hypertension:**
* Enalapril: 0.08 mg/kg/day to 0.5 mg/kg/day divided once or twice daily.
* Lisinopril: 0.07 mg/kg/day to 0.6 mg/kg/day once daily.
* *Lower doses often used in neonates and infants.*
## Dose Adjustments
* **Renal Impairment:** Dose reduction and slower titration are often required. Monitor serum creatinine and potassium closely.
* **Hepatic Impairment:** Enalapril and Ramipril may require dose adjustment. Captopril and Lisinopril are less affected.
## Contraindications
* History of angioedema related to ACE inhibitor therapy
* Concomitant use with aliskiren in patients with diabetes or renal impairment
* Pregnancy (FDA Pregnancy Category D)
## Adverse Effects
* **Common:** Cough (dry, persistent), dizziness, hyperkalemia, fatigue, headache.
* **Serious:** Angioedema (potentially life-threatening), acute kidney injury, hypotension, rash, hepatic dysfunction.
## Key Drug Interactions
* **Potassium-sparing diuretics and potassium supplements:** Increased risk of hyperkalemia.
* **NSAIDs:** May reduce antihypertensive effect and increase risk of renal impairment, especially in elderly or volume-depleted patients.
* **Diuretics:** Increased risk of symptomatic hypotension, particularly with the first dose.
* **Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal dysfunction. Avoid concomitant use in patients with diabetes or renal impairment.
* **ARBs:** Increased risk of angioedema, hyperkalemia, and renal dysfunction. Avoid concomitant use.
* **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema.
## Monitoring
* Blood pressure (prior to and during therapy)
* Serum creatinine and electrolytes (potassium) (prior to therapy, within 1-2 weeks of initiation or dose change, and periodically thereafter)
* Renal function (especially in patients with CKD or at risk)
* Signs/symptoms of angioedema or hypersensitivity reactions
## Clinical Pearls
* Cough is a common dose-limiting side effect and may occur weeks to months after starting therapy. If cough is bothersome, consider switching to an ARB.
* First-dose hypotension can occur, especially in patients who are volume-depleted or on diuretic therapy. Consider withholding diuretics temporarily before initiating ACE inhibitor therapy.
* ACE inhibitors are renoprotective in proteinuric kidney disease.
* Discontinue ACE inhibitors immediately if angioedema occurs.
* Monitor potassium closely, especially in patients with renal impairment, heart failure, or those taking potassium-sparing agents.
***
**Disclaimer:** This information is intended for clinical use and does not replace professional medical advice. Always consult the most current prescribing information and relevant clinical guidelines for complete details, including contraindications, warnings, and drug interactions. Dosing may vary based on individual patient factors and local protocols.
