Ace%25252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252520inhibitors

# ACE Inhibitors ## Overview Angiotensin-converting enzyme (ACE) inhibitors are a class of medications primarily used for managing 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 (to improve survival) * Diabetic nephropathy (proteinuric) * Chronic kidney disease (proteinuric) ## Adult Dosing Dosing varies significantly by agent and indication. Typical starting doses are low and titrated upwards. * **Hypertension:** Doses vary widely. For example, lisinopril: 10 mg PO once daily, may increase to 20-40 mg PO once daily. Max typically 40 mg/day. * **Heart Failure:** Doses vary widely. For example, enalapril: 2.5-5 mg PO twice daily, may increase to 10-20 mg PO twice daily. Max typically 40 mg/day. * **Post-MI:** Doses vary. For example, ramipril: 2.5 mg PO twice daily, increased to 5 mg PO twice daily, then to target of 10 mg PO twice daily. * **Diabetic Nephropathy:** Doses vary. For example, captopril: 25 mg PO three times daily, may increase to 50 mg PO three times daily. Max typically 150 mg/day. Individual agent dosing guidelines should be consulted. ## Pediatric Dosing ACE inhibitor use in pediatrics is less established and often based on expert opinion or specific trial data. Dosing is highly individualized and depends on the agent and indication. * **Hypertension:** * **Enalapril:** 0.08 mg/kg/day PO divided every 12-24 hours (max 0.58 mg/kg/day or 40 mg/day). * **Lisinopril:** 0.07-0.2 mg/kg/day PO once daily (max 20 mg/day). * **Captopril:** 0.3 mg/kg/dose PO every 8 hours (max 6 mg/kg/day or 450 mg/day). Consult pediatric guidelines for specific agents and age ranges. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary. Consult specific drug monographs for detailed guidance based on creatinine clearance. * **Hepatic Impairment:** Generally, no dose adjustment is needed for drugs like enalapril or lisinopril. Captopril may require caution due to its hepatic metabolism. ## Contraindications * History of angioedema related to prior ACE inhibitor treatment * Concomitant use with aliskiren in patients with diabetes mellitus * Pregnancy (especially second and third trimesters) * Hypersensitivity to ACE inhibitors ## Adverse Effects * **Common:** Cough (dry, persistent), dizziness, fatigue, hyperkalemia, hypotension. * **Serious:** Angioedema (potentially life-threatening), acute kidney injury, severe hypotension, hyperkalemia. ## Key Drug Interactions * **Potassium-sparing diuretics, potassium supplements, aliskiren, ARBs:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Diuretics:** Increased risk of hypotension. * **Lithium:** Increased lithium levels and toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. ## Monitoring * **Blood Pressure:** Regularly monitor after initiation and dose changes. * **Renal Function:** Assess baseline and periodically thereafter (creatinine, BUN). * **Serum Potassium:** Assess baseline and periodically thereafter, especially in patients with renal impairment or on potassium-sparing agents. * **Angioedema:** Counsel patients on signs/symptoms and to discontinue immediately if they occur. ## Clinical Pearls * The characteristic dry cough is thought to be due to increased bradykinin levels and typically resolves after discontinuation. * Start with low doses and titrate slowly, especially in patients who are volume-depleted, have hyponatremia, or renal impairment. * Discontinue immediately if angioedema occurs. Cross-reactivity with ARBs is possible but less common than with other ACE inhibitors. * Avoid concomitant use with ARBs and aliskiren in patients with diabetes due to increased risk of adverse events. * ACE inhibitors are generally considered renoprotective in patients with proteinuria. *** *This information is intended for clinical use and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant clinical guidelines before making any treatment decisions.*