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# ACE Inhibitors
## Overview
ACE inhibitors (e.g., lisinopril, enalapril, ramipril) are a class of medications primarily used to manage hypertension and heart failure by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor.
## Primary Indications
* Hypertension
* Heart failure (systolic dysfunction)
* Post-myocardial infarction (for certain agents and in specific patient populations)
* Diabetic nephropathy (in patients with proteinuria)
## Adult Dosing
Dosing varies by agent and indication. Titration is typically based on patient response and tolerability.
* **Hypertension:**
* Lisinopril: Start at 5-10 mg once daily. Usual range 10-40 mg once daily. Max 80 mg once daily.
* Enalapril: Start at 5 mg once daily or 2.5 mg twice daily. Usual range 10-40 mg once daily. Max 40 mg once daily.
* Ramipril: Start at 2.5 mg once daily. Usual range 5-20 mg once daily. Max 20 mg once daily.
* **Heart Failure:**
* Lisinopril: Start at 5 mg once daily. Target dose 20 mg once daily.
* Enalapril: Start at 2.5 mg twice daily. Target dose 10 mg twice daily. Max 20 mg twice daily.
* Ramipril: Start at 2.5 mg twice daily. Target dose 5 mg twice daily. Max 10 mg twice daily.
## Pediatric Dosing
Dosing in pediatric patients is generally based on body weight and can vary significantly by agent and indication. Exact dosing often depends on local protocols or specialist recommendations.
* **Hypertension:**
* Lisinopril: 0.07-0.2 mg/kg/day once daily. Max 20 mg/day.
* Enalapril: 0.1-0.5 mg/kg/day in 1-2 divided doses. Max 40 mg/day.
## Dose Adjustments
* **Renal Impairment:** Dose reduction is often necessary. Specific recommendations vary by agent and degree of renal impairment (e.g., for lisinopril: CrCl < 30 mL/min, start at 5 mg; CrCl 10-30 mL/min, start at 2.5 mg).
* **Hepatic Impairment:** Use with caution; dosage adjustments may be needed for agents metabolized by the liver (e.g., enalapril).
## Contraindications
* History of angioedema related to previous ACE inhibitor treatment.
* Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment.
* Pregnancy (Category D).
* Known hypersensitivity to the specific ACE inhibitor.
## Adverse Effects
* **Common:** Cough (dry, persistent), dizziness, hypotension, hyperkalemia, fatigue.
* **Serious:** Angioedema (including life-threatening laryngeal edema), acute kidney injury, severe hypotension.
## Key Drug Interactions
* **Potassium-sparing diuretics, potassium supplements, spironolactone, eplerenone, aliskiren, ARBs, NSAIDs:** Increased risk of hyperkalemia.
* **Lithium:** Increased risk of lithium toxicity.
* **Diuretics (especially potassium-wasting):** Increased risk of symptomatic hypotension.
* **NSAIDs:** May reduce antihypertensive effect and increase risk of renal impairment.
* **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema.
## Monitoring
* Blood pressure (at baseline and regularly during treatment).
* Serum creatinine and electrolytes (potassium) within 1-2 weeks of starting therapy, after dose increases, and periodically thereafter.
* Signs and symptoms of angioedema.
* Renal function in patients with pre-existing renal disease.
## Clinical Pearls
* Cough is a common side effect, often dose-dependent and may necessitate discontinuation or switching to an ARB.
* Initiate at low doses and titrate slowly, especially in volume-depleted patients, the elderly, or those with renal impairment.
* First-dose hypotension can occur, particularly in patients taking diuretics. Advise patients to monitor for dizziness and to rise slowly.
* Avoid in pregnancy due to risk of fetal injury or death.
* Monitor potassium closely, especially with concomitant use of other drugs that increase potassium.
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*This information is intended for healthcare professionals. Always consult the current prescribing information and relevant clinical guidelines for definitive recommendations.*
