Ace%252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252520inhibitors

# ACE Inhibitors ## Overview ACE inhibitors (e.g., lisinopril, enalapril, ramipril) are a class of medications that block the action of angiotensin-converting enzyme, leading to vasodilation and reduced sodium and water retention. This results in decreased blood pressure and reduced workload on the heart. ## Primary Indications * Hypertension * Heart failure (systolic dysfunction) * Post-myocardial infarction (to improve survival) * Diabetic nephropathy (proteinuric kidney disease) ## Adult Dosing Dosing is highly individualized and depends on the specific agent, indication, and patient response. Titration is essential. * **Hypertension:** * Lisinopril: Start at 5-10 mg once daily. Titrate up to 40 mg daily. * Enalapril: Start at 5 mg once or twice daily. Titrate up to 40 mg daily (divided doses). * Ramipril: Start at 2.5 mg once daily. Titrate up to 20 mg daily. * Maximum doses vary by agent and indication; refer to specific drug monographs. * **Heart Failure:** * Enalapril: Start at 2.5 mg twice daily. Titrate up to 20 mg daily (divided doses). * Lisinopril: Start at 5 mg once daily. Titrate up to 40 mg daily. * Ramipril: Start at 1.25 mg once daily. Titrate up to 10 mg daily. * **Post-MI:** Generally initiated within 24 hours of symptom onset or reperfusion. * Captopril: Start at 6.25 mg three times daily. Titrate up to 50 mg three times daily. * Enalapril: Start at 2.5 mg twice daily. Titrate up to 10 mg twice daily. * **Diabetic Nephropathy:** Specific dosing protocols exist; consult guidelines. ## Pediatric Dosing Established pediatric dosing is available for some agents, but often based on limited data. Consult specific drug monographs and pediatric resources. * **Hypertension (age 6-16 years):** * Enalapril: Doses range from 0.07 mg/kg once daily to 0.38 mg/kg twice daily, not to exceed adult maximums. * Lisinopril: Doses range from 0.07 mg/kg once daily to 0.61 mg/kg once daily, not to exceed adult maximums. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary. The degree of reduction depends on the specific agent and the patient's creatinine clearance (CrCl). For example, with Lisinopril: * CrCl 30-80 mL/min: May need dose reduction. * CrCl 10-30 mL/min: Start at half the usual starting dose. * CrCl <10 mL/min: Start at one-quarter the usual starting dose. * **Hepatic Impairment:** Generally no dose adjustment needed for most ACE inhibitors, but caution is advised. ## Contraindications * History of angioedema related to previous ACE inhibitor treatment. * Hereditary or idiopathic angioedema. * Concomitant use with aliskiren in patients with diabetes. * Pregnancy (especially second and third trimesters; Category D). ## Adverse Effects * **Common:** Cough (dry, persistent), dizziness, fatigue, headache, hypotension, hyperkalemia. * **Less Common/Serious:** Angioedema (potentially life-threatening, affecting face, lips, tongue, throat), acute kidney injury (especially in bilateral renal artery stenosis), rash, neutropenia/agranulocytosis (rare), elevated liver enzymes. ## Key Drug Interactions * **Potassium-sparing diuretics, potassium supplements, salt substitutes:** Increased risk of hyperkalemia. * **NSAIDs, COX-2 inhibitors:** May blunt antihypertensive effect and increase risk of renal impairment, especially in patients with volume depletion or underlying renal disease. * **Diuretics (especially thiazides or loop diuretics):** Increased risk of symptomatic hypotension, particularly after the first dose. * **Aliskiren:** Increased risk of hyperkalemia, hypotension, and renal impairment. Avoid concomitant use, especially in patients with diabetes. * **Lithium:** Increased lithium levels and risk of toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus), DPP-4 inhibitors (e.g., sitagliptin):** Increased risk of angioedema. ## Monitoring * **Baseline:** Blood pressure, serum creatinine, electrolytes (especially potassium), complete blood count (CBC). * **During Therapy:** * Blood pressure (especially after dose initiation/titration). * Serum creatinine and electrolytes within 1-2 weeks of initiation or dose change, and periodically thereafter. Monitor more frequently in patients with renal impairment, heart failure, or diuretic use. * Angioedema symptoms. ## Clinical Pearls * The characteristic dry cough is usually dose-independent and resolves upon discontinuation. * Hypotension is most common with the first dose, in patients who are volume-depleted, or on concurrent diuretic therapy. Consider a lower starting dose or temporary discontinuation of diuretics. * Angioedema can occur at any time during therapy and requires immediate discontinuation of the ACE inhibitor. * ACE inhibitors are generally renoprotective in patients with proteinuria and diabetes. * Avoid in patients with bilateral renal artery stenosis due to risk of severe renal failure. *** *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.*