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# ACE Inhibitors ## Overview ACE inhibitors (e.g., lisinopril, enalapril, ramipril) are a class of medications that block the conversion of angiotensin I to angiotensin II, leading to vasodilation and reduced aldosterone secretion. This results in decreased blood pressure and reduced workload on the heart. ## Primary Indications * Hypertension * Heart failure (systolic dysfunction) * Post-myocardial infarction (to reduce mortality and prevent remodeling) * Diabetic nephropathy (to slow progression of kidney disease) ## Adult Dosing Dosing is highly individualized and depends on the specific agent, indication, and patient response. Titration is common. * **Hypertension:** Initial doses vary. For lisinopril, common starting dose is 10 mg once daily, titrating to a maximum of 40 mg daily. For enalapril, start at 5 mg once or twice daily, titrating to a maximum of 40 mg daily. For ramipril, start at 2.5 mg once daily, titrating to a maximum of 10 mg daily. * **Heart Failure:** Common starting doses: Lisinopril 5 mg once daily, Enalapril 2.5 mg twice daily, Ramipril 2.5 mg twice daily. Target doses are often higher and should be titrated as tolerated. * **Post-MI:** Common starting doses: Lisinopril 5 mg once daily (initiate within 24 hours of MI), Ramipril 2.5 mg twice daily. Doses are titrated upwards. ## Pediatric Dosing ACE inhibitors are used in pediatric patients for hypertension and heart failure, but dosing is less standardized and requires careful titration. Dosing often based on weight. * **Hypertension:** Example for enalapril: 0.08 mg/kg/day to 0.4 mg/kg/day divided once or twice daily. * **Heart Failure:** Example for enalapril: 0.1 mg/kg/day divided once or twice daily. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary. In patients with severe renal impairment (CrCl < 30 mL/min), initiation at lower doses and slower titration is recommended. For lisinopril, avoid in severe renal insufficiency. For enalapril, start at 2.5 mg daily in moderate renal impairment and 2.5 mg every other day in severe impairment. * **Hepatic Impairment:** Generally, no dose adjustment is needed, but caution is advised. ## Contraindications * Known hypersensitivity to the drug or other ACE inhibitors. * History of angioedema related to prior ACE inhibitor treatment. * Concomitant use with aliskiren in patients with diabetes. * Pregnancy (especially in the second and third trimesters). ## Adverse Effects * **Common:** Cough (dry, persistent), dizziness, hypotension, headache, fatigue, hyperkalemia. * **Serious:** Angioedema (potentially life-threatening), acute kidney injury (especially in susceptible individuals), hyperkalemia, neutropenia/agranulocytosis (rare). ## Key Drug Interactions * **Potassium-sparing diuretics, potassium supplements, aliskiren, ARBs, heparin, trimethoprim:** Increased risk of hyperkalemia. * **NSAIDs, aspirin:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Diuretics (especially loop or thiazide):** Increased risk of hypotension and volume depletion. * **Lithium:** Increased risk of lithium toxicity. * **mTOR inhibitors (e.g., sirolimus, everolimus), DPP-4 inhibitors (e.g., saxagliptin, linagliptin):** Increased risk of angioedema. ## Monitoring * Blood pressure. * Renal function (serum creatinine, BUN). * Serum potassium. * Symptoms of angioedema, cough. ## Clinical Pearls * The characteristic dry cough is thought to be due to increased bradykinin levels. Discontinuation of the ACE inhibitor usually resolves the cough. * Angioedema is a medical emergency; discontinue immediately and manage airway. * Initiate at low doses and titrate slowly, especially in patients who are volume-depleted, on diuretics, or with renal impairment. * Monitor potassium closely, especially with concomitant use of other potassium-elevating agents. * ACE inhibitors are generally considered safe and effective in patients with diabetes, often providing renal protective benefits. *** **Disclaimer:** This information is intended for clinical professionals. Always consult the most current prescribing information and relevant clinical guidelines for definitive guidance. Dosing and management may vary based on patient-specific factors and local protocols.