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# ACE Inhibitors ## Overview Angiotensin-converting enzyme (ACE) inhibitors are a class of medications used primarily to treat 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 (reduced ejection fraction) * Post-myocardial infarction (left ventricular dysfunction) * Diabetic nephropathy (proteinuria) ## Adult Dosing Dosing varies by agent and indication. Common starting doses for hypertension: * **Lisinopril:** 10 mg orally once daily. * **Enalapril:** 5 mg orally once or twice daily. * **Ramipril:** 2.5 mg orally once daily. * **Benazepril:** 10 mg orally once daily. * **Captopril:** 25 mg orally twice or three times daily. Maintenance doses are titratable based on response, often up to maximums such as: * Lisinopril: 40 mg once daily * Enalapril: 40 mg once daily (oral) * Ramipril: 10 mg once daily * Benazepril: 40 mg once daily * Captopril: 50 mg three times daily For heart failure, typical starting doses are lower, and titration is slower. For diabetic nephropathy, doses are often similar to hypertension. ## Pediatric Dosing * **Hypertension:** Recommended doses vary by age and weight. * **Captopril:** 0.3 mg/kg/dose orally every 8-12 hours, titratable up to 2 mg/kg/day. * **Enalapril:** 0.1 mg/kg/dose orally once daily, titratable up to 0.5 mg/kg/day. * **Lisinopril:** 0.07 mg/kg/dose orally once daily, titratable up to 0.6 mg/kg/day. * Specific protocols or local guidelines may dictate precise pediatric dosing. ## Dose Adjustments * **Renal Impairment:** Dose reduction is often necessary, especially in severe renal impairment. Initial doses may be lower, and titration guided by renal function and potassium levels. * **Hepatic Impairment:** Generally less dose adjustment needed, but caution is advised. ## Contraindications * Known hypersensitivity to ACE inhibitors or any component of the formulation. * History of angioedema related to previous ACE inhibitor treatment. * Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment. * Pregnancy (especially second and third trimesters). ## Adverse Effects * **Common:** Cough (dry, persistent), dizziness, hypotension, hyperkalemia, fatigue, headache. * **Serious:** Angioedema (potentially life-threatening), acute kidney injury, hepatotoxicity, neutropenia, hyperkalemia. ## Key Drug Interactions * **Potassium-Sparing Diuretics, Potassium Supplements, Aldosterone Antagonists:** Increased risk of hyperkalemia. * **NSAIDs, COX-2 Inhibitors:** May decrease antihypertensive effect and increase risk of renal impairment. * **Diuretics:** Increased risk of hypotension, especially with thiazide diuretics. * **Lithium:** Increased serum lithium levels and risk of lithium toxicity. * **mTOR Inhibitors (e.g., sirolimus, everolimus), DPP-4 Inhibitors (e.g., saxagliptin, linagliptin):** Increased risk of angioedema. * **Sacubitril/Valsartan:** Avoid concurrent use; increased risk of angioedema. If switching from ACE inhibitor to sacubitril/valsartan, ensure at least a 36-hour washout period. ## Monitoring * **Blood Pressure:** Regularly monitor to assess efficacy and detect hypotension. * **Renal Function (Serum Creatinine, BUN):** Monitor at baseline and periodically, especially with dose increases or in patients with pre-existing renal disease. * **Serum Potassium:** Monitor at baseline and periodically, especially in patients with renal impairment, diabetes, or those taking potassium-sparing agents. * **Angioedema:** Educate patients to report any swelling of the face, lips, tongue, or throat immediately. ## Clinical Pearls * The characteristic dry cough is typically dose-dependent and may resolve upon discontinuation. * Initiate at a low dose and titrate slowly, particularly in elderly patients, those with renal impairment, or those on concomitant diuretics. * Angioedema can occur at any time during therapy and is a medical emergency. * ACE inhibitors are generally considered renoprotective in patients with diabetes and proteinuria. *** *This information is for educational purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider to ensure the most accurate and up-to-date information and to determine the best course of treatment for any medical condition. Prescribing information can change; always verify current prescribing information.*