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# Angiotensin-Converting Enzyme (ACE) Inhibitors ## Overview ACE inhibitors are a class of medications primarily used to treat hypertension and heart failure. They work by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, thereby leading to vasodilation and decreased blood pressure. ## Primary Indications * Hypertension * Heart failure (reduced ejection fraction) * Post-myocardial infarction (to improve survival) * Diabetic nephropathy (to slow progression) ## Adult Dosing Dosing varies significantly by specific agent. Common agents and starting doses include: * **Benazepril:** 10 mg once daily. Max: 40 mg daily. * **Captopril:** 25 mg twice daily. Max: 150 mg twice daily. * **Enalapril:** 5 mg once or twice daily. Max: 40 mg daily. * **Fosinopril:** 10 mg once daily. Max: 80 mg daily. * **Lisinopril:** 10 mg once daily. Max: 40 mg daily. * **Moexipril:** 7.5 mg once daily. Max: 30 mg daily. * **Perindopril:** 5 mg once daily. Max: 10 mg daily. * **Quinapril:** 10 mg once or twice daily. Max: 80 mg daily. * **Ramipril:** 2.5 mg once daily. Max: 10 mg daily. * **Trandolapril:** 1 mg once daily. Max: 4 mg daily. ## Pediatric Dosing Pediatric dosing is highly variable and often based on body weight. * **Enalapril:** 0.07 mg/kg/day orally, divided every 12-24 hours. Max: 0.61 mg/kg/day or 40 mg/day. * **Lisinopril:** 0.07 mg/kg/day orally, once daily. Max: 20 mg/day. * Other agents may have established pediatric doses, but these are less common. Dosing requires careful titration and monitoring. ## Dose Adjustments * **Renal Impairment:** Reduce dose, especially in severe renal impairment (CrCl < 30 mL/min). Captopril may require more frequent dosing adjustments due to its short half-life. * **Hepatic Impairment:** Use with caution. Some agents may require dose reduction. ## 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). ## Adverse Effects * **Common:** Dry cough, dizziness, headache, fatigue, hyperkalemia, hypotension. * **Less Common/Serious:** Angioedema (can be life-threatening), renal impairment/failure (especially in those with bilateral renal artery stenosis), hyperkalemia, acute kidney injury. ## Key Drug Interactions * **Potassium-sparing diuretics, potassium supplements, salt substitutes:** Increased risk of hyperkalemia. * **NSAIDs:** May reduce antihypertensive effect and increase risk of renal dysfunction. * **Diuretics:** Additive hypotensive effect, increased risk of first-dose hypotension. * **Lithium:** Increased lithium levels and toxicity. * **ARBs (Angiotensin II Receptor Blockers):** Increased risk of hyperkalemia, hypotension, and renal dysfunction; generally avoided. * **mTOR inhibitors (e.g., sirolimus, everolimus):** Increased risk of angioedema. ## Monitoring * **Blood Pressure:** Regularly monitor for hypotension, especially after initiation or dose increases. * **Renal Function:** Monitor serum creatinine and BUN, particularly in patients with renal impairment, heart failure, or bilateral renal artery stenosis. * **Potassium:** Monitor serum potassium levels, especially in patients with renal impairment, diabetes, or those taking potassium-sparing agents. * **Angioedema:** Educate patients on signs and symptoms and advise to seek immediate medical attention if they occur. ## Clinical Pearls * The characteristic dry cough is thought to be due to increased bradykinin levels. * Angioedema is a rare but potentially fatal side effect; discontinue ACE inhibitor immediately if suspected. * Initiate at a low dose and titrate slowly, especially in patients with heart failure or renal impairment, to minimize risk of hypotension and worsening renal function. * ACE inhibitors are renoprotective in patients with diabetic nephropathy. * Discontinue ACE inhibitors if pregnancy is planned or confirmed. *** *Disclaimer: 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 guidelines for complete details before making any treatment decisions.*