Lisinopril

# Lisinopril ## Overview - **Classification**: Angiotensin-Converting Enzyme (ACE) Inhibitor - **Mechanism**: Inhibits the conversion of angiotensin I to angiotensin II, leading to vasodilation, decreased aldosterone secretion, and reduced sympathetic activity. ## Primary Indications 1. **Hypertension** - Treatment of high blood pressure 2. **Heart Failure** - Adjunctive treatment for symptomatic heart failure 3. **Acute Myocardial Infarction** - Hemodynamically stable patients within 24 hours of MI ## Adult Dosing ### Standard Dosing **Hypertension** - **Dose**: Initial **10 mg** (or **5 mg** if on diuretics/renal impairment) - **Frequency**: Once daily - **Route**: Oral - **Maximum**: **20-40 mg/day** (up to **80 mg/day** in rare cases) **Heart Failure** - **Dose**: Initial **2.5 mg** - **Frequency**: Once daily - **Route**: Oral - **Titration**: Gradually increase to maintenance dose of **5-40 mg/day** based on response **Acute Myocardial Infarction** - **Dose**: Initial **5 mg** (within 24 hours of symptom onset) - **Frequency**: Once daily - **Route**: Oral - **Duration**: Followed by **5 mg** after 24 hours, then **10 mg** once daily for 6 weeks - **Maximum**: **10 mg/day** for MI ### Dose Adjustments - **Renal Impairment**: - CrCl **>30 mL/min**: No initial adjustment needed. - CrCl **10-30 mL/min**: Initial **2.5-5 mg** daily. - CrCl **<10 mL/min** (including dialysis): Initial **2.5 mg** daily. - **Hepatic Impairment**: No specific dose adjustment needed; use with caution. - **Elderly Patients**: Consider lower initial doses due to potential renal decline and increased sensitivity. ## Pediatric Dosing ### Neonates (0-28 days) - **Generally not recommended** due to limited data and potential safety concerns. ### Infants (1-12 months) - **Generally not recommended** for routine use due to limited data and safety concerns. - Use only if compelling indication and no alternative, with close monitoring. ### Children (6-16 years) - for Hypertension - **Dose**: Initial **0.07 mg/kg** - **Frequency**: Once daily - **Maximum**: Initial dose should not exceed **5 mg/day**. - **Titration**: Adjust dose every 1-2 weeks based on response, up to **0.6 mg/kg/day** or **40 mg/day**, whichever is less. - **Special Notes**: Monitor closely for hypotension and renal function. ### Adolescents (13-18 years) - for Hypertension - **Dose**: Approach adult dosing, start with **5 mg** daily. - **Frequency**: Once daily - **Maximum**: Up to **40 mg/day**. ## Safety Information ### Contraindications - **Absolute**: History of angioedema related to previous ACE inhibitor treatment. - **Absolute**: Hereditary or idiopathic angioedema. - **Absolute**: Concomitant use with sacubitril/valsartan (Entresto). - **Absolute**: Concomitant use with aliskiren in patients with diabetes or renal impairment (CrCl <60 mL/min). - **Absolute**: Pregnancy (especially 2nd and 3rd trimesters). ### Common Adverse Effects - **Very Common (>10%)**: Dry, persistent cough - **Common (1-10%)**: Dizziness, headache, fatigue, hypotension, nausea, diarrhea, hyperkalemia - **Serious but Rare**: Angioedema (swelling of face, lips, tongue, glottis), acute renal failure, neutropenia/agranulocytosis (very rare) ### Key Drug Interactions - **Potassium-sparing diuretics/Potassium supplements**: Increased risk of hyperkalemia. Avoid co-administration or monitor K+ closely. - **NSAIDs (e.g., ibuprofen, naproxen)**: May reduce hypotensive effect and increase risk of renal impairment, especially in elderly or dehydrated patients. - **Lithium**: May increase lithium levels, leading to toxicity. Monitor lithium levels closely. - **Sacubitril/Valsartan (Entresto)**: Concomitant use contraindicated due to increased angioedema risk. Separate by at least 36 hours. - **Aliskiren**: Contraindicated in diabetes/renal impairment; increased risk of hyperkalemia, renal impairment, and hypotension. ## Monitoring & Follow-up - **Before Treatment**: Measure blood pressure (BP), serum electrolytes (especially potassium), and renal function (BUN, serum creatinine). - **During Treatment**: - **BP**: Regularly, especially after initial dose or titration. - **Renal Function/Electrolytes**: Within 1-2 weeks of initiation/dose change, then periodically (e.g., every 3-6 months). - **Potassium**: More frequently in patients at risk for hyperkalemia. - **Clinical Signs**: Monitor for signs of angioedema (facial swelling, difficulty breathing/swallowing), persistent cough, dizziness, or signs of hyperkalemia (weakness, palpitations). ## Clinical Pearls - 💡 **Initial Dose Effect**: First-dose hypotension can occur, especially in volume-depleted patients. Consider holding diuretics for 2-3 days prior. - 💡 **Cough**: The characteristic dry, persistent cough often develops weeks to months after initiation and resolves days to weeks after discontinuation. - 💡 **Angioedema**: Counsel patients on symptoms of angioedema and to seek immediate medical attention if it occurs. - 💡 **Pregnancy**: Absolutely contraindicated in 2nd and 3rd trimesters due to risk of fetal injury/death. Discontinue immediately if pregnancy detected. > **⚠️ Important**: This information is for educational purposes only. Always consult current prescribing information, local guidelines, and clinical judgment before prescribing.