Can you prescribe an Angiotensin-Converting Enzyme (ACE) inhibitor and hydrochlorothiazide?

From the Guidelines

The combination of an ACE inhibitor and hydrochlorothiazide is a recommended treatment option for hypertension, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This combination is commonly used to treat hypertension and heart failure, with ACE inhibitors blocking the angiotensin-converting enzyme to reduce blood pressure and hydrochlorothiazide working as a diuretic to remove excess fluid from the body. Some key points to consider when prescribing this combination include:

• The 2024 ESC guidelines recommend that ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics (thiazides and thiazide-like drugs) have demonstrated the most effective reduction of BP and CVD events, and are therefore recommended as first-line treatments to lower BP 1.
• The guidelines also recommend that combination BP-lowering treatment is recommended for most patients with confirmed hypertension (BP ≥140/90 mmHg) as initial therapy, with preferred combinations being a RAS blocker (either an ACE inhibitor or an ARB) with a dihydropyridine CCB or diuretic 1.
• If you need these medications, you should schedule an appointment with your primary care provider or cardiologist who can evaluate your medical history, current health status, potential drug interactions, and determine appropriate dosing based on your specific needs. They will also monitor you for side effects such as cough with ACE inhibitors or electrolyte imbalances with hydrochlorothiazide. Some examples of fixed-dose combinations of ACE inhibitors and hydrochlorothiazide include:
• Benazepril-hydrochlorothiazide (5/6.25,10/12.5,20/12.5,20/25) 1
• Captopril-hydrochlorothiazide (25/15,25/25,50/15,50/25) 1
• Enalapril-hydrochlorothiazide (5/12.5,10/25) 1
• Lisinopril-hydrochlorothiazide (10/12.5,20/12.5,20/25) 1 It's essential to note that only licensed healthcare providers can legally prescribe these medications after conducting a proper medical evaluation.

From the FDA Drug Label

For Control of Hypertension: The adult initial dose of hydrochlorothiazide capsules is one capsule given once daily whether given alone or in combination with other antihypertensives. Hydrochlorothiazide capsules are indicated in the management of hypertension either as the sole therapeutic agent, or in combination with other antihypertensives. Unlike potassium sparing combination diuretic products, hydrochlorothiazide capsules may be used in those patients in whom the development of hyperkalemia cannot be risked, including patients taking ACE inhibitors

Yes, hydrochlorothiazide can be prescribed in combination with an ACE inhibitor, as stated in the drug label 2 and 2.

• The drug label explicitly mentions that hydrochlorothiazide can be used in combination with other antihypertensives, including ACE inhibitors.
• It is recommended to use the adult initial dose of one capsule given once daily, and total daily doses greater than 50 mg are not recommended.

From the Research

ACE Inhibitors and Hydrochlorothiazide

• ACE inhibitors, such as lisinopril, are effective in lowering blood pressure in patients with essential hypertension 3.
• The addition of hydrochlorothiazide to lisinopril can enhance blood pressure reduction in patients who do not respond adequately to lisinopril alone 3.
• Lisinopril has been shown to be at least as effective as hydrochlorothiazide in lowering blood pressure, and it can also attenuate hypokalemia induced by thiazide diuretics 3.

Combination Therapy

• The combination of an ACE inhibitor and a diuretic, such as hydrochlorothiazide, is a common treatment approach for hypertension 4.
• This combination can be effective in managing blood pressure and reducing the risk of cardiovascular complications 3, 5.
• However, it is essential to monitor potassium levels and renal function when using this combination, as ACE inhibitors and diuretics can increase the risk of hyperkalemia and renal impairment 4.

Dosage and Administration

• ACE inhibitors can be administered once or twice daily, depending on the specific medication and patient needs 6.
• Twice-daily dosing of ACE inhibitors may promote added blood pressure-lowering effects, but it is crucial to consider patient adherence and potential safety concerns 6.
• The dosage of ACE inhibitors, such as lisinopril, can range from 2.5 to 40 mg/day, depending on the patient's response and renal function 5.