From the FDA Drug Label
- 4 Dose in Patients with Renal Impairment No dose adjustment of lisinopril tablets is required in patients with creatinine clearance > 30 mL/min. In patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, reduce the initial dose of lisinopril tablets to half of the usual recommended dose i.e., hypertension, 5 mg; systolic heart failure, 2.5 mg and acute MI, 2. 5 mg.
The ACE inhibitor dosage for patients with CKD should be adjusted based on creatinine clearance.
- For patients with creatinine clearance > 30 mL/min, the usual recommended dose can be used.
- For patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, the initial dose should be reduced to half of the usual recommended dose.
- For patients on hemodialysis or creatinine clearance < 10 mL/min, the recommended initial dose is 2.5 mg once daily. However, the provided information does not directly address the dosage at each stage of albuminuria. 1
From the Research
For patients with chronic kidney disease (CKD) and albuminuria, ACE inhibitors or ARBs should be initiated at low doses and titrated upward based on tolerance and response, with a focus on reducing proteinuria and slowing CKD progression, as supported by the most recent study 2.
Key Considerations
- For mild albuminuria (30-300 mg/day), start with low doses such as lisinopril 5-10 mg daily, enalapril 5 mg daily, losartan 25-50 mg daily, or valsartan 80 mg daily.
- For moderate to severe albuminuria (>300 mg/day), the same starting doses apply, but more aggressive titration to maximum tolerated doses is recommended, with target doses including lisinopril 20-40 mg daily, enalapril 20 mg daily, losartan 100 mg daily, or valsartan 320 mg daily.
- Dose adjustments should be made every 2-4 weeks while monitoring blood pressure, serum potassium, and kidney function, with blood pressure targets of 130/80 mmHg or lower, as suggested by 3.
Monitoring and Adjustments
- If hyperkalemia occurs (potassium >5.5 mEq/L) or if there's an acute decline in eGFR >30%, consider dose reduction or discontinuation, as recommended by 4.
- The combination of ACE inhibitors and ARBs may be considered for patients with proteinuric renal disease, as it has been shown to decrease proteinuria and slow CKD progression, according to 5.
Benefits of ACE Inhibitors and ARBs
- These medications reduce intraglomerular pressure by dilating the efferent arteriole, thereby decreasing proteinuria and slowing CKD progression beyond their blood pressure-lowering effects, as explained in 6.
- ARBs may be preferred for diabetic patients with albuminuria due to their renoprotective effects, as suggested by 3.