Can I increase lisinopril (10 mg by mouth daily) to 20 mg by mouth daily if the blood pressure remains 115/107 mm Hg?

Yes, increase lisinopril from 10mg to 20mg daily for this uncontrolled blood pressure

You should increase the lisinopril dose to 20mg daily, as the current blood pressure of 115/107 mmHg remains above target (particularly the diastolic of 107 mmHg), and 20mg is the standard maintenance dose supported by clinical trials and FDA labeling.

Rationale for Dose Escalation

The FDA-approved dosing for lisinopril in hypertension starts at 10mg daily with a usual maintenance range of 20-40mg daily 1. Clinical trials demonstrate that blood pressure reduction is dose-dependent across the 2.5-80mg range, with 10mg and 20mg producing greater antihypertensive effects than lower doses 2. Your patient's diastolic pressure of 107 mmHg is significantly elevated and requires more aggressive control.

Target Blood Pressure

Current guidelines recommend:

• Target BP <140/90 mmHg as a minimum 3, 4
• More recent evidence supports targeting systolic BP 120-129 mmHg when well-tolerated 5
• The 2020 ISH guidelines recommend achieving target within 3 months 6

Your patient's diastolic of 107 mmHg is well above any reasonable target, making dose escalation clearly indicated.

Dosing Algorithm

Following the evidence-based approach 7, 1:

1. Start at 10mg daily (current dose) ✓
2. Titrate to 20mg daily if BP not controlled (your next step)
3. Consider 40mg daily if still uncontrolled on 20mg
4. Add a second agent (thiazide diuretic or calcium channel blocker) if monotherapy insufficient 3, 8

The Canadian guidelines specifically list lisinopril target doses of 20-35mg daily based on major clinical trials 7, and the ATLAS trial showed that higher doses (32.5-35mg) provided better outcomes than low doses (2.5-5mg) 9.

Safety Considerations

Before increasing the dose, verify:

• Renal function: No dose adjustment needed if creatinine clearance >30 mL/min 1
• Serum potassium: Monitor 5-7 days after dose increase 9
• Blood pressure tolerance: Ensure patient isn't experiencing symptomatic hypotension (unlikely given current BP)

Common Pitfalls to Avoid

• Don't add a second agent before optimizing the first: Maximize lisinopril to at least 20mg before adding a diuretic or calcium channel blocker 10, 3
• Don't accept inadequate BP control: That diastolic of 107 mmHg significantly increases cardiovascular risk
• Don't delay titration: Guidelines recommend achieving target BP within 3 months 6
• Monitor potassium and creatinine 5-7 days after the dose increase 9

Next Steps if 20mg Insufficient

If BP remains uncontrolled on lisinopril 20mg daily after 2-4 weeks:

1. Consider increasing to 40mg daily (maximum studied dose for efficacy) 1
2. Or add a thiazide diuretic (hydrochlorothiazide 12.5-25mg) or calcium channel blocker (amlodipine 5-10mg) 3, 8
3. Single-pill combinations are preferred for adherence 5

The evidence strongly supports dose escalation in your patient, as monotherapy at 10mg is clearly insufficient for this level of hypertension.