Can I use an Angiotensin-Converting Enzyme Inhibitor (ACEI) alone, without a thiazide diuretic, in a patient with hypotension and weakness who is already on the minimum dose of 10mg?

From the Guidelines

Yes, you can use an ACE inhibitor alone without a thiazide diuretic in a patient experiencing hypotension and weakness who is already on the minimum dose of 10mg. In fact, discontinuing the thiazide diuretic is appropriate in this situation since the patient's symptoms suggest possible volume depletion or excessive blood pressure reduction. Consider maintaining the patient on the ACE inhibitor monotherapy (such as lisinopril or enalapril 10mg daily) and closely monitor their blood pressure and symptoms. If hypotension persists even with the ACE inhibitor alone, you may need to temporarily reduce the dose further or consider an alternative antihypertensive class. Ensure the patient maintains adequate hydration and salt intake, and check electrolytes and kidney function to rule out other causes of weakness, as suggested by 1. The rationale is that thiazide diuretics can potentiate hypotension when combined with ACE inhibitors through complementary mechanisms of blood pressure reduction, and removing the diuretic often resolves these adverse effects while maintaining some cardiovascular and renal protection from the ACE inhibitor. Additionally, it is essential to monitor for potential adverse effects such as worsening renal function and hyperkalemia, as outlined in 1, and adjust the treatment plan accordingly to prioritize the patient's morbidity, mortality, and quality of life. Key considerations include:

• Monitoring blood pressure and symptoms closely
• Ensuring adequate hydration and salt intake
• Checking electrolytes and kidney function
• Being aware of potential adverse effects such as worsening renal function and hyperkalemia, as discussed in 1
• Adjusting the treatment plan as needed to prioritize the patient's morbidity, mortality, and quality of life.

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2. 1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. Use with diuretics in adults If blood pressure is not controlled with lisinopril tablets alone, a low dose of a diuretic may be added (e.g., hydrochlorothiazide, 12. 5 mg).

Using ACEI alone is possible: The patient is already on the minimum dose of 10mg, and the drug label states that the recommended initial dose is 10 mg once a day. It also mentions that if blood pressure is not controlled with lisinopril tablets alone, a low dose of a diuretic may be added, but it does not explicitly state that a diuretic is required.

• Key consideration: The patient has hypotension and weakness, so careful monitoring of blood pressure and potential adjustment of the dose is necessary to avoid exacerbating these conditions. 2

From the Research

Patient Considerations

• The patient is taking the minimum dose of 10mg of an Angiotensin-Converting Enzyme Inhibitor (ACEI) and is experiencing hypotension and weakness.
• The use of ACEI alone, without a thiazide diuretic, may not be sufficient to control blood pressure in some patients, as combination therapy with a thiazide diuretic has been shown to improve blood pressure reduction over either drug used alone 3.
• However, in patients with hypotension and weakness, the use of a thiazide diuretic may exacerbate these conditions, and therefore, the decision to use ACEI alone or in combination with a thiazide diuretic should be made on a case-by-case basis.

Safety and Efficacy

• The combination of ACEI and thiazide diuretic has been shown to be safe and effective in a wide range of patient populations, including those with hypertension, heart failure, and chronic renal disease 4, 5.
• The use of ACEI alone has been shown to reduce systemic vascular resistance and improve renal function in patients with hypertension and chronic renal disease 4.
• However, the use of ACEI alone may not be sufficient to control blood pressure in some patients, and the addition of a thiazide diuretic may be necessary to achieve optimal blood pressure control 3, 5.

Treatment Options

• The treatment of hypertension in patients with hypotension and weakness requires careful consideration of the potential benefits and risks of different treatment options.
• The use of ACEI alone or in combination with a thiazide diuretic may be considered, depending on the individual patient's needs and medical history.
• Other treatment options, such as calcium channel blockers or beta-blockers, may also be considered, depending on the patient's specific needs and medical history 6, 7.