From the Guidelines
Lisinopril (Zestril) is an angiotensin-converting enzyme (ACE) inhibitor that effectively treats hypertension and heart failure by blocking the conversion of angiotensin I to angiotensin II, thereby reducing blood pressure and cardiac workload. Its mechanism of action involves preventing the formation of angiotensin II, which normally causes blood vessel constriction and increases sodium and water retention. By inhibiting this process, lisinopril promotes vasodilation, decreases blood volume, and reduces cardiac afterload. The typical starting dose is 10 mg once daily for hypertension and 5 mg once daily for heart failure, with gradual titration based on response, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1. Common side effects include dry cough (due to increased bradykinin levels), dizziness, headache, fatigue, and hypotension. More serious adverse effects include angioedema, hyperkalemia, and acute kidney injury. Lisinopril is contraindicated during pregnancy (especially second and third trimesters due to fetal harm), in patients with a history of angioedema related to previous ACE inhibitor therapy, and in those with bilateral renal artery stenosis, as stated in the british hypertension society guidelines for hypertension management 2004 (BHS-IV) 1. Patients should be educated to take lisinopril at the same time each day, monitor their blood pressure regularly, report persistent cough or swelling of face/lips/tongue, avoid potassium supplements unless prescribed, rise slowly from sitting/lying positions to prevent dizziness, and maintain adequate hydration while avoiding excessive salt substitutes. They should also understand the importance of regular kidney function and potassium level monitoring, especially when starting therapy, as emphasized in the 2007 guidelines for the management of arterial hypertension by the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) 1.
Key Points for Patient Education
- Take lisinopril at the same time each day
- Monitor blood pressure regularly
- Report persistent cough or swelling of face/lips/tongue
- Avoid potassium supplements unless prescribed
- Rise slowly from sitting/lying positions to prevent dizziness
- Maintain adequate hydration while avoiding excessive salt substitutes
- Regular kidney function and potassium level monitoring, especially when starting therapy
Follow-Up and Monitoring
Regular follow-up appointments are crucial to monitor the effectiveness of lisinopril and adjust the dosage as needed. Patients should be monitored for signs of hypotension, hyperkalemia, and acute kidney injury, as well as for changes in kidney function and potassium levels. The 2020 international society of hypertension global hypertension practice guidelines recommend treating hypertension to a target <130/80 mm Hg but >120/70 mm Hg 1.
Contraindications and Precautions
Lisinopril is contraindicated in patients with a history of angioedema related to previous ACE inhibitor therapy, bilateral renal artery stenosis, and during pregnancy (especially second and third trimesters due to fetal harm) 1. Caution should be exercised when using lisinopril in patients with renal impairment, as it may worsen kidney function, and in patients with heart failure, as it may exacerbate the condition. The british hypertension society guidelines for hypertension management 2004 (BHS-IV) provide a comprehensive list of compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs, including ACE inhibitors like lisinopril 1.
Side Effects and Adverse Reactions
Common side effects of lisinopril include dry cough, dizziness, headache, fatigue, and hypotension. More serious adverse effects include angioedema, hyperkalemia, and acute kidney injury. The 2007 guidelines for the management of arterial hypertension by the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) provide guidance on the management of side effects and adverse reactions associated with ACE inhibitors like lisinopril 1.
Quality of Life and Morbidity
Lisinopril has been shown to improve quality of life and reduce morbidity in patients with hypertension and heart failure, as demonstrated in various clinical trials and studies, including the ALLHAT trial 1 and the 2020 international society of hypertension global hypertension practice guidelines 1. By reducing blood pressure and cardiac workload, lisinopril can help to alleviate symptoms, improve exercise tolerance, and reduce the risk of cardiovascular events. However, the potential for side effects and adverse reactions, such as dry cough and hypotension, should be carefully considered and managed to optimize patient outcomes. The british hypertension society guidelines for hypertension management 2004 (BHS-IV) emphasize the importance of individualizing treatment and considering the potential benefits and risks of ACE inhibitors like lisinopril in different patient populations 1.
Mortality
Lisinopril has been shown to reduce mortality in patients with heart failure, as demonstrated in various clinical trials and studies, including the SOLVD trial and the 2020 international society of hypertension global hypertension practice guidelines 1. By reducing blood pressure and cardiac workload, lisinopril can help to reduce the risk of cardiovascular events and improve survival in patients with heart failure. However, the potential for side effects and adverse reactions, such as hyperkalemia and acute kidney injury, should be carefully considered and managed to optimize patient outcomes. The 2007 guidelines for the management of arterial hypertension by the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) provide guidance on the management of patients with heart failure and the use of ACE inhibitors like lisinopril to reduce mortality and improve outcomes 1.
From the FDA Drug Label
CLINICAL PHARMACOLOGY 12. 1 Mechanism of Action Lisinopril inhibits angiotensin-converting enzyme (ACE) in human subjects and animals. ACE is a peptidyl dipeptidase that catalyzes the conversion of angiotensin I to the vasoconstrictor substance, angiotensin II. Angiotensin II also stimulates aldosterone secretion by the adrenal cortex The beneficial effects of lisinopril in hypertension and heart failure appear to result primarily from suppression of the renin-angiotensin-aldosterone system.
Lisinopril Mechanism of Action (MOA):
- Lisinopril inhibits angiotensin-converting enzyme (ACE), which catalyzes the conversion of angiotensin I to angiotensin II.
- The inhibition of ACE results in decreased plasma angiotensin II, leading to decreased vasopressor activity and aldosterone secretion.
ADVERSE REACTIONS 6. 1 Clinical Trials Experience The following adverse reactions (events 2% greater on lisinopril than on placebo) were observed with lisinopril alone: headache (by 3.8%), dizziness (by 3.5%), cough (by 2. 5%).
Lisinopril Side Effects:
- Common side effects include:
- Headache (3.8%)
- Dizziness (3.5%)
- Cough (2.5%)
- Hypotension (3.8%)
- Chest pain (2.1%)
- Renal dysfunction (1.3%)
- Hyperkalemia (2.2% in hypertension and 4.8% in heart failure)
CONTRAINDICATIONS Lisinopril is contraindicated in patients with: -a history of angioedema or hypersensitivity related to previous treatment with an angiotensin converting enzyme inhibitor -hereditary or idiopathic angioedema Do not co-administer aliskiren with lisinopril in patients with diabetes [see Drug Interactions (7.4)]
Lisinopril Contraindications:
- History of angioedema or hypersensitivity related to previous treatment with an angiotensin-converting enzyme inhibitor
- Hereditary or idiopathic angioedema
- Co-administration with aliskiren in patients with diabetes
Patient Education:
- Patients should be informed about the potential side effects of lisinopril, including hypotension, cough, and hyperkalemia.
- Patients should be advised to monitor their blood pressure and potassium levels regularly.
- Patients should be informed about the importance of adhering to their medication regimen and follow-up appointments with their healthcare provider.
- Patients with diabetes should be aware of the potential interaction between lisinopril and aliskiren.
- Patients should be advised to report any symptoms of angioedema, such as swelling of the face, lips, tongue, or throat, to their healthcare provider immediately 2, 2, 2.
From the Research
Mechanism of Action (MOA)
- Lisinopril is an orally active angiotensin-converting enzyme (ACE) inhibitor 3, 4, 5
- It inhibits ACE activity, reducing plasma angiotensin II and aldosterone, and increasing plasma renin activity 5
- This results in a smooth, gradual blood pressure reduction in hypertensive patients without affecting heart rate or cardiovascular reflexes 5
Side Effects
- Lisinopril is well tolerated, with few serious adverse effects being reported 3, 4, 6, 7
- Common adverse events include dizziness, headache, hypotension, and diarrhea 7
- High doses of lisinopril may be associated with a higher incidence of adverse events, such as hypotension and worsening renal function 7
Contraindications
- No specific contraindications are mentioned in the studies, but caution should be used when administering lisinopril with diuretics, nifedipine, or agents that may increase concentrations of potassium 4
Follow-up
- Patients with congestive heart failure should be monitored for improvements in symptomatic end-points and clinical status 7
- Renal function should be monitored, especially in patients with severe renal impairment 5
Patient Education
- Patients should be informed about the importance of taking lisinopril as directed, and the potential for adverse effects 6
- Patients should also be educated on the signs and symptoms of hypotension, and what to do if they experience them 7
- Patients with diabetes should be monitored for changes in blood glucose control, as lisinopril may have a beneficial effect on diabetic nephropathy 6