What is the appropriate starting dose and titration of Lisinopril (Angiotensin-Converting Enzyme inhibitor) for a patient with hypertension or heart failure?

From the Guidelines

For hypertension, the recommended starting dose of lisinopril is 10 mg once daily, which can be titrated upward every 2-4 weeks based on blood pressure response, typically to 20-40 mg daily with a maximum dose of 80 mg daily, as supported by the most recent guidelines 1. For heart failure, a lower starting dose of 2.5-5 mg once daily is appropriate, with gradual increases to a target dose of 20-40 mg daily as tolerated, according to the American College of Cardiology/American Heart Association guidelines 1. Patients with renal impairment, those on diuretics, or elderly individuals should start at a lower dose of 2.5-5 mg daily due to increased risk of hypotension, as recommended by the European Society of Cardiology 1. Lisinopril should be taken at the same time each day to maintain consistent blood levels. Blood pressure, renal function, and potassium levels should be monitored regularly, especially after initiation and dose changes, as emphasized by the British Hypertension Society guidelines 1. Some key points to consider when prescribing lisinopril include:

• Starting with a low dose and titrating upward as needed and tolerated
• Monitoring for potential side effects such as cough, hypotension, and renal insufficiency
• Avoiding combinations with other drugs that may increase the risk of adverse effects, such as potassium-sparing diuretics and non-steroidal anti-inflammatory drugs
• Considering alternative treatments, such as angiotensin receptor blockers, in patients who are intolerant to ACE inhibitors, as suggested by the European Society of Cardiology 1. Overall, the use of lisinopril in the treatment of hypertension and heart failure should be guided by the most recent clinical guidelines and tailored to the individual patient's needs and response to treatment, with a focus on minimizing morbidity, mortality, and improving quality of life, as supported by the highest quality evidence available 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2.1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. Dosage should be adjusted according to blood pressure response. The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose. 2.2 Heart Failure The recommended starting dose for lisinopril tablets, when used with diuretics and (usually) digitalis as adjunctive therapy for systolic heart failure, is 5 mg once daily.

The appropriate starting dose of Lisinopril for a patient with hypertension is 10 mg daily, and for a patient with heart failure is 5 mg daily. The dose may be titrated according to blood pressure response, up to a maximum of 40 mg daily.

• For patients with hypertension, the usual dosage range is 20 mg to 40 mg per day.
• For patients with heart failure, the dose may be increased as tolerated to a maximum of 40 mg once daily. 2

From the Research

Lisinopril Dosage and Titration

• The usual initial oral dosage of lisinopril is 10 mg once a day, with a range of 20-40 mg/day 3.
• Lower dosages may be necessary in patients with renal impairment or congestive heart failure, elderly persons, and those receiving diuretics 3.
• For patients with hypertension, lisinopril is effective in lowering blood pressure at dosages of 20 to 80 mg once daily 4.
• In patients with congestive heart failure, lisinopril 2.5 to 20 mg once daily improved indices of cardiac function and appeared to produce greater benefit than captopril in one controlled study 4.
• High doses of lisinopril (32.5 to 35mg, administered once daily) demonstrated clinically important advantages over low doses (2.5 to 5mg, administered once daily) of the drug in the treatment of congestive heart failure 5.

Titration and Monitoring

• The antihypertensive effect of lisinopril begins within 2 h, peaks around 6 h, and lasts for at least 24 h 6.
• Peak serum concentrations occur 6-8 h after oral dosing, and steady state is achieved in 2-3 days with little accumulation 6.
• Significant accumulation occurs in patients with severe renal impairment (creatinine clearance less than or equal to 30 ml/min) 6.
• Patients should be monitored for adverse events, such as hypotension, dizziness, and cough, and the dose of lisinopril should be adjusted accordingly 7.

Special Considerations

• Lisinopril is well tolerated, with few serious adverse effects being reported 4, 7.
• Clinically significant drug interactions have not been reported, but caution should be used when lisinopril is administered with diuretics, nifedipine, or agents that may increase concentrations of potassium 3.
• The safety and tolerability of lisinopril have been assessed in a large number of patients, and the drug has been found to be well tolerated in long-term treatment of hypertension and congestive heart failure 7.