What is the recommended initial dose of lisinopril (angiotensin-converting enzyme inhibitor) for a first-time diagnosis of hypertension (HTN)?

Initial Lisinopril Dosing for First-Time Diagnosis of Hypertension

The recommended initial dose of lisinopril for a first-time diagnosis of hypertension in adults is 10 mg once daily. 1

Dosing Guidelines

Initial Therapy

• For adults with newly diagnosed hypertension: 10 mg once daily 1
• For patients already taking diuretics: 5 mg once daily 1
• For patients with renal impairment:
  • Creatinine clearance >30 mL/min: Standard dosing
  • Creatinine clearance 10-30 mL/min: Half the usual dose (5 mg)
  • Creatinine clearance <10 mL/min or on hemodialysis: 2.5 mg once daily 1

Dose Titration

• Adjust according to blood pressure response
• Usual effective dosage range: 20-40 mg per day as a single daily dose
• Maximum dose: Up to 80 mg daily has been used, but doesn't typically provide additional benefit 1

Considerations for Special Populations

Elderly Patients

• Clinical studies have shown lisinopril to be effective in elderly patients with hypertension
• Dosages ranging from 2.5 to 40 mg/day have been effective 2
• Elderly patients may respond to lower doses, but this is typically related to renal function rather than age itself

Patients with Renal Impairment

• Dose adjustment is required based on creatinine clearance
• For moderate impairment (creatinine clearance 10-30 mL/min): Start with 5 mg daily 1
• For severe impairment (creatinine clearance <10 mL/min): Start with 2.5 mg daily 1

Treatment Algorithm

1. Initial Assessment:

   • Confirm hypertension diagnosis (BP ≥140/90 mmHg on multiple occasions)
   • Assess renal function (creatinine clearance)
   • Check if patient is currently on diuretics

2. Initial Dosing:

   • Standard patient: 10 mg once daily
   • Patient on diuretics: 5 mg once daily
   • Patient with renal impairment: Adjust as noted above

3. Follow-up and Titration:

   • Reassess blood pressure after 2-4 weeks
   • If target not achieved, increase dose to 20 mg daily
   • Further titration to 40 mg if needed

Important Considerations

• ACE inhibitors like lisinopril are among the recommended first-line agents for hypertension management 3
• For patients with stage 2 hypertension (BP ≥160/100 mmHg), consider initiating therapy with two antihypertensive medications 3
• ACE inhibitors are particularly beneficial for patients with albuminuria, diabetes, or heart failure 3
• Avoid combining ACE inhibitors with ARBs or direct renin inhibitors 3

Common Side Effects and Monitoring

• Monitor serum creatinine, eGFR, and potassium levels at baseline and at least annually 3
• Common side effects include cough, headache, dizziness, and asthenia 3
• Serious but rare side effects include hyperkalemia, acute kidney injury, and angioedema 3

By following these guidelines, you can safely and effectively initiate lisinopril therapy for a patient with newly diagnosed hypertension.