At what Glomerular Filtration Rate (GFR) can I initiate Lisinopril (angiotensin-converting enzyme inhibitor) therapy?

Lisinopril Initiation Based on GFR

Lisinopril can be initiated at any GFR level, but dosing must be adjusted based on renal function: use full dose for GFR >30 mL/min/1.73m², reduce to half the usual dose for GFR 10-30 mL/min/1.73m², and start at 2.5 mg daily for GFR <10 mL/min/1.73m² or patients on hemodialysis. 1

Dosing Algorithm Based on GFR

GFR (mL/min/1.73m²)	Initial Lisinopril Dose	Maximum Dose
>30	10 mg daily (standard)	40 mg daily
10-30	5 mg daily (half dose)	40 mg daily
<10 or hemodialysis	2.5 mg daily	40 mg daily

Special Considerations

For Hypertension

• Start at 10 mg daily if GFR >30 mL/min/1.73m²
• Start at 5 mg daily if GFR 10-30 mL/min/1.73m²
• Start at 2.5 mg daily if GFR <10 mL/min/1.73m² 1
• If also taking diuretics, start at 5 mg daily regardless of GFR

For Heart Failure

• Start at 5 mg daily if GFR >30 mL/min/1.73m²
• Start at 2.5 mg daily if GFR 10-30 mL/min/1.73m²
• Start at 2.5 mg daily if GFR <10 mL/min/1.73m² 1

For Acute MI

• Start at 5 mg daily if GFR >30 mL/min/1.73m²
• Start at 2.5 mg daily if GFR 10-30 mL/min/1.73m² or if systolic BP ≤120 mmHg
• Start at 2.5 mg daily if GFR <10 mL/min/1.73m² 1

Monitoring Recommendations

• Check serum creatinine, potassium, and blood pressure within 1 week of starting or increasing dose of lisinopril 2
• Temporarily suspend lisinopril during intercurrent illness, planned IV radiocontrast administration, bowel preparation prior to colonoscopy, or before major surgery 2
• Monitor for hyperkalemia, especially in patients with GFR <30 mL/min/1.73m² 3

Clinical Evidence

Studies have demonstrated that lisinopril is effective and generally well-tolerated in patients with impaired renal function when appropriately dosed 4, 5, 6. In patients with moderate to severe renal impairment, lisinopril provided effective blood pressure control with a median dose of 10 mg daily 6.

Important Cautions

• ACE inhibitors like lisinopril should not be discontinued routinely in people with GFR <30 mL/min/1.73m² as they remain nephroprotective 2
• Hyperkalemia occurred in approximately one-third of patients with impaired renal function during long-term follow-up 3
• Monitor GFR during treatment, as some patients may experience a decrease in GFR over time, particularly those without initial renal vasodilation response to ACE inhibitor therapy 3

Common Pitfalls to Avoid

1. Failure to adjust dose based on renal function: Always check GFR before prescribing and adjust dose accordingly
2. Not monitoring potassium levels: Hyperkalemia is a significant risk, especially with GFR <30 mL/min/1.73m²
3. Continuing full dose during acute illness: Temporarily suspend or reduce dose during conditions that may worsen renal function
4. Overlooking drug interactions: Be cautious with concomitant use of potassium-sparing diuretics, potassium supplements, or NSAIDs

Remember that while lisinopril requires dose adjustment in renal impairment, it remains an effective antihypertensive option across all levels of kidney function when properly dosed.