Can I add lisinopril (angiotensin-converting enzyme inhibitor) to the patient's regimen?

Adding Lisinopril to Patient's Regimen

Yes, lisinopril can be added to the patient's regimen as ACE inhibitors are recommended first-line therapy for patients with heart failure with reduced ejection fraction (HFrEF) and have been shown to reduce mortality and hospitalizations. 1

Benefits of Adding Lisinopril

• ACE inhibitors have conclusively demonstrated significant benefits in heart failure:

  • Increase survival
  • Reduce hospital admissions
  • Improve NYHA class and quality of life 1
  • Prevent 13 deaths and 99 hospitalizations per 1000 patient-years of treatment 1

• Lisinopril specifically:

  • Provides once-daily dosing convenience
  • Does not require hepatic metabolism (excreted unchanged in urine) 2
  • Has demonstrated efficacy in improving cardiac function in heart failure patients 3

Dosing Recommendations

• Start with a low dose: 2.5-5.0 mg once daily 1
• Gradually titrate dose at intervals of not less than 2 weeks 1
• Target dose: 30-35 mg once daily, or highest tolerated dose 1
• Remember that some ACE inhibitor is better than no ACE inhibitor 1

Monitoring Requirements

• Check blood chemistry (urea, creatinine, potassium) and blood pressure within 1-2 weeks of initiation 1
• Continue periodic monitoring, especially in patients with:
  • Pre-existing hypotension
  • Hyponatremia
  • Diabetes mellitus
  • Azotemia
  • Those taking potassium supplements 1

Potential Adverse Effects to Watch For

Hypotension

• More common in patients with:
  • Very low systemic blood pressure (systolic <80 mmHg) 1
  • Volume depletion
  • Concurrent diuretic use 4
• Management: Consider reducing diuretic dose if no signs of congestion 1

Renal Function Changes

• Small increases in creatinine are expected and often don't require intervention 1
• More significant if:
  • Pre-existing renal dysfunction (creatinine >2.5 mg/dL) 1
  • Bilateral renal artery stenosis 1

Hyperkalemia

• Risk increases with:
  • Elevated baseline potassium (>5.0 mmol/L) 1
  • Concurrent use of potassium-sparing diuretics 4
  • Renal impairment 4

Cough

• Common side effect but rarely requires discontinuation 1
• Important to differentiate from pulmonary edema 1
• If troublesome, consider ARB substitution 1

Contraindications

• History of angioedema with previous ACE inhibitor use 4
• Pregnancy (Category D) 4
• Avoid co-administration with aliskiren in patients with diabetes 4

Special Considerations

• If patient is on diuretics:

  • Consider decreasing or discontinuing diuretic temporarily
  • Increase salt intake prior to starting lisinopril
  • If neither is possible, start with lower dose of lisinopril 4

• For patients with renal impairment:

  • Significant accumulation occurs with severe renal impairment (CrCl ≤30 ml/min) 2
  • Lower starting dose and more careful monitoring required 5

• Drug interactions to monitor:

  • Diuretics (risk of hypotension, but lisinopril attenuates potassium loss from thiazides) 4
  • NSAIDs (may reduce antihypertensive effect) 4
  • Antidiabetic medications (increased risk of hypoglycemia) 4
  • Other RAS blockers (avoid dual blockade) 4

By following these recommendations, lisinopril can be safely and effectively added to the patient's regimen to improve outcomes in heart failure management.