Should lisinopril (ACE inhibitor) be increased to 20 mg in a patient with uncontrolled hypertension?

Management of Uncontrolled Hypertension with Lisinopril

The lisinopril dose should be increased from 10 mg to 20 mg daily for this patient with uncontrolled hypertension based on both home and clinic blood pressure readings. 1

Rationale for Dose Increase

• The patient's blood pressure readings (167/84 in clinic, range 166/88 to 192/108 at home) are significantly above the target of <130/80 mmHg recommended for hypertension management 2
• According to FDA drug information, blood pressure reduction occurs sooner and is greater in patients treated with 20 mg of lisinopril compared to 5 mg, supporting dose escalation to 20 mg 1
• The recommended goal dose for lisinopril is 20-40 mg daily, as indicated in clinical guidelines 3
• Home blood pressure readings showing values as high as 192/108 mmHg indicate severe uncontrolled hypertension requiring more aggressive treatment

Dosing Considerations

• The standard titration approach for lisinopril is to start at 10 mg daily and increase to 20 mg if blood pressure remains uncontrolled 1
• Dose-response studies have demonstrated that 20 mg of lisinopril provides greater antihypertensive effect than lower doses 4
• The magnitude of antihypertensive response at 24 hours post-dose appears to be dose-related across the 2.5 to 80 mg daily range, supporting once-daily dosing at higher doses for better 24-hour control 4

Monitoring Recommendations

• After increasing the dose:
  • Check blood pressure within 2-4 weeks to assess response
  • Monitor renal function and electrolytes within 1-2 weeks of dose adjustment 2
  • Continue home blood pressure monitoring to evaluate the effectiveness of the increased dose

Additional Considerations

• If blood pressure remains uncontrolled on lisinopril 20 mg:
  • Consider adding a thiazide diuretic as the next step, which has shown consistent effectiveness when combined with ACE inhibitors 2
  • If hypertension persists despite three agents including a diuretic, consider adding a mineralocorticoid receptor antagonist like spironolactone 2

Potential Pitfalls and Caveats

• Watch for potential side effects with dose increase:

  • Dizziness due to first-dose hypotension (though studies show 20 mg should not pose greater risk than 10 mg) 4
  • Cough (ACE inhibitor-specific side effect)
  • Changes in renal function, especially in patients with underlying kidney disease 5

• Ensure the patient is adherent to the medication regimen, as non-adherence is a common cause of apparent treatment resistance

• Verify the patient is not taking medications that can interfere with blood pressure control (NSAIDs, decongestants, etc.) 2