Lisinopril Dosage and Treatment Protocol for Hypertension and Heart Failure
For hypertension, the recommended initial dose of lisinopril is 10 mg once daily, with a usual dosage range of 20-40 mg once daily; for heart failure, start with 5 mg once daily (or 2.5 mg if hyponatremic) and titrate to a maximum of 40 mg once daily. 1
Dosing for Hypertension
Initial Therapy
- Initial dose: 10 mg once daily 1
- Usual maintenance range: 20-40 mg once daily 1
- Maximum dose: Up to 80 mg daily has been used, but with minimal additional benefit 2, 1
Special Situations
- With diuretics: Start with 5 mg once daily 1
- Consider reducing or withholding diuretics for 24 hours before starting to minimize first-dose hypotension 2
- Pediatric patients (≥6 years):
- Initial: 0.07 mg/kg once daily (up to 5 mg total)
- Maximum: 0.61 mg/kg once daily (up to 40 mg) 1
Dosing for Heart Failure
Initial Therapy
- Standard initial dose: 5 mg once daily 1
- With hyponatremia (serum sodium <130 mEq/L): 2.5 mg once daily 1
- Target dose: 20 mg once daily 3
Titration Schedule
- Increase dose at intervals of at least 2 weeks 3, 2
- Typical titration: Double the dose at each step (e.g., 5 mg → 10 mg → 20 mg → 40 mg) 3
- Maximum dose: 40 mg once daily 1
Dosing for Post-Myocardial Infarction
- Initial dose: 5 mg orally
- Titration: 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg once daily
- Duration: Continue for at least 6 weeks
- With low systolic BP (≤120 mmHg and >100 mmHg): Start with 2.5 mg 1
Renal Impairment Adjustments
- CrCl >30 mL/min: No adjustment needed
- CrCl 10-30 mL/min: Start with half the usual dose
- Hypertension: 5 mg
- Heart failure: 2.5 mg
- CrCl <10 mL/min or hemodialysis: Initial dose 2.5 mg once daily 1, 4
Monitoring Protocol
Initial Phase
- Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increase 2
- Monitor for first-dose hypotension, especially in patients:
- On diuretics
- Volume-depleted
- With heart failure
- With renal impairment 1
Maintenance Phase
- Check blood pressure, renal function, and electrolytes at 3 months after reaching maintenance dose
- Continue monitoring every 6 months thereafter 2
- An increase in creatinine up to 50% or to 3 mg/dL is acceptable 2
Important Contraindications
- History of angioedema with previous ACE inhibitor use 3
- Pregnancy 3
- Bilateral renal artery stenosis 3, 2
Common Side Effects to Monitor
- Cough (occurs in up to 20% of patients) 3, 5
- Dizziness, headache 5
- Hypotension 1, 5
- Hyperkalemia 2
- Worsening renal function 2, 6
Clinical Pearls
- Diuretic dose may need adjustment to minimize hypovolemia and hypotension 1
- Avoid potassium-sparing diuretics during initiation 2
- Avoid NSAIDs and COX-2 inhibitors if possible 2
- Transient hypotension after initial dose does not preclude continued therapy 1
- In the ATLAS study, higher doses of lisinopril (32.5-35 mg daily) showed better outcomes than lower doses (2.5-5 mg daily) in heart failure patients 6
By following these evidence-based dosing and monitoring recommendations, lisinopril can be effectively and safely used to manage both hypertension and heart failure, with appropriate dose adjustments for special populations.