What is the recommended dosing for lisinopril (Angiotensin-Converting Enzyme inhibitor) in patients with hypertension or heart failure?

Lisinopril Dosing for Hypertension and Heart Failure

For hypertension, lisinopril should be started at 10 mg once daily and titrated up to 20-40 mg once daily based on blood pressure response, while for heart failure, the recommended starting dose is 5 mg once daily (or 2.5 mg if hyponatremic), titrated up to a maximum of 40 mg once daily. 1

Dosing for Hypertension

Initial Dosing

• Adults: 10 mg once daily 1
• Adults taking diuretics: 5 mg once daily 1
• Pediatric patients (>6 years): 0.07 mg/kg once daily (up to 5 mg total) 1
• Renal impairment:
  • CrCl >30 mL/min: No dose adjustment needed
  • CrCl 10-30 mL/min: Start with half the usual dose (5 mg)
  • CrCl <10 mL/min or hemodialysis: 2.5 mg once daily 1

Maintenance Dosing

• Usual range: 20-40 mg once daily 1
• Maximum dose: Up to 80 mg daily (minimal additional benefit beyond 40 mg) 2, 1
• Titration: Adjust dose at 2-week intervals based on blood pressure response 2

Dosing for Heart Failure

Initial Dosing

• Standard: 5 mg once daily 1
• With hyponatremia (serum sodium <130 mEq/L): 2.5 mg once daily 1
• Renal impairment:
  • CrCl 10-30 mL/min: 2.5 mg once daily
  • CrCl <10 mL/min: 2.5 mg once daily 1

Maintenance Dosing

• Target dose: 30-35 mg once daily 3, 2
• Maximum dose: 40 mg once daily 1
• Titration: Double dose at not less than 2-week intervals 3

Monitoring Protocol

1. Initial monitoring:

   • Check serum potassium and creatinine 5-7 days after starting treatment 3
   • Recheck every 5-7 days until potassium values stabilize 3

2. During titration:

   • Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increase 2

3. Maintenance monitoring:

   • Check at 3 months after reaching maintenance dose
   • Then every 6 months thereafter 2

Important Considerations

When to Adjust Therapy

• Hypotension:

  • Asymptomatic low blood pressure usually doesn't require therapy change 3
  • For symptomatic hypotension, consider reducing diuretic dose if no signs of congestion 3

• Worsening renal function:

  • Small increases in creatinine are expected and acceptable
  • An increase up to 50% or to 3 mg/dL can be acceptable 2

• Hyperkalemia:

  • Monitor potassium levels closely, especially when initiating therapy

Precautions

• Consider reducing or withholding diuretics for 24 hours before starting lisinopril 3
• Avoid potassium-sparing diuretics during initiation of therapy 3
• Avoid NSAIDs and COX-2 inhibitors 2

Contraindications

• History of angioedema
• Bilateral renal artery stenosis
• Pregnancy 2

Patient Advice

• Treatment improves symptoms within weeks to months 3
• Report adverse effects like dizziness, symptomatic hypotension, and cough 3
• For heart failure patients, explain that treatment improves symptoms and increases survival 3

Lisinopril is generally well-tolerated, with the most common side effects being headache, dizziness, cough, nausea, diarrhea, and fatigue 4. The ATLAS study demonstrated that higher doses (32.5-35 mg) were more effective than lower doses (2.5-5 mg) in reducing hospitalizations and mortality in heart failure patients 5.