What are the contraindications for Lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor)?

Contraindications for Lisinopril

Lisinopril is absolutely contraindicated in patients with a history of angioedema related to previous ACE inhibitor treatment, hereditary or idiopathic angioedema, and in patients with diabetes who are taking aliskiren. 1

Absolute Contraindications

• History of angioedema or hypersensitivity to previous ACE inhibitor treatment 1
• Hereditary or idiopathic angioedema 1
• Concomitant use of aliskiren in patients with diabetes 1
• Pregnancy (all trimesters) due to risk of fetal toxicity, especially in second and third trimesters 2
• Bilateral renal artery stenosis or stenosis of the artery to a solitary kidney 2

Relative Contraindications/Use with Caution

Renal Conditions

• Significant renal impairment (serum creatinine >3 mg/dL) 2
• Renal artery stenosis (unilateral) - requires careful monitoring 2

Cardiovascular Conditions

• Severe hypotension (systolic blood pressure <80 mm Hg) 2
• Cardiogenic shock or hemodynamic instability - stabilize patient first before initiating therapy 2

Electrolyte Abnormalities

• Hyperkalemia (serum potassium >5.5 mmol/L) 2
• Patients on potassium-sparing diuretics - increased risk of hyperkalemia 2

Other Conditions

• Volume depletion from diuretic therapy, dialysis, diarrhea, or vomiting - correct volume depletion before initiating therapy 2
• Concomitant NSAID use - may reduce antihypertensive effect and increase risk of renal dysfunction 2
• Concomitant use of cyclosporine - increased risk of acute renal failure 2

Monitoring Requirements

When initiating lisinopril in patients with risk factors:

1. Renal function monitoring:

   • Check baseline renal function
   • Recheck 1-2 weeks after initiation
   • Monitor after dose increases
   • More frequent monitoring in patients with renal impairment 2

2. Potassium monitoring:

   • Check baseline potassium levels
   • Recheck 1-2 weeks after initiation
   • Monitor when adding medications that may increase potassium (potassium-sparing diuretics, potassium supplements) 2

3. Blood pressure monitoring:

   • Monitor closely when initiating therapy, especially in patients with heart failure or who are volume depleted 2

Clinical Pearls

• A 10-20% increase in serum creatinine after initiating lisinopril is expected and not necessarily a reason to discontinue therapy, particularly in patients with chronic kidney disease 2
• First-dose hypotension can occur, especially in volume-depleted patients; consider administering the first dose at bedtime 2
• In patients undergoing procedures with radiocontrast agents, lisinopril may increase the risk of contrast-induced nephropathy 2
• For patients requiring ACE inhibition who develop cough, consider switching to an angiotensin receptor blocker (ARB) 2

Remember that while these contraindications exist, lisinopril remains a valuable medication for treating hypertension, heart failure, and post-myocardial infarction patients when used appropriately with proper monitoring.