What is the highest recommended dose of lisinopril (Angiotensin-Converting Enzyme inhibitor)?

Maximum Recommended Dose of Lisinopril

The maximum recommended dose of lisinopril is 40 mg once daily for hypertension and heart failure. 1, 2

Dosing Guidelines for Lisinopril

Initial and Maximum Dosing

• Starting dose: 2.5-5 mg once daily 1, 2
• Maintenance dose range: 5-40 mg once daily 1, 2
• Maximum dose: 40 mg once daily 1, 2

Dosing by Indication

1. Hypertension:

   • Initial: 2.5-5 mg once daily
   • Target: 20-40 mg once daily 1, 2

2. Heart Failure:

   • Initial: 2.5 mg once daily (lower starting dose due to risk of hypotension)
   • Target: 20-40 mg once daily 1
   • In the ATLAS trial, high-dose lisinopril (32.5-35 mg daily) showed significant benefits over low-dose (2.5-5 mg daily) with a 12% reduction in death or hospitalization 1, 3

Titration Protocol

1. Start with 2.5-5 mg once daily
2. Check blood pressure, renal function, and electrolytes 1-2 weeks after initiation 1
3. Increase dose gradually every 1-2 weeks as tolerated
4. Aim for the target dose of 20-40 mg once daily 1, 2

Special Considerations

Dose Adjustments

• Renal impairment: Lower doses required when GFR < 30 mL/min 1, 4
• Elderly patients: May require lower initial doses (2.5 mg) 5
• Concomitant diuretic therapy: Consider reducing or withholding diuretics for 24 hours before initiating lisinopril 1

Monitoring

• Check blood pressure, renal function, and electrolytes:
  • 1-2 weeks after initiation
  • 1-2 weeks after each dose increase
  • At 3 months and then every 6 months 1

Clinical Pearls

Importance of Target Dosing

• Many patients are undertreated with suboptimal doses of ACE inhibitors 1
• Higher doses provide greater clinical benefits, as demonstrated in the ATLAS trial 1, 3
• Physicians often fail to uptitrate to target doses due to concerns about hypotension or renal function 1

Common Pitfalls to Avoid

1. Permanent dose reduction after temporary adverse effects: In clinical trials, 40% of patients who required temporary dose reduction were subsequently restored to target doses 1

2. Fear of hypotension: The most dramatic decreases in blood pressure typically occur with the initial dose, not during uptitration 1

3. Overreaction to mild renal function changes: Most occurrences of worsening renal function reflect changes in intrarenal hemodynamics rather than renal injury 1

4. Failure to recognize the higher target doses for heart failure compared to hypertension: The doses used in heart failure trials are often higher than those commonly used for hypertension 1

Remember that achieving target doses of ACE inhibitors is associated with improved outcomes in heart failure patients, and efforts should be made to reach these doses whenever possible.