Lisinopril Dosing for Hypertension and Heart Failure
For hypertension, lisinopril should be started at 10 mg once daily and titrated to a target dose of 20-40 mg daily; for heart failure, start at 5 mg once daily (2.5 mg if hyponatremic) and titrate to a target dose of 20-40 mg daily. 1, 2
Dosing for Hypertension
Initial Therapy
- Starting dose: 10 mg once daily 1
- For patients already on diuretics: 5 mg once daily 1
- For pediatric patients >6 years: 0.07 mg/kg once daily (up to 5 mg total) 1
- For renal impairment (CrCl ≤30 mL/min): 5 mg once daily 1
Dose Titration
- Adjust according to blood pressure response
- Usual effective range: 20-40 mg once daily 1
- Maximum dose: 80 mg daily (minimal additional benefit beyond 40 mg) 3, 1
- If blood pressure not controlled with lisinopril alone, add a low-dose diuretic (e.g., hydrochlorothiazide 12.5 mg) 1
Dosing for Heart Failure
Initial Therapy
- Starting dose: 5 mg once daily 2, 1
- For hyponatremia (serum sodium <130 mEq/L): 2.5 mg once daily 1
- For renal impairment (CrCl ≤30 mL/min): 2.5 mg once daily 1
Dose Titration
- Titrate by doubling the dose at not less than 2-week intervals 3
- Target dose: 20-40 mg once daily 2
- The ATLAS trial showed high doses (32.5-35 mg daily) were more effective than low doses (2.5-5 mg daily) in reducing hospitalization risk and improving outcomes 4, 2
Monitoring and Follow-up
Initial Monitoring
- Check serum potassium and creatinine 5-7 days after starting treatment 2, 3
- Recheck every 5-7 days until potassium values stabilize 3
During Titration
- Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increase 2, 3
- At 3 months after reaching maintenance dose, and every 6 months thereafter 3
Acceptable Changes in Parameters
- Increase in creatinine up to 50% or to 3 mg/dL is acceptable 3
- Asymptomatic hypotension usually doesn't require therapy change 3
Special Considerations
Renal Impairment
- CrCl >30 mL/min: No dose adjustment required 1
- CrCl 10-30 mL/min: Start with half the usual dose 1
- Hemodialysis or CrCl <10 mL/min: Initial dose 2.5 mg once daily 1
Hypotension Management
- For symptomatic hypotension, consider reducing diuretic dose if no signs of congestion 3
- If prolonged hypotension occurs (systolic BP <90 mmHg for >1 hour), discontinue lisinopril 1
Contraindications
- History of angioedema
- Pregnancy
- Bilateral renal artery stenosis 3
Practical Tips
- Avoid potassium-sparing diuretics during initiation of therapy 2
- Avoid NSAIDs and COX-2 inhibitors which may reduce effectiveness 2, 3
- Consider reducing or withholding diuretics for 24 hours before starting treatment 2
- For heart failure patients, diuretic dose may need adjustment to minimize hypovolemia 3, 1
- The appearance of hypotension after initial dose does not preclude subsequent careful dose titration 1
Clinical Outcomes
- In heart failure, lisinopril improves exercise duration and left ventricular ejection fraction 5
- High-dose lisinopril (32.5-35 mg daily) demonstrated 8% lower risk of all-cause mortality, 12% lower risk of death or hospitalization, and 24% fewer hospitalizations for heart failure compared to low-dose therapy 4
- Lisinopril is well tolerated with few serious adverse effects, making it suitable for long-term treatment 6, 7