Maximum Dosage of Lisinopril for Hypertension and Heart Failure
The maximum recommended dosage of lisinopril is 40 mg once daily for both hypertension and heart failure, according to FDA labeling and clinical practice guidelines. 1, 2
Dosing for Hypertension
Initial Dosing
- Standard initial dose: 10 mg once daily 1
- For patients on diuretics: 5 mg once daily 1
- For pediatric patients (>6 years): 0.07 mg/kg once daily (up to 5 mg total) 1
Titration and Maximum Dose
- Usual effective range: 20-40 mg once daily 1
- Maximum FDA-approved dose: 40 mg once daily 1
- Doses up to 80 mg have been studied but do not appear to provide additional benefit 1
- Titration should be based on blood pressure response
Dosing for Heart Failure
Initial Dosing
- Standard initial dose: 5 mg once daily 2, 1
- For patients with hyponatremia (serum sodium <130 mEq/L): 2.5 mg once daily 1
Titration and Maximum Dose
- Maximum recommended dose: 40 mg once daily 2, 1
- Mean doses achieved in clinical trials: 32.5-35.0 mg once daily 2
- Titration should occur by doubling the dose at intervals of at least 2 weeks 3
Dose Adjustments for Special Populations
Renal Impairment
- Creatinine clearance >30 mL/min: No adjustment needed
- Creatinine clearance 10-30 mL/min: Start with half the usual dose (2.5 mg for heart failure)
- Creatinine clearance <10 mL/min or hemodialysis: Initial dose 2.5 mg once daily 1
Monitoring Recommendations
- Blood pressure, renal function, and electrolytes should be monitored 1-2 weeks after each dose increase 3
- After reaching maintenance dose: Check at 3 months and then every 6 months 3
- Initial monitoring should include checking serum potassium and creatinine 5-7 days after starting treatment 3
Clinical Considerations
- High doses of lisinopril (32.5-35 mg daily) have demonstrated better clinical outcomes than low doses (2.5-5 mg daily) in heart failure patients, with a 24% reduction in hospitalizations for heart failure 4
- Despite higher incidence of some adverse events with high doses, the frequency of treatment discontinuations was similar between high and low dose groups 4
- Common adverse effects include dizziness, headache, hypotension, and diarrhea 4
- Asymptomatic hypotension usually doesn't require therapy change, but for symptomatic hypotension, consider reducing diuretic dose if no signs of congestion 3
Contraindications
- History of angioedema
- Pregnancy
- Bilateral renal artery stenosis 3
While doses up to 80 mg have been studied, there is no evidence of additional benefit beyond the maximum recommended dose of 40 mg daily for either hypertension or heart failure.