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

Lisinopril Dosing for Hypertension and Heart Failure

For patients with hypertension, lisinopril should be initiated at 10 mg once daily and titrated to a usual dosage range of 20-40 mg once daily, while heart failure patients should start at 5 mg once daily (or 2.5 mg if hyponatremic) and titrate to a maximum of 40 mg once daily. 1

Dosing in Hypertension

Initial Dosing

• Start with 10 mg once daily for most adults with hypertension 1
• Lower starting dose of 5 mg once daily for patients already taking diuretics 1
• For patients with renal impairment (GFR ≤30 mL/min), start with half the usual dose (5 mg) 1

Maintenance and Target Dosing

• Adjust dose according to blood pressure response 1
• Usual maintenance dose range: 20-40 mg once daily 1
• Maximum dose: up to 80 mg daily has been used but with minimal additional benefit 1
• Target blood pressure for hypertensive patients should be <130/80 mmHg, especially in those with increased cardiovascular risk 2

Pediatric Dosing (≥6 years old)

• Starting dose: 0.07 mg/kg once daily (up to 5 mg total) 1
• Maximum dose: 0.61 mg/kg once daily (up to 40 mg) 1
• Not recommended for children <6 years or with GFR <30 mL/min/1.73m² 1

Dosing in Heart Failure

Initial Dosing

• Start with 5 mg once daily when used with diuretics and (usually) digitalis 1
• Lower starting dose of 2.5 mg once daily for patients with hyponatremia (serum sodium <130 mEq/L) 1

Maintenance and Target Dosing

• Increase gradually as tolerated to a maximum of 40 mg once daily 1
• Target dose: 20-40 mg once daily 2
• Higher doses (32.5-35 mg daily) have shown greater clinical benefits than lower doses (2.5-5 mg daily) in the ATLAS trial, with a 12% reduction in death or hospitalization 2, 3

Dosing Algorithm and Titration

1. Initial Assessment:

   • Determine if patient has hypertension, heart failure, or both
   • Check renal function (GFR) and serum sodium levels
   • Review current medications, especially diuretics

2. Starting Dose Selection:

   • Hypertension only: 10 mg once daily (5 mg if on diuretics)
   • Heart failure: 5 mg once daily (2.5 mg if hyponatremic)
   • Renal impairment (GFR 10-30 mL/min): Half the usual starting dose
   • Severe renal impairment (GFR <10 mL/min) or hemodialysis: 2.5 mg once daily 1

3. Titration Schedule:

   • Check blood pressure, renal function, and electrolytes 1-2 weeks after starting treatment 2
   • Increase dose every 1-2 weeks as tolerated 4
   • For heart failure, aim to reach target dose of 20-40 mg daily 2
   • For hypertension, titrate to achieve target BP <130/80 mmHg 2

4. Monitoring:

   • Check blood pressure, renal function, and electrolytes after each dose increment 2
   • Monitor at 3 months and then every 6 months once stable 4

Special Considerations

Renal Impairment

• GFR >30 mL/min: No dose adjustment required
• GFR 10-30 mL/min: Start with half the usual dose
• GFR <10 mL/min or hemodialysis: Start with 2.5 mg once daily 1

Concomitant Medications

• If blood pressure not controlled with lisinopril alone, a low-dose diuretic may be added (e.g., hydrochlorothiazide 12.5 mg) 1
• Avoid potassium-sparing diuretics during initiation of therapy 2
• Avoid NSAIDs and COX-2 inhibitors if possible 2

Common Pitfalls and Caveats

• Hypotension may occur after initial dosing, especially in volume-depleted patients; consider reducing or withholding diuretics 24 hours before starting lisinopril 2
• Monitor for worsening renal function, especially in patients with pre-existing renal impairment
• If renal function deteriorates substantially, stop treatment 2
• ACE inhibitors commonly cause dry cough (up to 20% of patients) 4
• Angioedema is a rare but serious adverse effect that requires immediate discontinuation 5

By following this evidence-based dosing regimen and monitoring protocol, clinicians can optimize the benefits of lisinopril therapy while minimizing potential adverse effects in patients with hypertension and heart failure.