What is the recommended starting dose of lisinopril (angiotensin-converting enzyme inhibitor) for patients with hypertension?

Starting Dose of Lisinopril for Hypertension

The recommended starting dose of lisinopril for adult patients with hypertension is 10 mg once daily, with subsequent adjustment based on blood pressure response. 1

Dosing Guidelines for Different Patient Populations

Standard Adult Dosing

• Initial dose: 10 mg once daily 1
• Usual maintenance dose range: 20-40 mg once daily 1
• Maximum dose: Up to 80 mg daily (though doses above 40 mg provide minimal additional benefit) 1

Special Populations

Patients Taking Diuretics

• Starting dose: 5 mg once daily 1
• This lower starting dose helps prevent excessive hypotension that may occur when adding lisinopril to existing diuretic therapy

Patients with Renal Impairment

• Normal to mild impairment (CrCl >30 mL/min): Standard dosing
• Moderate to severe impairment (CrCl 10-30 mL/min): Initial dose should be reduced to 5 mg 1
• Hemodialysis or CrCl <10 mL/min: Initial dose of 2.5 mg once daily 1, 2

Pediatric Patients (≥6 years)

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

Dose Titration Protocol

1. Start with appropriate initial dose based on patient characteristics
2. Assess blood pressure response after 2-4 weeks
3. If target blood pressure not achieved, increase dose incrementally
4. Allow 2-4 weeks between dose adjustments to assess full effect 1, 3

Monitoring Parameters

• Blood pressure: The antihypertensive effect begins within 2 hours, peaks around 6 hours, and lasts for at least 24 hours 3
• Renal function: Monitor serum creatinine and potassium, especially in patients with renal impairment 1
• Watch for hypotension, particularly in patients on diuretics or with volume depletion 1

Common Side Effects and Precautions

• Common adverse effects include cough, headache, dizziness, and asthenia 4
• Serious adverse effects include hyperkalemia, acute kidney injury, angioedema, and fetal toxicity 4
• Contraindications include history of angioedema, pregnancy, and bilateral renal artery stenosis 5

Clinical Pearls

• Lisinopril has a long duration of action allowing for once-daily dosing 3
• Unlike some other ACE inhibitors, lisinopril is not metabolized and is excreted unchanged in urine 3
• Food does not significantly affect lisinopril bioavailability 3
• In patients with renal impairment, lisinopril has been shown to effectively control blood pressure at lower doses (median 10 mg daily, range 2.5-40 mg) 2
• Most patients achieve adequate blood pressure reduction with lisinopril monotherapy, but hydrochlorothiazide can be added if needed 6

By following these dosing recommendations, clinicians can effectively initiate lisinopril therapy while minimizing the risk of adverse effects, particularly in special populations requiring dose adjustments.