What is the recommended starting dose for lisinopril (angiotensin-converting enzyme inhibitor) in a new patient with hypertension?

Recommended Starting Dose of Lisinopril for New Hypertensive Patients

The recommended initial dose of lisinopril for a new hypertensive patient is 10 mg once daily. 1

Dosing Algorithm

Initial Dosing

• Standard starting dose: 10 mg once daily for most new adult hypertensive patients 1
• Lower starting dose: 5 mg once daily in specific situations:
  • Patients already taking diuretics 1
  • Patients with renal impairment (creatinine clearance ≤30 mL/min) 1
  • Elderly patients 2

Dose Titration

• After initiating therapy, adjust dosage according to blood pressure response
• The usual maintenance dosage range is 20-40 mg once daily 1
• Allow 2-4 weeks between dose adjustments to assess full effect
• Maximum dose is 80 mg daily, though doses above 40 mg provide minimal additional benefit 1, 2

Special Populations

Renal Impairment

• For patients with creatinine clearance ≤30 mL/min: start with 5 mg once daily 1
• For patients with creatinine clearance <10 mL/min or on hemodialysis: start with 2.5 mg once daily 1
• Titrate cautiously with close monitoring of renal function 3

Elderly Patients

• Consider starting with a lower dose (5 mg daily) due to potential for greater sensitivity to blood pressure-lowering effects 2
• Titrate more gradually to avoid hypotension

Patients Taking Diuretics

• If possible, discontinue diuretic 2-3 days before starting lisinopril to reduce risk of hypotension
• If diuretic cannot be discontinued, start with 5 mg of lisinopril 1
• Monitor closely for hypotension after initial dose

Monitoring

• Check blood pressure within 1-2 weeks after initiating therapy or changing doses 4
• Monitor renal function and serum potassium:
  • Before starting therapy
  • 1-2 weeks after each dose increment
  • At 3-6 month intervals during maintenance therapy 4
  • When adding other treatments that may affect renal function

Common Adverse Effects to Monitor

• Cough (occurs in 5-20% of patients) 4
• Hypotension, especially after initial dose 4
• Hyperkalemia (more common with renal impairment) 4
• Acute kidney injury (monitor creatinine) 4
• Angioedema (rare but serious) 4

Clinical Pearls

• Lisinopril has a long duration of action allowing for once-daily dosing 2
• Unlike some other ACE inhibitors, lisinopril does not require hepatic metabolism for activation 2
• Peak effect occurs 6-8 hours after administration 2
• Food does not affect bioavailability 2
• Lisinopril is as effective as other antihypertensive classes including hydrochlorothiazide, beta-blockers, and calcium channel blockers 5, 6

Pitfalls to Avoid

• Avoid initiating at high doses, which increases risk of first-dose hypotension
• Do not use in pregnancy (contraindicated) 4
• Avoid use in patients with history of angioedema with previous ACE inhibitor therapy 4
• Do not combine with ARBs or direct renin inhibitors due to increased risk of hypotension, hyperkalemia, and renal dysfunction 7
• Use caution in patients with bilateral renal artery stenosis 4

Lisinopril is an effective first-line agent for hypertension with the convenience of once-daily dosing and minimal drug interactions 8. Starting at the appropriate dose based on patient characteristics and careful monitoring will help optimize both efficacy and safety.