Is starting a patient on lisinopril (angiotensin-converting enzyme inhibitor) a reasonable approach for managing hypertension with persistent blood pressure readings over 145/92 mmHg?

Lisinopril for Hypertension Management with BP >145/92 mmHg

Starting lisinopril is an appropriate first-line treatment for a patient with persistent blood pressure readings over 145/92 mmHg, with a recommended initial dose of 10 mg once daily. 1

Initial Treatment Approach

• For patients with hypertension and BP readings >145/92 mmHg:
  • Start with lisinopril 10 mg once daily
  • Titrate dose according to blood pressure response
  • Usual effective dosage range: 20-40 mg per day as a single daily dose 1
  • Maximum dose: up to 80 mg daily (though additional benefit beyond 40 mg is limited) 1

Monitoring and Follow-up

• Check blood pressure control and adverse effects 4-12 weeks after initiation 2
• Monitor serum potassium and renal function within 3 months of starting lisinopril 2
• If BP targets are not achieved, assess medication adherence before adjusting therapy 2
• Follow-up can occur every 6 months if levels remain stable 2

Combination Therapy Considerations

• If blood pressure is not controlled with lisinopril alone, add a low-dose thiazide diuretic (e.g., hydrochlorothiazide 12.5 mg) 1
• After adding a diuretic, it may be possible to reduce the lisinopril dose 1
• For patients already on diuretics, start with a lower dose of lisinopril (5 mg once daily) 1

Special Considerations

Renal Function

• For patients with creatinine clearance >30 mL/min: standard dosing applies
• For patients with creatinine clearance 10-30 mL/min: start with half the usual dose (5 mg)
• For patients on hemodialysis or with creatinine clearance <10 mL/min: start with 2.5 mg once daily 1

Demographic Considerations

• African American patients may have less robust response to ACE inhibitors; consider adding a thiazide diuretic or calcium channel blocker if response is inadequate 2
• Patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) should preferentially receive an ACE inhibitor like lisinopril 2

Mechanism and Benefits

Lisinopril works by inhibiting angiotensin-converting enzyme (ACE), which:

• Reduces plasma angiotensin II and aldosterone
• Increases plasma renin activity
• Produces smooth, gradual blood pressure reduction without affecting heart rate 3
• Begins working within 2 hours, peaks around 6 hours, and lasts for at least 24 hours 3

Lisinopril offers several advantages:

• Does not produce hypokalemia, hyperglycemia, hyperuricemia, or hypercholesterolemia 3
• Has natriuretic properties while maintaining or improving renal blood flow 3
• Reduces total peripheral resistance while maintaining or improving cardiac contractility 4
• Promotes regression of left ventricular hypertrophy 4

Potential Pitfalls and Cautions

• Avoid in pregnancy: ACE inhibitors are contraindicated in pregnant women or women of childbearing potential not using reliable contraception 2
• Avoid combining with ARBs: This increases adverse effects without additional benefit 2
• First-dose hypotension: May occur, especially in volume-depleted patients (e.g., those on diuretics) 1
• Hyperkalemia risk: More common in older patients, those with diabetes or chronic kidney disease 2
• Angioedema: A rare but serious side effect that requires immediate discontinuation 5

Lisinopril is well-tolerated in most patients, with few serious adverse effects reported in clinical trials 6, 5. Its once-daily dosing provides convenient administration and good adherence potential 6.