What is the starting dose of lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor) for patients with hypertension or heart failure?

Starting Dose of Lisinopril for Hypertension and Heart Failure

For patients with hypertension, the recommended starting dose of lisinopril is 10 mg once daily, while for heart failure patients, the starting dose is 2.5-5 mg once daily. 1, 2, 3

Dosing for Hypertension

• Initial dose: 10 mg once daily 1
• Adjust according to blood pressure response
• Usual dosage range: 20-40 mg per day as a single daily dose
• If taking diuretics: Start with 5 mg once daily 1
• Maximum dose: Up to 80 mg has been used but doesn't appear to provide greater effect 1

Special Populations (Hypertension)

• Pediatric patients (≥6 years with GFR >30 mL/min/1.73m²): 0.07 mg/kg once daily (up to 5 mg total) 1
• Renal impairment:
  • GFR >30 mL/min: No dose adjustment needed
  • GFR 10-30 mL/min: Start with half the usual dose (5 mg)
  • GFR <10 mL/min or on hemodialysis: Start with 2.5 mg once daily 1

Dosing for Heart Failure

• Initial dose: 2.5-5 mg once daily 2, 3, 1
• For patients with hyponatremia (serum sodium <130 mEq/L): Start with 2.5 mg once daily 1
• Target dose: 20-35 mg once daily 2
• Maximum dose: 40 mg once daily 1

Titration for Heart Failure

• Double the dose at intervals of not less than 2 weeks 2, 3
• Aim for target dose or highest tolerated dose 2
• Remember: Some ACE inhibitor is better than no ACE inhibitor 2

Monitoring Recommendations

• Check blood chemistry (urea, creatinine, potassium) and blood pressure:
  • 5-7 days after starting treatment 3
  • 1-2 weeks after each dose increase 3
  • At 3 months, then every 6 months once at maintenance dose 3

Precautions and Contraindications

• Seek specialist advice for:

  • Significant renal dysfunction (creatinine >2.5 mg/dL or >221 μmol/L) 2
  • Hyperkalemia (>5.0 mmol/L) 2
  • Symptomatic or severe asymptomatic hypotension (systolic BP <90 mmHg) 2

• Absolute contraindications:

  • History of angioedema
  • Pregnancy
  • Bilateral renal artery stenosis 3

Common Side Effects and Management

• Cough: Rarely requires discontinuation; if very troublesome, consider angiotensin receptor blocker 2
• Hypotension: Asymptomatic low BP usually doesn't require therapy change 2
• Worsening renal function: Some increase in creatinine is expected and acceptable (up to 50% above baseline or to 3 mg/dL) 2

Clinical Pearls

• The ATLAS study showed that higher doses of lisinopril (32.5-35 mg daily) were more effective than lower doses in reducing major clinical events in heart failure patients 4
• Consider withholding diuretics for 24 hours before starting lisinopril to reduce risk of first-dose hypotension 3
• Lisinopril is not metabolized and is excreted unchanged in urine, making it a good choice for patients with hepatic impairment 5

Remember that achieving target doses or the highest tolerated dose is important for maximizing clinical benefits in both hypertension and heart failure.