What is the initial dose of lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor) for treating hypertension?

Initial Dosing of Lisinopril for Hypertension

The recommended initial dose of lisinopril for treating hypertension is 10 mg once daily, which can be titrated up to a usual dosage range of 20-40 mg per day administered as a single daily dose. 1

Dosing Guidelines

Standard Initial Dosing

• Initial dose: 10 mg once daily for most patients with hypertension 1
• Usual maintenance range: 20-40 mg once daily 1
• Maximum FDA-approved dose: Up to 80 mg daily (though doses above 40 mg rarely provide additional benefit) 1

Special Populations Requiring Lower Initial Doses

1. Patients taking diuretics:

   • Initial dose: 5 mg once daily 1
   • This lower starting dose helps prevent excessive blood pressure reduction

2. Patients with renal impairment:

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

3. Heart failure patients:

   • Initial dose: 5 mg once daily (or 2.5 mg if hyponatremic) 1
   • This is different from the hypertension dosing regimen

Dose Titration

• Adjust dose according to blood pressure response
• Allow 2-3 days to reach steady state before further dose adjustments 2
• If blood pressure is not controlled with lisinopril alone, consider adding a low-dose thiazide diuretic (e.g., hydrochlorothiazide 12.5 mg) 1

Clinical Pearls

• Lisinopril's antihypertensive effect begins within 2 hours, peaks around 6 hours, and lasts for at least 24 hours, making it suitable for once-daily dosing 2
• Food does not significantly affect lisinopril bioavailability 2
• Lisinopril is excreted unchanged in the urine, making dose adjustments necessary in renal impairment 1
• Monitor serum potassium and renal function within 1-2 weeks after initiation and after dose increases 3
• Avoid use in pregnancy as ACE inhibitors are contraindicated 3

Common Pitfalls to Avoid

• Starting with too high a dose in volume-depleted patients, which may cause first-dose hypotension
• Failure to reduce the starting dose in patients already taking diuretics
• Not monitoring renal function and potassium levels after initiation
• Using in pregnant women or women planning pregnancy (contraindicated)
• Not considering ethnic differences in response (African American patients may have less robust response to ACE inhibitors as monotherapy) 4

Remember that the initial dose may need to be adjusted based on individual patient characteristics, but the standard starting dose for uncomplicated hypertension is 10 mg once daily.