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

Starting Dose of Lisinopril for Adults with Hypertension

The recommended starting dose of lisinopril for adults with hypertension is 10 mg once daily. 1

Dosing Guidelines

• The FDA-approved initial dose for adults with hypertension is 10 mg once daily, with subsequent adjustment based on blood pressure response 1
• The usual maintenance dosage range is 20 to 40 mg per day administered as a single daily dose 1
• Doses up to 80 mg have been used but do not appear to provide greater antihypertensive effect 1
• For patients taking diuretics, a lower initial dose of 5 mg once daily is recommended to prevent excessive hypotension 1

Special Population Considerations

• Renal Impairment:

  • For patients with creatinine clearance >30 mL/min: No dose adjustment required 1
  • For patients with creatinine clearance 10-30 mL/min: Start with half the usual dose (5 mg) 1
  • For patients on hemodialysis or with creatinine clearance <10 mL/min: Start with 2.5 mg once daily 1

• Elderly Patients:

  • While specific starting doses for elderly are not explicitly stated, low-dose thiazides are generally preferred first-line for elderly patients with hypertension 2
  • When ACE inhibitors like lisinopril are used in elderly patients, careful monitoring for hypotension is recommended, especially if combined with diuretics 2

Combination Therapy Considerations

• If blood pressure is not adequately controlled with lisinopril alone, a low dose of a thiazide diuretic (e.g., hydrochlorothiazide 12.5 mg) may be added 1
• For patients with stage 2 hypertension (BP ≥160/100 mm Hg), initiation with two antihypertensive agents of different classes is recommended 2
• The 2017 ACC/AHA guidelines suggest combination therapy (preferably with a single pill combination) as initial treatment for patients with stage 2 hypertension 2

Follow-Up and Monitoring

• After initiating lisinopril, follow-up evaluation of adherence and response to treatment should occur at monthly intervals until blood pressure control is achieved 2
• Allow at least 4 weeks to observe the full response before making dose adjustments, unless urgent BP lowering is required 2
• Monitor for common side effects including cough, dizziness, headache, and hyperkalemia 3
• Pay particular attention to renal function and potassium levels, especially in patients with chronic kidney disease or those taking potassium supplements or potassium-sparing diuretics 2

Clinical Pearls

• Lisinopril offers the convenience of once-daily administration with 24-hour blood pressure control 4
• Unlike some other ACE inhibitors, lisinopril is not a prodrug and is absorbed in its active form 3
• Lisinopril can attenuate hypokalemia induced by thiazide diuretics when used in combination therapy 4
• Avoid use in pregnancy due to risk of fetal harm 2
• Do not use in combination with ARBs or direct renin inhibitors due to increased risk of adverse effects without additional benefit 2