What is the recommended treatment and dosage for high blood pressure and heart failure using Lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor)?

Lisinopril Treatment for High Blood Pressure and Heart Failure

For high blood pressure, lisinopril should be initiated at 10 mg once daily and titrated up to 20-40 mg daily; for heart failure, start at 5 mg once daily (or 2.5 mg if hyponatremic) and titrate up to a maximum of 40 mg daily as tolerated. 1

Dosing for Hypertension

• Initial dose: 10 mg once daily for adults 1
• Maintenance dose: 20-40 mg once daily (doses up to 80 mg have been used but provide limited additional benefit) 1
• When used with diuretics: Start with 5 mg once daily 1
• For patients with renal impairment (creatinine clearance ≤30 mL/min): Start with half the usual dose (5 mg) 1

Dosing for Heart Failure

• Initial dose: 5 mg once daily when used with diuretics and (usually) digitalis 1
• For patients with hyponatremia (serum sodium <130 mEq/L): Start with 2.5 mg once daily 1
• Maintenance dose: Titrate up to 40 mg once daily as tolerated 1
• Higher doses (32.5-35 mg daily) have shown greater clinical benefits than lower doses (2.5-5 mg daily) in reducing hospitalizations and improving outcomes 2

Administration Protocol

1. Start with low-dose administration; check serum potassium and creatinine after 5-7 days and titrate accordingly 3
2. Recheck every 5-7 days until potassium values are stable 3
3. Review the need for and dose of diuretics and vasodilators 3
4. Consider reducing or withholding diuretics for 24 hours before starting treatment 3
5. Start with a low dose and build up to maintenance dosages shown to be effective in large trials 3
6. Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 3

Special Considerations

• Renal function: If renal function deteriorates substantially, stop treatment 3
• Medications to avoid:
  • Potassium-sparing diuretics during initiation of therapy 3
  • NSAIDs and COX-2 inhibitors 3
• Elderly patients: Lisinopril is just as effective in older (>65 years) patients as in younger patients 4
• Timing: Consider evening administration when starting therapy to minimize potential blood pressure effects, though morning administration with supervision is acceptable 3

Common Side Effects and Management

• Hypotension: May occur especially after initial dose (1.3% in hypertension, 4.8% in heart failure) 5
• Cough: Common side effect that rarely requires discontinuation 5
• Worsening renal function: Monitor creatinine; an increase up to 50% above baseline or to 3 mg/dL (266 μmol/L) is acceptable 3
• Hyperkalaemia: Monitor potassium levels; values up to 6.0 mmol/L may be acceptable 3
• Other common side effects: Dizziness, headache, diarrhea, and fatigue 5

Important Cautions

• Seek specialist advice for patients with:
  • Significant renal dysfunction (creatinine >2.5 mg/dL or >221 μmol/L) 3
  • Hyperkalaemia (>5.0 mmol/L) 3
  • Symptomatic or severe asymptomatic hypotension (systolic BP <90 mmHg) 3
• Absolute contraindications: Bilateral renal artery stenosis and history of angioedema during previous ACE inhibitor therapy 3

Combination Therapy

• In hypertension: If blood pressure is not controlled with lisinopril alone, a low dose of a diuretic (e.g., hydrochlorothiazide 12.5 mg) may be added 1
• In heart failure: Lisinopril should always be administered in combination with diuretics and beta-blockers if tolerated 3

Expected Benefits

• In hypertension: Effective blood pressure control across all grades of essential hypertension 6
• In heart failure: Improved cardiac function, reduced hospitalizations, and increased survival 2
• Higher doses of lisinopril (32.5-35 mg daily) provide greater benefits than lower doses (2.5-5 mg daily) in reducing hospitalization for heart failure (24% fewer) 2