Lisinopril Dosage and Treatment Protocol for Hypertension and Heart Failure
For patients with hypertension and heart failure, lisinopril should be initiated at 2.5-5.0 mg once daily for heart failure and 10 mg once daily for hypertension, with titration to target doses of 5-20 mg daily for heart failure and 20-40 mg daily for hypertension. 1, 2
Dosing Protocol for Hypertension
Initial Therapy
- Start with 10 mg once daily for hypertension 1
- If patient is already on diuretics, start with 5 mg once daily to minimize risk of hypotension 1
- For patients with renal impairment (creatinine clearance ≤30 mL/min), start with half the usual dose (5 mg) 1
Maintenance and Titration
- Titrate dose at 2-week intervals based on blood pressure response 2
- Usual maintenance dose range: 20-40 mg once daily 1
- Maximum dose: up to 80 mg daily has been used but may not provide additional benefit 1, 3
- Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 2
Dosing Protocol for Heart Failure
Initial Therapy
- Start with 5 mg once daily when used with diuretics and (usually) digitalis 1, 2
- For patients with hyponatremia (serum sodium <130 mEq/L), start with 2.5 mg once daily 1
- For patients with renal impairment (creatinine clearance ≤30 mL/min), start with 2.5 mg once daily 1
Maintenance and Titration
- Double the dose at not less than 2-week intervals 2
- Target dose: 5-20 mg once daily, with maximum of 35 mg daily 2
- The ATLAS trial demonstrated that higher doses (32.5-35 mg daily) were more effective than lower doses (2.5-5 mg daily) in reducing hospitalizations and the combined endpoint of death or hospitalization 3, 2
- Continue monitoring blood pressure, renal function, and electrolytes throughout treatment 2
Monitoring Protocol
Initial Monitoring
- Check serum potassium and creatinine 5-7 days after starting treatment 2
- Recheck every 5-7 days until potassium values are stable 2
Ongoing Monitoring
- Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 2
- Follow-up at 3 months after reaching maintenance dose 2
- Subsequently monitor at 6-month intervals 2
Special Considerations and Precautions
Before Initiating Therapy
- Review need for and dose of diuretics and vasodilators 2
- Consider reducing or withholding diuretics for 24 hours before starting lisinopril 2
- Avoid potassium-sparing diuretics during initiation of therapy 2
- Avoid NSAIDs and COX-2 inhibitors 2
Management of Common Issues
Hypotension
- Asymptomatic low blood pressure generally does not require treatment modification 2
- For symptomatic hypotension, consider reducing doses of diuretics, nitrates, or other vasodilators 2
- If hypotension persists despite these measures, consider reducing lisinopril dose 2
Renal Function Changes
- Some increase in blood urea nitrogen, creatinine, and potassium is expected and often doesn't require action 2
- An increase in creatinine of up to 50% above baseline or to 3 mg/dL (266 μmol/L), whichever is greater, is acceptable 2
- If greater rises occur, consider stopping concomitant nephrotoxic drugs and reducing diuretic dose if no signs of congestion 2
Cough
- ACE inhibitor-induced cough rarely requires discontinuation 2
- If troublesome cough develops and is proven to be due to ACE inhibition, consider substitution with an angiotensin receptor blocker 2
Contraindications
- Bilateral renal artery stenosis 2
- History of angioedema with previous ACE inhibitor therapy 2
- Pregnancy (especially second and third trimesters) 1
Expected Benefits
- Improved survival and reduced hospitalizations in heart failure patients 2, 3
- Effective blood pressure control in hypertensive patients 1, 4
- Improved quality of life and NYHA functional class in heart failure patients 2, 3
Lisinopril offers the advantage of once-daily dosing and does not require biotransformation for pharmacological activity, making it a suitable option for both hypertension and heart failure management 4, 5.