Should I always start a patient on 5 mg of lisinopril (angiotensin-converting enzyme inhibitor) or can I start them on 10 mg?

Lisinopril Starting Dose Recommendations

For uncomplicated hypertension, you should start with 10 mg of lisinopril once daily as the standard initial dose, but use 5 mg for patients taking diuretics, the elderly, or those with renal impairment. 1

Initial Dosing Algorithm

• For standard hypertension treatment in most adults:

  • Initial dose: 10 mg once daily 1
  • Usual maintenance range: 20-40 mg once daily 1

• Start with 5 mg once daily in these specific situations:

  • Patients concurrently taking diuretics 1
  • Elderly patients (especially those ≥65 years) 2
  • Patients with renal impairment (GFR 30-60 mL/min) 1, 3
  • Patients with heart failure 4

• Start with 2.5 mg once daily in:

  • Patients with severe renal impairment (GFR <30 mL/min) 1, 5
  • Patients with hyponatremia (serum sodium <130 mEq/L) 1
  • Patients with acute MI and low systolic BP (≤120 mmHg) 1

Dose Titration

• Adjust dose based on blood pressure response 1
• Allow 2-4 weeks between dose increases to properly assess response 4
• Target doses in hypertension: 20-40 mg once daily (maximum 80 mg) 1
• For heart failure patients: titrate gradually to target of 20 mg daily or maximum tolerated dose 4

Special Considerations

• Risk of first-dose hypotension: This is particularly important in volume-depleted patients (e.g., those on high-dose diuretics), where starting at 5 mg reduces this risk 1, 6
• Renal function: Dose adjustments are necessary for impaired renal function; monitor renal function and electrolytes after initiation 1, 3
• Elderly patients: Lower starting doses (5 mg) are recommended due to potential for greater sensitivity to blood pressure-lowering effects 2

Common Pitfalls to Avoid

• Starting too high in vulnerable populations: Avoid starting at 10 mg in the elderly, those on diuretics, or with renal impairment as this increases risk of hypotension 1, 2
• Inadequate monitoring: Check renal function and electrolytes 1-2 weeks after initiation, especially in at-risk patients 4
• Too rapid titration: Allow adequate time between dose increases to assess full effect and tolerance 4
• Failure to reach target dose: When tolerated, attempt to reach evidence-based target doses for optimal outcomes, particularly in heart failure patients 4

Evidence Quality and Considerations

• The FDA drug label provides the clearest guidance on initial dosing, recommending 10 mg for uncomplicated hypertension and 5 mg for patients on diuretics 1
• Clinical studies support lower starting doses (5 mg) in elderly patients and those with renal impairment 2, 3
• Research suggests that 10 mg and 20 mg doses produce similar peak antihypertensive effects initially, but the magnitude of effect at 24 hours appears dose-related 7