When should lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor) and amlodipine (Calcium Channel Blocker (CCB)) be held?

When to Hold Lisinopril and Amlodipine

Lisinopril (ACE inhibitor) and amlodipine (calcium channel blocker) should be held in specific clinical situations where they may cause harm, particularly during periods of hemodynamic instability, acute illness with volume depletion, or when there are significant adverse effects.

When to Hold Lisinopril (ACE Inhibitor)

Hold for:

• Very low systemic blood pressure (systolic BP <80 mmHg) 1
• Acute kidney injury or markedly increased serum creatinine (>3 mg/dL) 1
• Hyperkalemia (serum potassium >5.0-5.5 mEq/L) 1
• Volume depletion or dehydration to prevent acute kidney injury 2
• Bilateral renal artery stenosis due to risk of acute renal failure 1
• Angioedema (discontinue permanently if this occurs) 1
• Pregnancy (contraindicated due to fetal harm) 1

Special Considerations:

• Perioperative management: Consider holding on the day of surgery if concerns for hypotension exist 1
• Acute severe hypertension with pulmonary edema: While ACE inhibitors are part of treatment, they should be initiated only after stabilization with IV medications 1
• Combined use with ARBs: Never use ACE inhibitors and ARBs concurrently due to increased adverse effects without additional benefit 2

When to Hold Amlodipine (Calcium Channel Blocker)

Hold for:

• Severe hypotension that could exacerbate ischemia 1
• Significant peripheral edema (dose-related adverse effect, more common in women) 1, 3
• Concomitant use with sildenafil within 24 hours due to risk of profound hypotension 1
• Severe left ventricular dysfunction (use with caution, especially when combined with beta-blockers) 1

Special Considerations:

• Heart failure with reduced ejection fraction: Amlodipine should be used cautiously in these patients; avoid verapamil and diltiazem 1
• Palpitations, dizziness, and flushing (more common with higher doses of 10 mg) 3

Monitoring After Restarting

• Check blood pressure within 1-2 weeks after restarting 2
• Monitor renal function and serum potassium within 1-2 weeks, especially in patients with pre-existing kidney dysfunction 1, 2
• Assess for peripheral edema with amlodipine 3

Advantages of These Medications When Appropriately Used

• Lisinopril and amlodipine combination has shown marked additional effect on blood pressure compared to either medication alone 4
• Amlodipine has a long half-life (35-50 hours), allowing sustained anti-hypertensive effect for more than 24 hours following a single dose 3
• Lisinopril provides cardiovascular protection beyond blood pressure control in patients with heart failure 1

Clinical Decision Algorithm

1. Daily assessment: Evaluate blood pressure, volume status, and laboratory values
2. Hold lisinopril if:
   • SBP <80 mmHg
   • Creatinine >3 mg/dL or acute increase >30%
   • Potassium >5.5 mEq/L
   • Signs of volume depletion
3. Hold amlodipine if:
   • Severe hypotension
   • Significant peripheral edema
   • Recent sildenafil use
4. Restart when:
   • Hemodynamically stable
   • Renal function improved
   • Electrolytes normalized
   • Volume status restored

Remember that temporary discontinuation during acute illness is recommended for both medications, as they should be held during episodes of volume depletion to prevent acute kidney injury 2.