Lisinopril Dosing in Hypertension and Heart Failure
For patients with hypertension, lisinopril should be initiated at 10 mg once daily and titrated up to 20-40 mg once daily as needed for blood pressure control. For heart failure patients, start with 2.5-5.0 mg once daily and titrate to a target dose of 30-35 mg once daily. 1, 2
Dosing in Hypertension
Initial Dosing
- Start with 10 mg once daily for most adults with hypertension 2
- For patients already on diuretics, start with a lower dose of 5 mg once daily to minimize risk of first-dose hypotension 2
- For elderly patients or those with renal impairment, consider starting with 2.5-5 mg once daily 3
Maintenance and Target Dosing
- Titrate dose according to blood pressure response at intervals of not less than 2 weeks 1
- Usual maintenance dosage range is 20-40 mg once daily 2
- Maximum FDA-approved dose is 80 mg daily, though doses above 40 mg provide minimal additional benefit 2
- For patients with creatinine clearance <30 mL/min, reduce initial dose to half the usual recommended dose 2
Dosing in Heart Failure
Initial Dosing
- Start with 2.5-5.0 mg once daily 1, 2
- For patients with hyponatremia (serum sodium <130 mEq/L), start with 2.5 mg once daily 2
- For patients with significant renal dysfunction (creatinine >2.5 mg/dL or >221 μmol/L), seek specialist advice before initiating 1
Maintenance and Target Dosing
- Double the dose at intervals of not less than 2 weeks 1
- Target dose is 30-35 mg once daily 1
- In the ATLAS trial, higher doses (32.5-35 mg daily) showed greater reduction in hospitalization and mortality compared to lower doses (2.5-5 mg daily) 4
- Maximum dose is 40 mg once daily 2
- Remember that some ACE inhibitor is better than no ACE inhibitor if target dose cannot be achieved 1
Monitoring and Dose Adjustments
Monitoring Parameters
- Blood pressure, particularly for first-dose hypotension 1
- Renal function (urea, creatinine) and electrolytes (especially potassium) 1
- Monitor these parameters at baseline, 1-2 weeks after each dose increment, at 3 months, and then every 6 months 1
Dose Adjustment Considerations
- An increase in creatinine of up to 50% above baseline or to 3 mg/dL (266 μmol/L), whichever is greater, is acceptable 1
- For excessive increases in creatinine or potassium, consider reducing diuretic dose (if no signs of congestion) or stopping concomitant nephrotoxic drugs 1
- Asymptomatic hypotension generally does not require dose adjustment 1
- For symptomatic hypotension, consider reducing doses of other vasodilators or diuretics before reducing lisinopril 1
Special Populations
Renal Impairment
- For creatinine clearance 10-30 mL/min: reduce initial dose by half (hypertension: 5 mg; heart failure: 2.5 mg) 2
- For patients on hemodialysis or with creatinine clearance <10 mL/min: initial dose 2.5 mg once daily 2
- Maximum dose remains 40 mg daily even in renal impairment, but titrate more cautiously 2
Elderly Patients
- Consider starting at lower doses (2.5-5 mg daily) 3
- Titrate more gradually, but target doses remain the same as for younger adults 3
Common Side Effects and Management
- Cough: Common with ACE inhibitors; rarely requires discontinuation 1
- Worsening renal function: Expected to some degree; monitor and adjust as needed 1
- Hypotension: More common with first dose, especially in volume-depleted patients 1, 2
- Hyperkalemia: Monitor potassium levels, especially if combined with potassium-sparing diuretics 1
Remember that achieving target doses of lisinopril has been shown to improve outcomes in terms of mortality and hospitalization, particularly in heart failure patients 4. Always aim for the target dose or the highest tolerated dose if the target cannot be achieved 1.