Restarting Lisinopril and Amlodipine After Discontinuation
Both lisinopril and amlodipine can be restarted immediately at their previous doses without titration, as neither medication requires gradual reintroduction after a period of discontinuation. 1, 2
Key Principles for Restarting These Medications
Amlodipine Restart Protocol
- Restart at the previous maintenance dose without titration 1, 2
- Amlodipine has a prolonged elimination half-life of 40-60 hours, meaning drug levels persist for 7-10 days after discontinuation 1
- Studies demonstrate that blood pressure returns to baseline gradually over 7-10 days after stopping amlodipine, with no rebound hypertension 1
- The medication maintains antihypertensive effects for up to 3 days after discontinuation due to its long half-life 2
- Once restarted, amlodipine requires 1-1.5 weeks to reach steady-state plasma concentrations 1
Lisinopril Restart Protocol
- Restart at the previous maintenance dose immediately 3
- ACE inhibitors like lisinopril do not require gradual reintroduction after brief discontinuation periods 3
- In heart failure patients, continuing ACE inhibitors during acute decompensation is associated with better outcomes, supporting the safety of maintaining or restarting these agents 3
- Monitor serum creatinine and potassium within 1-2 weeks after restarting, particularly in patients with chronic kidney disease or heart failure 3
Important Monitoring Parameters After Restart
Blood Pressure Monitoring
- Measure blood pressure before each dose during the first week to assess for hypotension 4, 5
- Target blood pressure <140/90 mmHg for most patients (or <130/80 mmHg per newer guidelines) 5
- Reassess blood pressure control after 2-4 weeks of consistent treatment 5
Laboratory Monitoring for Lisinopril
- Check serum creatinine and potassium within 1-2 weeks after restarting 3
- A modest increase in creatinine (up to 30% from baseline) is acceptable and does not indicate true tubular injury 3
- Monitor for hyperkalemia, especially in patients with chronic kidney disease, diabetes, or those on other potassium-sparing medications 3
Symptom Monitoring
- Watch for orthostatic hypotension symptoms (dizziness, lightheadedness) particularly during the first week 4
- Monitor for peripheral edema with amlodipine, which is dose-related and more common in women 3
- Assess for signs of angioedema with lisinopril, though this is rare 3
Common Pitfalls to Avoid
Do Not Unnecessarily Titrate
- Avoid starting at lower doses than previously tolerated - both medications can be restarted at their maintenance doses 1, 2
- Unnecessary titration delays achievement of blood pressure control without improving safety 1
Do Not Confuse Hemodynamic Changes with Kidney Injury
- A modest rise in creatinine after restarting lisinopril (up to 30%) represents hemodynamic changes, not acute tubular necrosis 3
- This creatinine increase is associated with better long-term cardiovascular outcomes in heart failure patients 3
- Only discontinue if creatinine rises >30% or if there is evidence of true tubular injury on urinalysis 3
Avoid Abrupt Re-discontinuation
- If blood pressure becomes too low after restarting, reduce doses rather than abruptly stopping 6
- Abrupt discontinuation of antihypertensive therapy can cause rebound hypertension, though this is less common with ACE inhibitors and amlodipine than with beta-blockers or centrally-acting agents 6
Special Considerations
Duration of Prior Discontinuation
- Short discontinuations (days to weeks): Restart at previous doses immediately 1, 2
- Prolonged discontinuations (months): Still safe to restart at previous doses, but closer monitoring during the first 1-2 weeks is prudent 1