Can a patient with stage 2 hypertension be started on lisinopril (angiotensin-converting enzyme inhibitor) at 5 mg or is 2.5 mg the preferred initial dose?

Starting Dose of Lisinopril for Stage 2 Hypertension

You can start your patient at 5 mg lisinopril once daily for stage 2 hypertension (BP 150s/100s), as this is the FDA-approved standard initial dose for hypertension in adults. 1

FDA-Approved Dosing for Hypertension

• The FDA label specifies that the recommended initial dose for hypertension is 10 mg once daily in most adults 1
• However, 5 mg once daily is the appropriate starting dose for patients taking diuretics or those with certain conditions 1
• The 2.5 mg starting dose is reserved for specific populations: patients with heart failure (especially with hyponatremia), acute myocardial infarction with low systolic BP (≤120 mmHg), or significant renal impairment (creatinine clearance ≥10 and ≤30 mL/min) 1

Clinical Context for Your Patient

For stage 2 hypertension (BP 150s/100s) without the specific conditions listed above, starting at 5 mg is entirely appropriate and does not require starting at 2.5 mg. 1

• Multiple clinical trials have demonstrated that lisinopril 5-10 mg is well-tolerated as an initial dose in hypertensive patients 2, 3
• The antihypertensive effect begins within 2 hours, peaks around 6 hours, and lasts at least 24 hours 2
• Steady state is achieved in 2-3 days with minimal accumulation 2

Dose Titration Strategy

• Start at 5 mg once daily and assess BP response after 2-4 weeks 1
• Titrate upward to 10 mg, then 20 mg, and up to a maximum of 40 mg daily as needed for BP control 1
• If BP remains uncontrolled on lisinopril alone, add a low-dose thiazide diuretic (hydrochlorothiazide 12.5 mg) 1
• After adding a diuretic, you may be able to reduce the lisinopril dose 1

When to Use 2.5 mg Starting Dose

The 2.5 mg starting dose is specifically indicated for: 1

• Heart failure patients, particularly those with serum sodium <130 mEq/L
• Acute MI patients with systolic BP ≤120 mmHg (but >100 mmHg) in the first 3 days post-infarct
• Renal impairment with creatinine clearance between 10-30 mL/min
• Hemodialysis patients or creatinine clearance <10 mL/min

Common Pitfalls to Avoid

• Do not unnecessarily start at 2.5 mg in patients with uncomplicated stage 2 hypertension, as this delays achieving BP control and requires additional titration visits 1, 2
• Monitor renal function and potassium 2-4 weeks after initiation, especially if adding a diuretic 4
• Assess for orthostatic hypotension at follow-up, though lisinopril does not typically affect cardiovascular reflexes 2, 3
• Ensure the patient is not volume depleted before starting, as this increases hypotension risk 1

Evidence from Clinical Practice

• Studies in elderly hypertensive patients successfully used 10 mg as the starting dose (5 mg only if GFR 30-60 mL/min), with median effective doses of 20 mg daily 3
• Even in patients with renal impairment (GFR ≤60 mL/min), 5 mg starting doses were effective and well-tolerated, with median doses of 10 mg achieving BP control 5, 6
• Clinical trials demonstrate that lisinopril produces 11-15% systolic and 13-17% diastolic BP reductions when given once daily as monotherapy 2