How do I adjust my lisinopril (angiotensin-converting enzyme inhibitor) dose?

Lisinopril Dose Adjustment

Start lisinopril at 10 mg once daily for hypertension in most adults, titrating up to 20-40 mg daily based on blood pressure response, with dose reductions required for renal impairment (5 mg for creatinine clearance 10-30 mL/min, 2.5 mg for hemodialysis or creatinine clearance <10 mL/min). 1

Initial Dosing by Indication

Hypertension

• Standard starting dose: 10 mg once daily 1
• Maximum dose: 40 mg once daily 1
• Patients on diuretics: Start at 5 mg once daily 1
• Pediatric patients (≥6 years): Start at 0.07 mg/kg once daily (up to 5 mg), titrate to maximum 0.61 mg/kg (up to 40 mg) once daily 1

Heart Failure

• Standard starting dose: 5 mg once daily (with diuretics and digitalis) 1
• Hyponatremia (sodium <130 mEq/L): Start at 2.5 mg once daily 1
• Target dose: Titrate up to 40 mg once daily as tolerated 1
• Effective range: 2.5-20 mg once daily improves cardiac function indices 2, 3

Acute Myocardial Infarction

• Initial dose: 5 mg orally within 24 hours of symptom onset 1
• Titration schedule: 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg once daily 1
• Low systolic BP (≤120 mmHg and >100 mmHg): Start at 2.5 mg 1
• Duration: Continue for at least 6 weeks 1

Dose Adjustments for Renal Impairment

Critical adjustment based on creatinine clearance 1:

• CrCl >30 mL/min: No dose adjustment needed 1
• CrCl 10-30 mL/min: Reduce initial dose by 50%
  • Hypertension: Start at 5 mg daily 1
  • Heart failure: Start at 2.5 mg daily 1
  • Acute MI: Start at 2.5 mg daily 1
• CrCl <10 mL/min or hemodialysis: Start at 2.5 mg once daily 1
• Maximum dose with renal impairment: Titrate up to 40 mg daily as tolerated 1

The elimination half-life of 12.6 hours is prolonged in renal impairment, necessitating these reductions 4.

Titration Strategy

Upward Titration

• Timing: Assess blood pressure response after 2-4 weeks before increasing dose 2, 4
• Increments: Increase by 5-10 mg at each step 1
• Peak effect: Occurs 6-8 hours after dosing with 24-hour duration 4
• Therapeutic range: 10-80 mg once daily for hypertension, though 20-40 mg is typical 2, 4

Managing Hypotension

• After initial dose in heart failure: Hypotension does not preclude careful subsequent titration 1
• Systolic BP ≤100 mmHg in MI patients: Reduce to 5 mg daily maintenance or temporarily to 2.5 mg 1
• Prolonged hypotension (SBP <90 mmHg >1 hour): Withdraw lisinopril 1
• Diuretic adjustment: May need to reduce diuretic dose to minimize hypovolemia-related hypotension 1

Combination Therapy Adjustments

Adding Diuretics

• If inadequate BP control on lisinopril alone: Add low-dose hydrochlorothiazide 12.5 mg 1
• After adding diuretic: May be able to reduce lisinopril dose 1
• Benefit: Lisinopril attenuates thiazide-induced hypokalemia 2

Elderly Patients

• Starting dose: May need lower initial doses (2.5-10 mg) 4, 5
• Effective range: 2.5-40 mg/day in elderly populations 5
• Response rate: 68.2-89.1% of elderly patients respond to ≥8 weeks of treatment 5
• No significant age-related efficacy differences, though elderly patients may discontinue more frequently 5

Key Monitoring Parameters

• Blood pressure: Check 6-8 hours post-dose for peak effect 4
• Renal function: Monitor creatinine and creatinine clearance, especially when initiating or increasing dose 1
• Serum potassium: Monitor for hyperkalemia, particularly with concomitant diuretics or potassium supplements 4, 6
• Sodium levels: Check in heart failure patients before initiating therapy 1

Common Pitfalls to Avoid

• Do not adjust dose more frequently than every 2-4 weeks - peak antihypertensive effect is delayed 4
• Do not forget renal dose adjustments - lisinopril is eliminated primarily by kidneys and accumulates in renal dysfunction 4, 6
• Do not discontinue abruptly for hypotension in heart failure - temporary dose reduction is preferred 1
• Do not use standard doses in patients already on diuretics - start at 5 mg to avoid first-dose hypotension 1