Lisinopril Dosing for Hypertension and Heart Failure
For hypertension, start lisinopril at 10 mg once daily and titrate to a usual maintenance dose of 20-40 mg daily; for heart failure, start at 2.5-5 mg once daily and titrate to a target dose of 30-35 mg daily. 1
Hypertension Dosing
Initial Therapy
- Start with 10 mg once daily in most patients with hypertension 1
- If the patient is already on diuretics, reduce the starting dose to 5 mg once daily 1
- Titrate the dose upward at intervals of not less than 2 weeks based on blood pressure response 2
Target Maintenance Dose
- The usual maintenance range is 20-40 mg once daily 1
- Doses up to 80 mg have been studied but do not provide greater efficacy 1
- If blood pressure remains uncontrolled on lisinopril alone, add a low-dose diuretic (e.g., hydrochlorothiazide 12.5 mg) rather than exceeding 40 mg 1
Heart Failure Dosing
Starting Dose
- Begin with 5 mg once daily when used with diuretics and digitalis for systolic heart failure 1
- In patients with hyponatremia (serum sodium <130 mEq/L), start at 2.5 mg once daily 1
- The European Society of Cardiology recommends starting at 2.5 mg daily for all heart failure patients 2
Target Dose
- Titrate to a target of 30-35 mg once daily as tolerated 2, 3
- Maximum dose is 40 mg once daily 1
- Higher doses (32.5-35 mg daily) significantly reduce mortality and hospitalization compared to low doses (2.5-5 mg daily) in the ATLAS trial 2
Titration Strategy
- Double the dose at intervals of not less than 2 weeks 2
- Aim for the target dose or the highest tolerated dose - remember that some ACE inhibitor is better than none 2
- Diuretic doses may need adjustment during titration to minimize hypotension 1
Post-Myocardial Infarction Dosing
- In hemodynamically stable patients within 24 hours of MI, give 5 mg orally, then 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg once daily 2, 1
- For patients with low systolic blood pressure (≤120 mmHg and >100 mmHg), start with 2.5 mg 2, 1
- Continue therapy for at least 6 weeks 1
Renal Impairment Adjustments
- No dose adjustment needed if creatinine clearance >30 mL/min 1
- For creatinine clearance 10-30 mL/min: reduce initial dose by 50% (hypertension: 5 mg; heart failure: 2.5 mg; post-MI: 2.5 mg) 1
- For hemodialysis or creatinine clearance <10 mL/min: start at 2.5 mg once daily 1
Monitoring Requirements
Initial Monitoring
- Check serum potassium and creatinine after 5-7 days of starting therapy 2
- Recheck every 5-7 days during titration until potassium values are stable 2
Ongoing Monitoring
- Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 2, 3
- Check at 3 months, then every 6 months thereafter 2, 3
Acceptable Changes
- An increase in creatinine up to 50% above baseline, or to 3 mg/dL (266 μmol/L), whichever is greater, is acceptable 2, 3
- Asymptomatic hypotension does not require dose adjustment 2
Important Precautions
Avoid or Seek Specialist Advice When:
- Significant renal dysfunction (creatinine >2.5 mg/dL or >221 μmol/L) 2
- Hyperkalemia (potassium >5.0 mmol/L) 2
- Symptomatic or severe hypotension (systolic BP <90 mmHg) 2
Drug Interactions to Avoid
- Avoid NSAIDs and COX-2 inhibitors - they can worsen renal function and reduce ACE inhibitor efficacy 2
- Avoid potassium-sparing diuretics during initiation unless specifically needed for persistent hypokalemia 2
- Consider withholding diuretics for 24 hours before starting therapy to minimize first-dose hypotension 2
Common Pitfalls
Underdosing in Heart Failure
- Many clinicians fail to titrate to target doses - the ATLAS trial clearly demonstrated that higher doses (30-35 mg daily) reduce hospitalizations by 24% and the combined endpoint of death or hospitalization by 12% compared to low doses 2, 4
- The appearance of hypotension after the initial dose does not preclude careful subsequent titration 1