What is the dose of ACE inhibitors (Angiotensin-Converting Enzyme inhibitors) for hypertension?

From the Guidelines

The dose of ACE inhibitors for hypertension typically ranges from 10-40 mg daily, with goal doses at the higher end of the dose range when possible.

ACE Inhibitor Dosing

• The starting dose and goal dose for ACE inhibitors vary by medication, as outlined in the following table:
  • Benazepril (Lotensin): 10 mg daily, goal dose 20-40 mg/d in 1-2 divided doses 1
  • Captopril (Capoten): 6.25-25 mg 3 times per day, goal dose 25-150 mg 2 or 3 times per day 1
  • Enalapril (Vasotec): 5 mg daily, goal dose 10-40 mg daily in 1-2 divided doses 1
  • Lisinopril (Prinivil, Zestril): 10 mg daily, goal dose 20-40 mg daily 1
  • Ramipril (Altace): 1.25 mg daily, goal dose 1.25-20 mg daily in 1-2 divided doses 1

Clinical Considerations

• ACE inhibitors are effective in slowing the progression of kidney disease characterized by microalbuminuria in hypertensive patients with type 1 or type 2 diabetes 1
• The American Diabetes Association recommends an ACE inhibitor or angiotensin receptor blocker as first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine 1
• The European Society of Cardiology guidelines recommend a single-pill combination of two major drug classes, including ACE inhibitors, as first-line treatment for hypertension 1

From the Research

ACE Inhibitors for Hypertension

• The dose of ACE inhibitors for hypertension is typically initiated with low doses that may then be slowly adjusted upward 2
• The exact posology of ACE inhibitors might be crucial, since it has been shown that the side-effects of captopril are dose dependent 3
• A dose of 1/8 or 1/4 of the manufacturer's maximum recommended daily dose achieved a BP lowering effect that was 60 to 70% of the BP lowering effect of the maximum dose 4
• A dose of 1/2 of the manufacturer's maximum recommended daily dose achieved a BP lowering effect that was 90% of the maximum dose 4
• ACE inhibitor doses above the maximum recommended daily dose did not significantly lower BP more than the maximum dose 4

Dosage and Administration

• Captopril has a flat dose response curve and must be given at a dose not exceeding 150 mg/day, twice daily 3
• Enalapril seems to be a promising ACE inhibitor with a prolonged action of at least 24 hours 3
• Some ACE inhibitors, such as moexipril, should be taken 1 hour before meals, whereas others can be taken without regard to meals 5
• Dosage reductions are recommended for patients with renal impairment, elderly patients, and patients with hepatic impairment 5

Blood Pressure Lowering Efficacy

• The average trough BP lowering efficacy for ACE inhibitors as a class of drugs is -8 mm Hg for systolic blood pressure and -5 mm Hg for diastolic blood pressure 4
• ACE inhibitors reduced blood pressure measured 1 to 12 hours after the dose by about 11/6 mm Hg 4
• There are no clinically meaningful BP lowering differences between different ACE inhibitors 4