What is a good initial starting dose of lisinopril (Angiotensin-Converting Enzyme inhibitor) for hypertension (high blood pressure)?

Initial Starting Dose of Lisinopril for Hypertension

The recommended initial starting dose of lisinopril for hypertension is 10 mg once daily in most adults, though 5 mg once daily should be used if the patient is already taking diuretics or has renal impairment. 1

Standard Dosing for Uncomplicated Hypertension

• For adults with stage 1 hypertension (BP 140-159/90-99 mmHg), start with lisinopril 10 mg once daily as monotherapy. 1
• The usual maintenance dosage range is 20-40 mg per day administered as a single daily dose, with doses up to 80 mg studied but showing no greater effect. 1
• The antihypertensive effect begins within 2 hours, peaks around 6 hours, and lasts for at least 24 hours, making once-daily dosing appropriate. 2

Modified Starting Doses for Specific Situations

If the patient is already on diuretic therapy, reduce the starting dose to 5 mg once daily to minimize the risk of symptomatic hypotension. 1 This is critical because diuretics can potentiate the blood pressure-lowering effects of ACE inhibitors. 1

For patients with renal impairment:

• If creatinine clearance is >30 mL/min: use standard 10 mg starting dose 1
• If creatinine clearance is 10-30 mL/min: reduce initial dose to 5 mg once daily 1
• If creatinine clearance is <10 mL/min or on hemodialysis: start with 2.5 mg once daily 1

When to Use Combination Therapy Instead

For patients with stage 2 hypertension (BP ≥160/100 mmHg or >20/10 mmHg above target), initiate treatment with two antihypertensive agents of different classes rather than lisinopril monotherapy. 3 This approach achieves blood pressure control more rapidly and effectively. 3

Important Considerations About ACE Inhibitors as First-Line Therapy

While lisinopril is an acceptable first-line agent, thiazide-type diuretics (especially chlorthalidone) or calcium channel blockers may be superior choices for initial monotherapy in many patients. 3 In the largest head-to-head comparison (ALLHAT trial), chlorthalidone was superior to lisinopril in preventing heart failure, and ACE inhibitors were less effective than thiazide diuretics and calcium channel blockers in lowering blood pressure and preventing stroke. 3

For Black patients specifically, ACE inhibitors are notably less effective than calcium channel blockers in preventing heart failure and stroke, making thiazide diuretics or calcium channel blockers the preferred initial choice. 3

ACE inhibitors like lisinopril are particularly indicated as first-line therapy when specific comorbidities exist:

• Established coronary artery disease 3
• Albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) 3
• Heart failure with reduced ejection fraction 3
• Diabetes with cardiovascular disease 3

Dose Titration Strategy

• Allow at least 4 weeks to observe the full response before making dose adjustments, unless urgent blood pressure lowering is required. 4
• Check renal function and serum electrolytes within 1-2 weeks of starting treatment. 3, 5
• Consider dose up-titration after 2-4 weeks if blood pressure is not at goal. 3, 5
• Re-check renal function and electrolytes 1 and 4 weeks after any dose increase. 3, 5
• The target dose for cardiovascular protection is 20-35 mg once daily based on heart failure trials. 3

Critical Safety Monitoring

Before initiating lisinopril, verify adequate renal function and normal serum potassium. 3

Monitor for these key adverse effects:

• Symptomatic hypotension (especially after first dose in volume-depleted patients) 1
• Hyperkalemia (particularly in patients with chronic kidney disease or those taking potassium supplements) 4
• Worsening renal function (an increase in creatinine up to 50% from baseline is acceptable) 3, 5
• Persistent dry cough (occurs in 5-10% of patients) 3
• Angioedema (rare but potentially life-threatening) 3

Absolute Contraindications

Never use lisinopril in pregnancy due to risk of fetal harm. 4 Do not combine with ARBs or direct renin inhibitors, as this increases adverse effects without additional cardiovascular benefit. 3, 4