What is the typical dose of Angiotensin-Converting Enzyme Inhibitors (ACEIs) for various conditions?

ACEI Dosing Recommendations

Start ACE inhibitors at low doses and titrate upward to evidence-based target doses that have been proven to reduce mortality and hospitalization, not just to blood pressure response alone. 1

Starting Doses by Indication

Heart Failure with Reduced Ejection Fraction (HFrEF)

• Lisinopril: Start 2.5-5 mg once daily 1, 2
• Enalapril: Start 2.5 mg twice daily 1
• Captopril: Start 6.25 mg three times daily 1
• Ramipril: Start 1.25-2.5 mg once daily 1
• Use 2.5 mg starting dose for patients with hyponatremia (serum sodium <130 mEq/L) 2

Hypertension

• Lisinopril: Start 10 mg once daily 2
• Enalapril: Start 5 mg once daily 1
• Captopril: Start 6.25-25 mg three times daily 1
• Reduce to 5 mg once daily for lisinopril if patient is already on diuretics 2

Post-Myocardial Infarction

• Lisinopril: 5 mg orally within 24 hours, then 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg once daily 3, 2
• Start with 2.5 mg if systolic BP is 100-120 mmHg during first 3 days 2

Target Doses (Evidence-Based)

These target doses have been proven in clinical trials to reduce mortality and hospitalization—aim for these, not just blood pressure control. 1, 4

ACE Inhibitor	Target Dose	Clinical Trial Dose
Lisinopril	20-40 mg once daily	32.5-35 mg/day [1,4]
Enalapril	10-20 mg twice daily	16.6 mg/day [1]
Captopril	50 mg three times daily	122.7 mg/day [1]
Ramipril	10 mg once daily or 5 mg twice daily	N/A [1]
Trandolapril	4 mg once daily	N/A [1]

Titration Protocol

Double the dose at intervals of not less than 2 weeks if the lower dose has been well tolerated. 1

• Continue titrating until target dose is reached, regardless of blood pressure response 1
• In heart failure trials, doses were increased to predetermined targets, not based on therapeutic response 1
• If target dose cannot be tolerated, use the highest tolerated dose—some ACE inhibitor is better than none 1, 4
• The ATLAS trial demonstrated that higher doses (30-35 mg lisinopril daily) reduced hospitalizations by 24% compared to low doses (2.5-5 mg daily) 3

Monitoring Requirements

Check renal function and potassium 1-2 weeks after initiation and after each dose increase. 1, 3

• Baseline: creatinine, potassium, blood pressure 1
• After 1-2 weeks: recheck creatinine and potassium 1, 3
• After each dose titration: recheck within 1-2 weeks 3
• Long-term: monitor at 3 months, then every 6 months 4, 3

Acceptable Changes During Titration

• Creatinine increase up to 50% above baseline OR up to 3 mg/dL (whichever is greater) is acceptable 4, 3
• Potassium up to 5.5 mEq/L is generally acceptable 1
• Asymptomatic hypotension does not require dose reduction 1

Dose Adjustments for Renal Impairment

Reduce starting doses by half in patients with moderate renal dysfunction. 2

• CrCl >30 mL/min: No adjustment needed 2
• CrCl 10-30 mL/min: Start at half the usual dose (e.g., lisinopril 5 mg for hypertension, 2.5 mg for heart failure) 2
• CrCl <10 mL/min or hemodialysis: Start lisinopril at 2.5 mg once daily 2
• Creatinine >2.5 mg/dL (>221 μmol/L): Seek specialist advice before initiating 1

Critical Cautions

When to Seek Specialist Advice Before Initiating 1

• Creatinine >2.5 mg/dL (>221 μmol/L) 1
• Potassium >5.0 mEq/L 1
• Systolic BP <90 mmHg 1
• Bilateral renal artery stenosis 1

Absolute Contraindications 1

• History of angioedema with ACE inhibitors 1
• Pregnancy or planning pregnancy 1

When to Stop Titration 1, 3

• Symptomatic hypotension despite reducing diuretic dose 1
• Creatinine increase >50% above baseline AND >3 mg/dL 4, 3
• Potassium >5.5 mEq/L despite dietary modification 1

Common Pitfalls to Avoid

The most common error is failing to titrate to target doses—many clinicians stop at starting doses, missing significant mortality and morbidity benefits. 3

• Do not stop at starting doses: 60-70% of BP lowering occurs at starting doses, but mortality benefit requires target doses 3, 5
• Do not avoid NSAIDs and COX-2 inhibitors: These worsen renal function and reduce ACE inhibitor efficacy 3
• Do not add potassium-sparing diuretics during initiation unless specifically needed for persistent hypokalemia 3
• Do not discontinue for cough without rechallenge: ACE inhibitor-induced cough rarely requires discontinuation; only switch to ARB if cough is proven ACE inhibitor-related through withdrawal and rechallenge 1, 3
• Do not abruptly withdraw: Abrupt discontinuation can lead to clinical deterioration 1

Specific Condition Dosing

Diabetes with Chronic Kidney Disease

• Start with standard doses as above 1
• Target BP <130/80 mmHg 1
• Goal doses should be at the higher end of the dose range when possible 1

Elderly Patients (≥65 years)

• Start lisinopril 5-10 mg once daily depending on GFR 6
• Median effective dose is 20 mg daily 6
• No significant postural hypotension occurs with proper titration 6