Lisinopril Dosing for Hypertension
For hypertension, start lisinopril at 10 mg once daily and titrate to a usual maintenance dose of 20-40 mg once daily, with a maximum of 80 mg daily if needed, though doses above 40 mg rarely provide additional benefit. 1
Initial Dosing Strategy
- Standard starting dose: 10 mg once daily for most patients with hypertension 1
- Lower starting dose: 5 mg once daily if the patient is already taking diuretics, as concurrent diuretic use increases the risk of first-dose hypotension 1
- Elderly patients and those with renal impairment require dose adjustments (see below) 1
Dose Titration and Target
- Usual maintenance range: 20-40 mg once daily administered as a single dose 1
- Doses up to 80 mg have been studied but generally do not provide greater antihypertensive effect beyond 40 mg 1
- Allow at least 4 weeks between dose adjustments to observe the full blood pressure response, unless more urgent BP lowering is required 2, 3
- The American College of Cardiology recommends monthly follow-up until blood pressure control is achieved 3
Combination Therapy Considerations
- Most patients with hypertension require at least two drugs to achieve blood pressure goals 2
- If blood pressure is not controlled with lisinopril alone, add a low-dose thiazide diuretic (e.g., hydrochlorothiazide 12.5 mg) 1
- After adding a diuretic, you may be able to reduce the lisinopril dose 1
- For stage 2 hypertension (BP ≥160/100 mmHg), initiate two antihypertensive agents simultaneously rather than sequential monotherapy 2, 3
Special Populations
Renal Impairment
- Creatinine clearance >30 mL/min: No dose adjustment needed 1
- Creatinine clearance 10-30 mL/min: Start at 5 mg once daily (half the usual dose), titrate up to maximum 40 mg daily as tolerated 1
- Creatinine clearance <10 mL/min or hemodialysis: Start at 2.5 mg once daily 1
- Monitor renal function and potassium levels at least annually, more frequently in patients with chronic kidney disease 2
Elderly Patients
- Use caution with initial dosing, particularly when combining with diuretics due to increased hypotension risk 3
- Consider starting at lower doses in elderly patients, especially those with low systolic blood pressure 1
Patients with Diabetes or Chronic Kidney Disease
- ACE inhibitors like lisinopril are first-line therapy for hypertensive patients with diabetes and albuminuria (urinary albumin-to-creatinine ratio ≥30 mg/g) 2
- Use the maximum tolerated dose indicated for blood pressure treatment 2
- Target blood pressure <130/80 mmHg in these higher-risk patients 2
Monitoring and Safety
- Monitor blood pressure response at monthly intervals until control is achieved 3
- Monitor serum creatinine, estimated GFR, and potassium levels at least annually, more frequently in patients on diuretics or with renal impairment 2
- Common side effects include: cough (most common), dizziness, headache, and hyperkalemia 3
- An increase in creatinine up to 50% above baseline or to 3 mg/dL (266 μmol/L), whichever is greater, is acceptable 2
- Potassium levels up to 5.5-6.0 mmol/L may be acceptable with careful monitoring 2
Critical Contraindications
- Absolutely contraindicated in pregnancy due to risk of fetal harm 3
- Do not combine with ARBs or direct renin inhibitors - this increases adverse effects without additional benefit 2, 3
- Avoid in patients with history of angioedema related to ACE inhibitor use 1
Clinical Context from Major Trials
The ALLHAT trial demonstrated that lisinopril 10-40 mg daily was equally effective as chlorthalidone and amlodipine for the primary outcome of fatal CHD and nonfatal MI, though there were some differences in secondary outcomes including slightly higher rates of stroke and heart failure compared to the diuretic 2. This supports lisinopril as an appropriate first-line agent, particularly in patients with specific indications such as diabetes, chronic kidney disease, or heart failure 2.