Should I stop taking lisinopril?

Should You Hold Lisinopril with Creatinine 1.55?

No, do not hold lisinopril for a creatinine of 1.55 mg/dL alone—this level does not meet criteria for discontinuation, and stopping ACE inhibitors deprives patients of proven mortality benefit in heart failure, hypertension, and post-MI settings. 1, 2

Understanding the Creatinine Rise

The critical question is not the absolute creatinine value, but rather the clinical context and trajectory:

• An increase up to 30% from baseline is expected and acceptable when starting or titrating ACE inhibitors like lisinopril, and typically returns toward baseline in most patients 3, 1, 2
• The rise represents hemodynamic adjustment, not kidney damage in most cases, particularly if the patient is clinically stable or improving with decreasing congestion 3, 2
• Check the BUN-to-creatinine ratio: A low BUN with rising creatinine suggests RAAS inhibition rather than prerenal azotemia 2

When to Actually Hold Lisinopril

Hold or reduce lisinopril only in these specific circumstances:

• Severe hypotension: Systolic BP <80 mmHg or symptomatic hypotension 2, 4
• Severe hyperkalemia: Potassium >5.5 mmol/L (though consider potassium binders or SGLT2 inhibitors first to maintain therapy) 3, 1
• Severe renal failure: Creatinine clearance <30 mL/min requires dose reduction to half the usual dose, not discontinuation 4
• Prolonged hypotension post-MI: Systolic BP <90 mmHg for more than 1 hour 4
• True acute tubular necrosis: Look for sepsis, hypotension, bleeding, or other clear causes of kidney injury 2

Critical Monitoring Requirements

Before deciding to hold lisinopril, assess these parameters:

• Volume status: Is the patient euvolemic, hypervolemic, or hypovolemic? 2
• Blood pressure: Check for symptomatic hypotension or severe systolic BP drops 4
• Potassium level: Monitor for hyperkalemia, especially with concurrent diuretics or renal impairment 3, 1
• Clinical trajectory: Is the patient improving or deteriorating? 2
• Baseline creatinine: Calculate the percentage increase from baseline 1, 2

Strategies to Continue Therapy

If creatinine rises but doesn't meet discontinuation criteria, consider these approaches:

• Add an SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily): These reduce hyperkalemia risk by 16% and allow continuation of ACE inhibitors 3, 1
• Use potassium binders (patiromer): Reduces hyperkalemia events by 37% and facilitates guideline-directed medical therapy maintenance 3
• Optimize diuretic dosing: Ensure appropriate fluid balance before reflexively stopping ACE inhibitors 3
• Avoid NSAIDs: These reduce lisinopril efficacy and increase renal dysfunction risk 1

Dose Adjustment Protocol

If creatinine clearance is 10-30 mL/min (not just elevated creatinine):

• Reduce initial dose to 5 mg daily for hypertension 4
• Reduce to 2.5 mg daily for heart failure or post-MI 4
• Titrate up as tolerated to maximum 40 mg daily 4
• For hemodialysis or CrCl <10 mL/min: Start at 2.5 mg once daily 4

Recheck Timeline

After any dose adjustment or decision to continue therapy:

• Check renal function and potassium within 1-2 weeks of initiating or increasing dose 3, 1, 5
• Monitor blood pressure at least twice during the transition period 5
• Reassess volume status clinically at each visit 2

Common Pitfalls to Avoid

• Don't reflexively discontinue for every creatinine rise: This deprives patients of proven mortality benefit 1, 2
• Don't ignore volume status: Overdiuresis can cause prerenal azotemia that mimics ACE inhibitor-related changes 3, 2
• Don't forget to check potassium: Hyperkalemia is often the limiting factor, not creatinine alone 3, 1
• Don't use thiazides if GFR <30 mL/min: Switch to loop diuretics instead 3