What is the recommended dose of Lisinopril (angiotensin-converting enzyme inhibitor) for a patient with hypertension (HTN)?

Lisinopril Dosing for Hypertension

Start with 10 mg once daily in most adults with hypertension, titrate to 20-40 mg daily based on blood pressure response, with a maximum dose of 80 mg daily if needed. 1

Initial Dosing Strategy

• Standard adult starting dose: 10 mg once daily for patients not on diuretics 1
• Reduced starting dose: 5 mg once daily for patients already taking diuretics to minimize risk of hypotension 1
• Pediatric patients ≥6 years: 0.07 mg/kg once daily (up to 5 mg maximum initial dose) 2, 1

Dose Titration and Target Dosing

• Allow at least 4 weeks between dose adjustments to observe full blood pressure response unless urgent BP lowering is required 3
• Usual maintenance range: 20-40 mg once daily for most patients with hypertension 1
• Maximum dose: 80 mg daily, though doses above 40 mg do not appear to provide substantially greater effect 1
• Titrate upward according to blood pressure response, increasing the dose incrementally 2

Special Populations and Dose Adjustments

Renal Impairment

• Creatinine clearance >30 mL/min: No dose adjustment needed 1
• Creatinine clearance 10-30 mL/min: Start with 5 mg once daily, titrate to maximum 40 mg daily 1
• Hemodialysis or CrCl <10 mL/min: Start with 2.5 mg once daily 1
• Lisinopril is eliminated unchanged by the kidneys, requiring careful dose adjustment in renal impairment 4

Elderly Patients

• Lower starting doses may be necessary in elderly patients, particularly those with renal impairment or on diuretics 5
• Dosages effective in elderly patients typically range from 2.5-40 mg/day 6

Heart Failure

• Starting dose: 5 mg once daily when used with diuretics and digitalis 1
• Hyponatremia (sodium <130 mEq/L): Start with 2.5 mg once daily 1
• Titrate as tolerated to maximum 40 mg once daily 1

Combination Therapy Considerations

• Most patients require at least two antihypertensive drugs to achieve blood pressure goals 2, 3
• Stage 2 hypertension (BP ≥160/100 mmHg): Initiate two agents simultaneously rather than sequential monotherapy 3
• When adding a diuretic to lisinopril, consider starting with hydrochlorothiazide 12.5 mg 1
• After adding a diuretic, the lisinopril dose may be reduced 1
• Submaximal doses of two drugs produce larger BP responses with fewer side effects than maximal doses of a single drug 2

Monitoring Requirements

• Monitor serum creatinine, estimated GFR, and potassium levels at least annually, more frequently in patients on diuretics or with renal impairment 3
• Creatinine increases up to 50% above baseline or to 3 mg/dL (266 μmol/L) are acceptable 3
• Potassium levels up to 5.5-6.0 mmol/L may be acceptable with careful monitoring 3
• Follow-up monthly until blood pressure control is achieved 3

Common Pitfalls and Contraindications

• Do not combine with ARBs or direct renin inhibitors - increases adverse effects without additional benefit 3
• Absolutely contraindicated in pregnancy due to fetal toxicity 2
• Monitor for common adverse effects: cough, headache, dizziness, hyperkalemia, and acute kidney injury 2
• Use caution in patients with peripheral vascular disease due to association with renovascular disease 2

Clinical Context

• Lisinopril is effective in all grades of essential and renovascular hypertension 5, 7
• The ALLHAT trial demonstrated lisinopril 10-40 mg daily was equally effective as chlorthalidone and amlodipine for cardiovascular outcomes 3
• Particularly appropriate as first-line therapy in patients with diabetes, chronic kidney disease, heart failure, or post-myocardial infarction 3
• Target blood pressure <130/80 mmHg in patients with diabetes or chronic kidney disease 3