What is the recommended starting dose of Lisinopril (angiotensin-converting enzyme inhibitor) for an adult patient with hypertension and no significant comorbidities, such as impaired renal function or hypotension?

Lisinopril Starting Dose for Hypertension

The recommended starting dose of lisinopril for an adult with uncomplicated hypertension is 10 mg once daily, which can be titrated up to 20-40 mg daily based on blood pressure response. 1

Initial Dosing Strategy

• For stage 1 hypertension (BP 130-139/80-89 mmHg): Start with lisinopril 10 mg once daily as monotherapy and titrate upward as needed to achieve target BP <130/80 mmHg 1, 2

• For stage 2 hypertension (BP ≥140/90 mmHg or >20/10 mmHg above goal): Initiate two-drug combination therapy immediately rather than sequential monotherapy, preferably combining lisinopril with a thiazide diuretic or calcium channel blocker 3, 2

• The usual maintenance dosage range is 20-40 mg per day administered as a single daily dose, though doses up to 80 mg have been used without significantly greater effect 1

Important Considerations for ACE Inhibitor Selection

ACE inhibitors like lisinopril may not be the optimal first-line choice for all patients with uncomplicated hypertension. The evidence suggests important nuances:

• In the ALLHAT trial, lisinopril was less effective than chlorthalidone (a thiazide-type diuretic) in preventing heart failure and less effective than amlodipine (a calcium channel blocker) in preventing stroke 3

• For black patients without heart failure or chronic kidney disease: Thiazide-type diuretics or calcium channel blockers are preferred over ACE inhibitors as initial therapy, as ACE inhibitors are notably less effective in this population for stroke and heart failure prevention 3

• ACE inhibitors are specifically indicated as first-line therapy when compelling indications exist: diabetes with albuminuria (urinary albumin-to-creatinine ratio ≥30 mg/g), chronic kidney disease, or heart failure 4, 2

Dose Titration and Monitoring

• Allow at least 4 weeks between dose adjustments to observe the full blood pressure response, unless more urgent BP lowering is required 4

• Follow-up evaluation should occur at monthly intervals until blood pressure control is achieved 4, 2

• Once BP is controlled, monitor every 3-5 months 2

Combination Therapy Approach

• If starting with a diuretic: The recommended starting dose of lisinopril is reduced to 5 mg once daily when combined with hydrochlorothiazide 12.5 mg 1

• Most patients with hypertension require at least two drugs to achieve blood pressure goals, and submaximal doses of two drugs produce larger BP responses with fewer side effects than maximal doses of a single drug 4, 2

Essential Safety Monitoring

• Monitor serum creatinine, estimated GFR, and potassium levels within 1-2 weeks of initiation, with each dose increase, and at least annually thereafter 3, 2

• An increase in creatinine up to 50% above baseline or to 3 mg/dL (266 μmol/L), whichever is greater, is acceptable 4

• Potassium levels up to 5.5-6.0 mmol/L may be acceptable with careful monitoring 4

• Black patients have a greater risk of angioedema with ACE inhibitors compared to other populations 3

Critical Contraindications

• Absolutely contraindicated in pregnancy due to fetal toxicity 4, 1

• Do not combine lisinopril with ARBs or direct renin inhibitors, as this increases adverse effects without additional benefit 4, 2

Dose Adjustment for Renal Impairment

• No dose adjustment required if creatinine clearance >30 mL/min 1

• Creatinine clearance 10-30 mL/min: Reduce initial dose to 5 mg once daily 1

• Hemodialysis or creatinine clearance <10 mL/min: Start with 2.5 mg once daily 1