What is the recommended initial dose of lisinopril (angiotensin-converting enzyme inhibitor) for an adult patient with newly diagnosed hypertension?

Initial Lisinopril Dosing for New Hypertension

For an adult with newly diagnosed hypertension, start lisinopril at 10 mg once daily, as recommended by the FDA-approved dosing regimen. 1

Dosing Strategy Based on Hypertension Stage

Stage 1 Hypertension (130-139/80-89 mmHg)

• Start with monotherapy at 10 mg once daily 1
• Titrate dosage upward according to blood pressure response, with usual maintenance range of 20-40 mg daily 1
• Maximum studied dose is 80 mg daily, though doses above 40 mg provide minimal additional benefit 1

Stage 2 Hypertension (≥140/90 mmHg or >20/10 mmHg above goal)

• Initiate two-drug combination therapy immediately rather than lisinopril monotherapy 2
• Combine lisinopril with either a thiazide diuretic (hydrochlorothiazide 12.5 mg) or calcium channel blocker 2, 3
• When starting combination therapy with a diuretic, reduce lisinopril starting dose to 5 mg once daily 1

Critical Patient-Specific Considerations

Black Patients Without Heart Failure or CKD

• Do not use lisinopril as first-line monotherapy 2, 3, 4
• Start with thiazide diuretic or calcium channel blocker instead, as ACE inhibitors are less effective for stroke and heart failure prevention in this population 3, 4
• Black patients have increased risk of angioedema with ACE inhibitors 3

Patients with Compelling Indications for ACE Inhibitors

• Lisinopril is specifically indicated as first-line therapy for patients with diabetes plus albuminuria, chronic kidney disease, or heart failure 3, 4
• These patients benefit from ACE inhibitor therapy regardless of race 2, 4

Patients with Renal Impairment

• Start at 2.5-5 mg once daily if glomerular filtration rate is <30 mL/min 5, 6
• Median effective dose in renal impairment is 10 mg daily (range 2.5-40 mg) 5, 6
• Monitor renal function closely, as lisinopril is excreted unchanged by the kidney 5

Dose Titration Protocol

• Allow at least 4 weeks between dose adjustments to observe full blood pressure response 3
• Typical titration: 10 mg → 20 mg → 40 mg once daily 1
• If blood pressure remains uncontrolled on lisinopril alone, add low-dose thiazide diuretic (12.5 mg hydrochlorothiazide) rather than maximizing lisinopril dose 1
• Two submaximal doses of different drug classes produce larger BP reductions with fewer side effects than maximal single-drug doses 3

Essential Monitoring Requirements

Initial Monitoring (Within 1-2 Weeks)

• Check serum creatinine, estimated GFR, and potassium 3
• Acceptable creatinine increase: up to 50% above baseline or to 3 mg/dL, whichever is greater 3

Follow-Up Schedule

• Monthly follow-up after initiation or dose adjustment until BP control achieved 2, 4
• Once controlled, follow-up every 3-5 months 2, 3, 4
• Recheck electrolytes and renal function with each dose increase and at least annually 3, 4

Absolute Contraindications

• Pregnancy: Lisinopril causes fetal toxicity and is absolutely contraindicated 3
• Concurrent use with ARBs or direct renin inhibitors: Increases adverse effects without additional benefit 3
• History of angioedema with ACE inhibitors 1

Common Pitfalls to Avoid

• Do not combine lisinopril with ARBs (e.g., losartan, valsartan) as this increases risk of hyperkalemia, hypotension, and renal dysfunction without improving outcomes 3
• Do not use lisinopril as monotherapy in Stage 2 hypertension when BP is >20/10 mmHg above goal—start combination therapy immediately 2
• Do not delay treatment initiation for extensive laboratory testing—basic metabolic panel is sufficient to start therapy 2
• In elderly patients, monitor standing blood pressure to detect orthostatic hypotension 4