What is the dosing of lisinopril (Angiotensin-Converting Enzyme inhibitor) for patients with Impaired renal function or hypertension?

From the Guidelines

Lisinopril should be started at a dose of 2.5-5 mg once daily and titrated up to a target dose of 20-40 mg once daily for patients with heart failure, as recommended by the most recent guidelines 1. The dosing of lisinopril is crucial in managing heart failure, and the initial dose should be individualized based on the patient's condition.

• For patients with heart failure, the initial dose of lisinopril can be started at 2.5-5 mg once daily, with a target dose of 20-40 mg once daily, as per the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
• The dose titration should be done gradually, with close monitoring of the patient's blood pressure, renal function, and electrolyte levels.
• It is essential to note that the dose of lisinopril may need to be adjusted in patients with renal impairment or those who are elderly, as they may be more susceptible to the adverse effects of the medication.
• The mechanism of action of lisinopril, which involves the inhibition of angiotensin-converting enzyme (ACE), resulting in vasodilation and decreased blood pressure, is critical in managing heart failure.
• Regular monitoring of the patient's condition, including blood pressure, renal function, and electrolyte levels, is necessary to ensure the safe and effective use of lisinopril.
• The use of lisinopril in combination with other medications, such as beta-blockers and mineralocorticoid receptor antagonists, may be necessary to achieve optimal outcomes in patients with heart failure, as recommended by the guidelines 1.
• The guidelines also recommend that the dose of lisinopril be titrated to the maximum tolerated dose, with the goal of achieving a dose of 20-40 mg once daily, as this has been shown to improve outcomes in patients with heart failure 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2. 1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. Dosage should be adjusted according to blood pressure response. The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose. 2. 2 Heart Failure The recommended starting dose for lisinopril tablets, when used with diuretics and (usually) digitalis as adjunctive therapy for systolic heart failure, is 5 mg once daily. 2. 3 Reduction of Mortality in Acute Myocardial Infarction In hemodynamically stable patients within 24 hours of the onset of symptoms of acute myocardial infarction, give lisinopril tablets 5 mg orally, followed by 5 mg after 24 hours, 10 mg after 48 hours and then 10 mg once daily. 2. 4 Dose in Patients with Renal Impairment No dose adjustment of lisinopril tablets is required in patients with creatinine clearance > 30 mL/min. In patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, reduce the initial dose of lisinopril tablets to half of the usual recommended dose i.e., hypertension, 5 mg; systolic heart failure, 2.5 mg and acute MI, 2. 5 mg.

The dosing of lisinopril varies based on the condition being treated.

• Hypertension: The recommended initial dose is 10 mg once a day, with a usual dosage range of 20 mg to 40 mg per day.
• Heart Failure: The recommended starting dose is 5 mg once daily.
• Acute Myocardial Infarction: The initial dose is 5 mg orally, followed by 5 mg after 24 hours, 10 mg after 48 hours, and then 10 mg once daily.
• Renal Impairment: No dose adjustment is required for patients with creatinine clearance > 30 mL/min. For patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, the initial dose should be reduced to half of the usual recommended dose. 2

From the Research

Dosing of Lisinopril

• The dosing of lisinopril is discussed in the study 3, which states that lisinopril has been shown to be an effective antihypertensive agent at doses of 10 to 80 mg given once daily in patients with essential and secondary hypertension caused by renal artery stenosis.
• The study 3 also notes that accumulation of lisinopril occurs in patients with renal dysfunction, and dosage adjustment is necessary only when the creatinine clearance is less than 30 mL/min.
• There is no specific information in the other studies 4, 5, 6, 7 regarding the dosing of lisinopril, as they focus on the comparison of ACE inhibitors with other antihypertensive agents, their efficacy, and tolerability.

Administration and Pharmacokinetics

• According to the study 3, approximately 29% of lisinopril is absorbed after oral administration, and no measurable metabolism occurs, with excretion being primarily renal.
• The study 3 also mentions that lisinopril is absorbed in its active form, and its effectiveness is comparable to that of diuretics, beta blockers, and calcium-channel antagonists.

Clinical Use

• The studies 4, 5, 6, 7 discuss the clinical use of ACE inhibitors, including lisinopril, in the management of hypertension, but do not provide specific information on the dosing of lisinopril.
• The study 7 notes that ACE inhibitors, including lisinopril, are commonly prescribed medications for the management of hypertension and other chronic conditions, and are first-line therapy in hypertension management along with thiazide diuretics, calcium channel blockers, and angiotensin receptor blockers (ARB).