What is the common trade name, generic name, therapeutic category, pregnancy risk factors, and lactation class category of lisinopril (Zestril), its approved indications, and normal adult dose, particularly for a patient with potential impaired renal function (renal impairment) and history of hypertension or heart failure?

Lisinopril Drug Information

Trade Name and Generic Information

Lisinopril is the generic name, with Prinivil and Zestril being the most common trade names. 1, 2

Therapeutic Category

Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used as an antihypertensive and cardioprotective agent. 2

Pregnancy and Lactation Classification

• Pregnancy: Contraindicated - ACE inhibitors cause renal dysgenesis and are contraindicated during the second and third trimesters of pregnancy. 1, 3
• Lactation: Use with caution - Limited data available; alternative agents may be preferred during breastfeeding.

FDA-Approved Indications

Lisinopril has three primary FDA-approved indications: 2

1. Hypertension - Treatment in adults and pediatric patients ≥6 years of age to lower blood pressure
2. Heart Failure - To reduce signs and symptoms of systolic heart failure
3. Acute Myocardial Infarction - Reduction of mortality in hemodynamically stable patients within 24 hours of acute MI

Normal Adult Dosing by Indication

Hypertension 2

• Initial dose: 10 mg once daily
• Usual maintenance: 20-40 mg once daily
• Maximum dose: 80 mg once daily
• If taking diuretics concurrently, start with 5 mg once daily to avoid excessive hypotension 2

Heart Failure 4, 2

• Initial dose: 5 mg once daily (or 2.5 mg if hyponatremic with serum sodium <130 mEq/L)
• Target dose: 20-40 mg once daily 4
• The European Society of Cardiology recommends aiming for 30-35 mg once daily for optimal outcomes, with titration at intervals of not less than 2 weeks 4
• At least 50% of target dose (10 mg daily) should be achieved for optimal clinical benefit 4

Acute Myocardial Infarction 1, 2

• Day 1: 5 mg orally within 24 hours of symptom onset
• Day 2: 5 mg
• Day 3: 10 mg
• Maintenance: 10 mg once daily for at least 6 weeks
• For low systolic BP (≤120 mmHg and >100 mmHg), start with 2.5 mg 2

Dosing in Renal Impairment

Dose adjustment is critical in patients with impaired renal function: 2

• CrCl >30 mL/min: No adjustment needed
• CrCl 10-30 mL/min: Reduce initial dose by 50% (e.g., 5 mg for hypertension, 2.5 mg for heart failure)
• CrCl <10 mL/min or hemodialysis: Initial dose 2.5 mg once daily
• Maximum dose remains 40 mg daily after careful titration 2

Monitoring in Renal Impairment 3

• Check blood pressure, serum creatinine, and potassium within 2-4 weeks of initiation or dose increase 3
• An increase in creatinine up to 50% above baseline is acceptable when initiating therapy 4
• Continue monitoring regularly, as ACE inhibitors provide renoprotective effects in chronic kidney disease with albuminuria 3

Key Clinical Considerations

Compelling Indications 1

• Heart failure
• Left ventricular dysfunction post-MI or established coronary heart disease
• Type 1 diabetic nephropathy
• Type 2 diabetic nephropathy 1

Contraindications 1

• Pregnancy (absolute contraindication)
• Renovascular disease (relative contraindication; may be used under specialist supervision)
• History of angioedema with ACE inhibitors 4

Important Cautions 1

• Renal impairment: Use with caution and close monitoring; beneficial in chronic kidney disease but requires dose adjustment 3
• Peripheral vascular disease: Caution due to association with renovascular disease 1
• Hyperkalemia risk: Monitor potassium levels, especially when combined with potassium-sparing diuretics or in renal impairment 1, 4

Common Adverse Effects 4

• Cough: Occurs in up to 20% of patients but rarely requires discontinuation 4
• Hypotension: Particularly with initial doses in volume-depleted patients 4
• Hyperkalemia: More common in renal impairment or when combined with other RAAS blockers 1
• Angioedema: Rare but potentially life-threatening; warrants permanent discontinuation of all ACE inhibitors 4