From the FDA Drug Label
Although lisinopril was antihypertensive in all races studied, Black hypertensive patients (usually a low-renin hypertensive population) had a smaller average response to monotherapy than non-Black patients While the mechanism through which lisinopril lowers blood pressure is believed to be primarily suppression of the renin-angiotensin-aldosterone system, lisinopril is antihypertensive even in patients with low-renin hypertension
Lisinopril is effective in treating hypertension in both low-renin and high-renin patients. However, low-renin patients, such as Black hypertensive patients, may have a smaller average response to monotherapy with lisinopril compared to high-renin patients.
- Key points:
- Lisinopril is antihypertensive in all patients, regardless of renin levels.
- Low-renin patients may have a smaller response to lisinopril monotherapy.
- Concomitant administration of lisinopril and hydrochlorothiazide can further reduce blood pressure in both low-renin and high-renin patients 1
From the Research
Treatment for low renin versus high renin hypertension requires different medication approaches based on the underlying pathophysiology, with the most recent evidence suggesting that diuretics and calcium channel blockers are effective for low renin hypertension, while medications that block the renin-angiotensin-aldosterone system are most effective for high renin hypertension. For low renin hypertension, which typically involves sodium retention and volume expansion, diuretics are the first-line treatment, with thiazide diuretics like hydrochlorothiazide (12.5-25 mg daily) or chlorthalidone (12.5-25 mg daily) being particularly effective, as supported by the study published in 2024 2. Calcium channel blockers such as amlodipine (5-10 mg daily) are also beneficial, as noted in the study published in 2011 3. Patients should limit sodium intake to less than 2 grams daily. For high renin hypertension, which involves increased vasoconstriction due to angiotensin II, medications that block the renin-angiotensin-aldosterone system are most effective, including ACE inhibitors like lisinopril (10-40 mg daily), ARBs such as losartan (25-100 mg daily), and direct renin inhibitors like aliskiren (150-300 mg daily), as discussed in the study published in 2018 4. Beta-blockers like metoprolol (25-100 mg twice daily) can also help by reducing renin release. The distinction matters because using the wrong medication class based on renin status may result in suboptimal blood pressure control, highlighting the importance of plasma renin activity testing to guide medication selection, as emphasized in the study published in 2007 5. Some key points to consider in the treatment of low renin versus high renin hypertension include:
- The use of diuretics and calcium channel blockers for low renin hypertension
- The use of medications that block the renin-angiotensin-aldosterone system for high renin hypertension
- The importance of limiting sodium intake to less than 2 grams daily
- The role of plasma renin activity testing in guiding medication selection
- The potential for suboptimal blood pressure control if the wrong medication class is used based on renin status. African Americans and elderly patients more commonly have low renin hypertension, while younger patients and those with renal artery stenosis typically have high renin hypertension, as noted in the study published in 2024 2. Overall, the treatment of low renin versus high renin hypertension requires a tailored approach based on the underlying pathophysiology, with a focus on using the most effective medication classes and limiting sodium intake to achieve optimal blood pressure control.