What is the recommended dosage of lisinopril (Angiotensin-Converting Enzyme inhibitor) for a patient with hypertension or heart failure, considering factors such as age, Impaired renal function, and other comorbidities?

Lisinopril Dispensing Quantity and Dosing

For hypertension, dispense a 30-day supply of 10-20 mg tablets (30 tablets for once-daily dosing), with the standard starting dose being 10 mg once daily and usual maintenance range of 20-40 mg daily. 1

Standard Dispensing Quantities by Indication

Hypertension

• Initial prescription: Dispense 30 tablets of 10 mg strength for once-daily dosing 1
• Maintenance prescription: Dispense 30 tablets of 20 mg strength (most common maintenance dose) or 40 mg strength depending on titration 1
• The FDA-approved dosing range is 20-40 mg daily as a single dose, though doses up to 80 mg have been used 1

Heart Failure

• Initial prescription: Dispense 30 tablets of 5 mg strength (or 2.5 mg if patient has hyponatremia with serum sodium <130 mEq/L) 1
• Target maintenance prescription: Dispense 30 tablets of 30-35 mg strength for optimal outcomes 2, 3
• The European Society of Cardiology recommends targeting 30-35 mg once daily, as high-dose lisinopril (32.5-35 mg daily) reduces death or hospitalization by 12% and heart failure hospitalizations by 24% compared to low doses 4, 2, 5
• Maximum FDA-approved dose is 40 mg daily 1

Post-Myocardial Infarction

• Initial prescription: Dispense 30 tablets of 5 mg strength (or 2.5 mg if systolic BP ≤120 mmHg) 1
• Maintenance prescription: Dispense 30 tablets of 10 mg strength for once-daily dosing 1
• Therapy should continue for at least 6 weeks 1

Dose Adjustments for Renal Impairment

Moderate Renal Impairment (CrCl 10-30 mL/min)

• Initial prescription: Dispense 30 tablets of 5 mg strength for hypertension, or 2.5 mg for heart failure 1
• Reduce initial dose to half the usual recommended dose 1
• The European Heart Journal recommends dose adaptation when CrCl <30 mL/min, with initial dose of 1.25 mg daily and maximum of 5 mg/day 4

Severe Renal Impairment (CrCl <10 mL/min or Hemodialysis)

• Initial prescription: Dispense 30 tablets of 2.5 mg strength 1
• Start at 2.5 mg once daily and titrate as tolerated 1, 6, 7

Titration Schedule and Monitoring

Dose Escalation Protocol

• Increase doses at minimum 2-week intervals to allow full assessment of blood pressure response 4, 2, 3
• Double the dose at each titration step until target or maximum tolerated dose is reached 4
• For heart failure patients, aim for at least 50% of target dose (minimum 10 mg daily) for optimal clinical benefit 2

Monitoring Requirements

• Check blood pressure, serum creatinine, and potassium within 5-7 days after initiation or any dose increase 2, 3
• Repeat monitoring at 3 months, then every 6 months during maintenance therapy 2, 3
• An increase in creatinine up to 50% above baseline is acceptable during titration 2, 3

Critical Prescribing Considerations

When to Use Lower Starting Doses

• Volume depletion or concurrent diuretic use: Start with 5 mg daily for hypertension 1
• Hyponatremia (sodium <130 mEq/L): Start with 2.5 mg daily for heart failure 1
• Low systolic BP (≤120 mmHg) post-MI: Start with 2.5 mg daily 1
• Elderly patients or those with renal impairment: Consider starting at lower doses 8

Important Pitfalls to Avoid

• Asymptomatic hypotension does not require dose reduction—only symptomatic hypotension warrants intervention 4, 3
• Avoid NSAIDs and COX-2 inhibitors as they reduce ACE inhibitor efficacy and worsen renal function 3
• Avoid potassium-sparing diuretics during initiation due to hyperkalemia risk 3
• Some ACE inhibitor is better than no ACE inhibitor—use the highest tolerated dose even if target cannot be reached 4, 2

Pediatric Dosing (Age ≥6 years with GFR >30 mL/min/1.73m²)

• Start at 0.07 mg/kg once daily (maximum 5 mg) 1
• Titrate to maximum of 0.61 mg/kg once daily (not exceeding 40 mg) 1
• Calculate total monthly tablets needed based on weight-based dosing

Practical Dispensing Recommendations

For a typical new hypertension patient: Dispense #30 tablets of 10 mg strength with instructions for once-daily dosing, with refills allowing titration to 20-40 mg daily 1

For a heart failure patient: Dispense #30 tablets of 5 mg strength initially, with plan to titrate toward 30-35 mg daily over subsequent months for optimal mortality benefit 2, 5