What is the appropriate treatment and management plan for an adult patient with hypertension, possibly with comorbid conditions such as diabetes, kidney disease, or heart failure, who is prescribed Lisinopril (angiotensin-converting enzyme inhibitor) 20 mg once daily?

Lisinopril 20 mg Prescription for Hypertension

For an adult patient with hypertension, prescribe Lisinopril 20 mg orally once daily, which represents the standard therapeutic dose within the usual dosage range of 20-40 mg per day for blood pressure control. 1

Initial Dosing and Titration

• The FDA-approved starting dose for hypertension is 10 mg once daily, with upward titration based on blood pressure response to the usual maintenance range of 20-40 mg daily. 1
• Lisinopril 20 mg once daily has demonstrated superior blood pressure reductions compared to hydrochlorothiazide 12.5-50 mg daily in clinical trials, particularly for systolic blood pressure control. 1
• The antihypertensive effect becomes apparent within 1-2 hours after administration, with sustained 24-hour blood pressure control allowing true once-daily dosing. 2, 3
• Maximum blood pressure reduction is typically achieved after 2-4 weeks of therapy at a given dose. 1, 2

Target Blood Pressure Goals

• The WHO recommends a target blood pressure of <140/90 mmHg for all patients with hypertension without comorbidities. 4
• For patients with existing cardiovascular disease, the WHO recommends a more intensive target of <130 mmHg systolic. 4
• For high-risk patients with diabetes mellitus, chronic kidney disease, or high cardiovascular risk, the WHO suggests targeting <130 mmHg systolic, though this is a conditional recommendation. 4

Combination Therapy When Monotherapy is Insufficient

• If blood pressure remains uncontrolled on Lisinopril 20-40 mg daily, add hydrochlorothiazide 12.5 mg once daily as the preferred second agent. 1
• The WHO recommends combination therapy, preferably as a single-pill combination, using drugs from three classes: ACE inhibitors (like lisinopril), thiazide diuretics, and long-acting dihydropyridine calcium channel blockers. 4
• When adding a diuretic to lisinopril, reduce the lisinopril dose to 5 mg initially to minimize first-dose hypotension risk, then uptitrate as tolerated. 1
• The ACC/AHA guidelines favor ACE inhibitors or ARBs for patients with specific comorbidities: chronic kidney disease, diabetes with albuminuria, heart failure (preserved or reduced ejection fraction), or stable ischemic heart disease. 4

Special Populations and Dose Adjustments

Renal Impairment

• No dose adjustment is required for creatinine clearance >30 mL/min. 1
• For creatinine clearance 10-30 mL/min, start with 5 mg once daily (half the usual starting dose) and titrate to maximum 40 mg daily as tolerated. 1
• For hemodialysis patients or creatinine clearance <10 mL/min, start with 2.5 mg once daily. 1

Elderly Patients (≥65 years)

• Lisinopril 20 mg once daily is effective and well-tolerated in elderly patients aged 65-85 years, with preserved renal function and increased renal blood flow after one year of treatment. 5
• No routine dose adjustment is needed based on age alone, though blood pressure response and tolerability should guide dosing. 1, 5

Black Patients

• Lisinopril monotherapy is less effective in Black patients compared to Caucasian patients for blood pressure reduction. 1
• For Black patients, the ACC/AHA guidelines recommend preferentially starting with a dihydropyridine calcium channel blocker or thiazide diuretic rather than an ACE inhibitor as monotherapy. 4
• When ACE inhibitors are used in Black patients, combination with a thiazide diuretic or calcium channel blocker is typically required for adequate blood pressure control. 4

Heart Failure

• For systolic heart failure, start lisinopril 5 mg once daily when used with diuretics and digitalis, titrating to a maximum of 40 mg daily as tolerated. 1
• In patients with hyponatremia (serum sodium <130 mEq/L), start with 2.5 mg once daily. 1
• The ATLAS trial demonstrated that higher doses (35 mg) had outcomes at least as favorable as lower doses (2.5 mg) in heart failure patients. 1

Acute Myocardial Infarction

• In hemodynamically stable patients within 24 hours of acute MI, give lisinopril 5 mg orally, followed by 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg once daily for at least 6 weeks. 1
• For patients with low systolic blood pressure (≤120 mmHg and >100 mmHg) during the first 3 days post-infarct, initiate with 2.5 mg. 1

Monitoring and Follow-Up

• The WHO suggests monthly follow-up after initiating or changing antihypertensive medications until target blood pressure is achieved. 4
• Once blood pressure is controlled, the WHO suggests follow-up every 3-5 months. 4
• The ACC/AHA guidelines recommend approximately monthly visits for drug titration until blood pressure is controlled. 4
• Monitor serum potassium and creatinine when initiating therapy or adding other agents that affect the renin-angiotensin system, particularly in patients with chronic kidney disease. 4

Lifestyle Modifications to Prescribe Concurrently

• Sodium restriction to <1500 mg/day, or minimally a reduction of at least 1000 mg/day from current intake. 4
• Increased dietary potassium intake to 3500-5000 mg/day. 4
• Weight loss of at least 1 kg if overweight or obese, targeting ideal body weight. 4
• Aerobic or dynamic resistance exercise 90-150 minutes per week, or isometric resistance exercise 3 sessions per week. 4
• Alcohol moderation to ≤2 drinks per day in men, ≤1 per day in women. 4
• DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated and total fat. 4

Common Pitfalls to Avoid

• Do not combine lisinopril with an ARB (dual RAS blockade), as this increases adverse events including hyperkalemia and acute kidney injury without additional cardiovascular benefit. 4
• Do not use lisinopril in pregnancy—it is contraindicated due to fetal toxicity. 4
• Do not withhold appropriate dose escalation in elderly patients based solely on age; individualize based on blood pressure response and tolerability rather than chronological age. 5
• Verify medication adherence before assuming treatment failure, as non-adherence is the most common cause of apparent treatment resistance. 6
• Screen for interfering medications (NSAIDs, decongestants, oral contraceptives, systemic corticosteroids) that can elevate blood pressure and reduce lisinopril efficacy. 6
• Consider secondary hypertension if blood pressure remains severely elevated (≥160/100 mmHg) despite three-drug therapy at optimal doses, looking for primary aldosteronism, renal artery stenosis, or obstructive sleep apnea. 6

Prescription Example

Lisinopril 20 mg tablet
Sig: Take 1 tablet by mouth once daily
Disp: #30 tablets
Refills: 3