Starting Dose of Lisinopril After Discontinuing Amlodipine 5mg
Start lisinopril at 10 mg once daily, as this represents the standard initial dose for hypertension in patients with prior ACE inhibitor experience. 1
Rationale for 10mg Starting Dose
The ACC/AHA guidelines specify lisinopril dosing of 10-40 mg once daily for hypertension, with 10mg representing the typical starting dose for most patients. 1
For patients who have previously tolerated lisinopril, starting at 10mg is appropriate rather than using the lower 2.5-5mg dose reserved for heart failure or first-time ACE inhibitor use. 1
The antihypertensive efficacy of amlodipine 5mg is roughly comparable to lisinopril 10-20mg based on comparative trials, making 10mg a reasonable starting point to maintain blood pressure control during the transition. 2, 3
Monitoring After Initiation
Reassess blood pressure within 2-4 weeks after starting lisinopril to evaluate response and determine if dose adjustment to 20mg or higher is needed. 1
Check serum potassium and creatinine 1-2 weeks after initiating lisinopril, especially if the patient has chronic kidney disease, diabetes, or is on other medications affecting potassium. 1
Target blood pressure should be <140/90 mmHg minimum, ideally <130/80 mmHg for higher-risk patients. 1
Dose Titration Strategy
If blood pressure remains uncontrolled after 2-4 weeks on lisinopril 10mg, increase to 20mg once daily. 1
The usual dose range is 10-40mg once daily, with most patients achieving adequate control at 20mg. 1, 2
Maximum antihypertensive effect is typically achieved within 2-4 weeks of a given dose. 2
Critical Considerations
Do not combine lisinopril with an ARB, as dual RAS blockade increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit. 1
If blood pressure remains uncontrolled on lisinopril monotherapy at optimal dose (20-40mg), add either a calcium channel blocker (amlodipine 5-10mg) or thiazide diuretic (chlorthalidone 12.5-25mg or hydrochlorothiazide 25mg) as second-line therapy. 1, 4
Avoid use in patients with history of angioedema with ACE inhibitors, bilateral renal artery stenosis, pregnancy, or significant hyperkalemia. 1
Confirm medication adherence before assuming treatment failure, as non-adherence is the most common cause of apparent treatment resistance. 4