What is the recommended dose of lisinopril (angiotensin-converting enzyme inhibitor) for an adult patient with hypertension, considering factors such as blood pressure response, kidney function, and history of heart failure?

Lisinopril Dosing for Hypertension

For adults with hypertension, start lisinopril at 10 mg once daily and titrate to 20-40 mg daily based on blood pressure response, with a maximum dose of 80 mg daily if needed, though doses above 40 mg rarely provide additional benefit. 1

Initial Dosing Strategy

• Start with 10 mg once daily as the standard initial dose for most adults with hypertension 1
• Reduce to 5 mg once daily if the patient is already taking diuretics, as volume depletion increases the risk of first-dose hypotension 1
• Start with 2.5 mg once daily in patients with creatinine clearance 10-30 mL/min or those on hemodialysis 1

When to Use Lisinopril as First-Line Therapy

Lisinopril is specifically indicated as first-line therapy when compelling indications exist: diabetes with albuminuria, chronic kidney disease, or heart failure 2. For uncomplicated hypertension, particularly in black patients without these conditions, thiazide diuretics or calcium channel blockers are preferred over ACE inhibitors due to superior outcomes in preventing stroke and heart failure 2.

Dose Titration Protocol

• Titrate to 20-40 mg once daily as the usual maintenance range for blood pressure control 1
• Allow at least 4 weeks between dose adjustments to observe the full blood pressure response unless urgent BP lowering is required 2
• Maximum dose is 80 mg daily, though doses above 40 mg do not appear to provide greater antihypertensive effect 1

Combination Therapy Approach

For stage 2 hypertension (BP ≥140/90 mmHg or >20/10 mmHg above goal), initiate two-drug combination therapy immediately rather than starting with monotherapy 2, 3. The preferred combinations are:

• Lisinopril + thiazide diuretic (e.g., hydrochlorothiazide 12.5 mg) 1
• Lisinopril + calcium channel blocker 2
• Single-pill combinations are strongly favored to improve adherence 4

Most patients require at least two drugs to achieve blood pressure goals, and submaximal doses of two drugs produce larger BP responses with fewer side effects than maximal doses of a single drug 2.

Blood Pressure Targets

• Target <130/80 mmHg for adults under 65 years and those with known cardiovascular disease 4
• Target <140/90 mmHg for all patients without comorbidities 4
• For noninstitutionalized adults ≥65 years, target systolic BP <130 mmHg 4

Essential Safety Monitoring

Monitor serum creatinine, estimated GFR, and potassium within 1-2 weeks of initiation, with each dose increase, and at least annually thereafter 2. Key monitoring parameters include:

• An increase in creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable 2
• Recheck electrolytes and renal function 2-4 weeks after initiating therapy 4
• Black patients have a greater risk of angioedema with ACE inhibitors compared to other populations 2

Renal Dose Adjustments

• No adjustment needed if creatinine clearance >30 mL/min 1
• Start with 5 mg once daily if creatinine clearance 10-30 mL/min, titrate to maximum 40 mg daily 1
• Start with 2.5 mg once daily for hemodialysis patients or creatinine clearance <10 mL/min 1

Studies in patients with impaired renal function (GFR ≤60 mL/min) demonstrated effective blood pressure control with lisinopril starting at 2.5-5 mg daily, with median effective doses of 10 mg daily and no significant decline in GFR during treatment 5, 6.

Follow-Up Schedule

• Monthly visits after initiating or changing medications until blood pressure reaches target 3, 7
• Every 3-5 months once controlled and stable 2, 3

Critical Contraindications and Warnings

• Absolutely contraindicated in pregnancy due to fetal toxicity 2
• Do not combine with ARBs or direct renin inhibitors, as this increases adverse effects without additional benefit 2
• Avoid in patients with bilateral renal artery stenosis 4
• Use caution in patients with hypotension, renal failure, or hyperkalemia 4

Special Population Considerations

For black patients without heart failure or chronic kidney disease, prefer thiazide diuretics or calcium channel blockers over lisinopril as initial therapy, as ACE inhibitors are less effective in preventing stroke and heart failure in this population 2, 3.

Post-Myocardial Infarction Dosing

For hemodynamically stable patients within 24 hours of acute MI, the dosing differs from hypertension management: start with 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. Use 2.5 mg initially if systolic BP is 100-120 mmHg 4, 1.