What initial lisinopril dose should be prescribed for a 90‑kg adult with normal renal and hepatic function?

Lisinopril Dosing for a 90-kg Adult

For a 90-kg adult with normal renal and hepatic function, initiate lisinopril at 10 mg once daily and titrate to a target dose of 20–40 mg once daily based on blood pressure response, regardless of body weight. 1

Standard Dosing Protocol

• The FDA-approved initial dose for hypertension in adults is 10 mg once daily, with a usual maintenance range of 20–40 mg daily administered as a single dose. 1
• Doses up to 80 mg have been studied but do not provide greater antihypertensive effect than 40 mg. 1
• Body weight does not influence lisinopril dosing in adults with normal organ function; the drug is dosed according to blood pressure response and clinical indication, not kilograms. 1

Titration Strategy

• Adjust the dose upward every 2–4 weeks based on blood pressure measurements, aiming for a target of <130/80 mmHg in most patients. 2
• The median effective dose in clinical trials was approximately 32.5–35 mg daily, demonstrating that many patients require doses above the initial 10 mg to achieve optimal control. 2
• Titrate to the target doses proven efficacious in randomized controlled trials (20–40 mg daily for hypertension) rather than stopping at lower doses, even if partial blood pressure improvement occurs. 2

Combination Therapy When Monotherapy Is Insufficient

• If blood pressure remains ≥140/90 mmHg on lisinopril 40 mg daily, add hydrochlorothiazide 12.5–25 mg once daily rather than exceeding the maximum lisinopril dose. 1
• When initiating therapy in a patient already taking a diuretic, start lisinopril at 5 mg once daily to reduce the risk of first-dose hypotension. 1

Monitoring Requirements

• Measure blood pressure every 2–4 weeks during titration and aim to reach target within 3 months of starting therapy. 2
• Check serum creatinine and potassium within 1–2 weeks after initiation or dose escalation, then at least annually during maintenance. 2
• Monitor for symptomatic hypotension, especially after the first dose or when increasing the dose in volume-depleted patients. 1

Special Clinical Contexts

Heart Failure with Reduced Ejection Fraction

• Start at 5 mg once daily (or 2.5 mg if serum sodium <130 mEq/L) and titrate as tolerated to a maximum of 40 mg once daily. 1
• The target dose of 20–40 mg daily in heart failure trials was associated with significant mortality reduction. 2

Acute Myocardial Infarction

• In hemodynamically stable patients, give 5 mg orally within 24 hours of symptom onset, followed by 5 mg at 24 hours, 10 mg at 48 hours, then 10 mg once daily for at least 6 weeks. 1
• Initiate at 2.5 mg if systolic blood pressure is 100–120 mmHg during the first 3 days post-infarction. 1

Renal Impairment Adjustments (Not Applicable to This 90-kg Patient with Normal Function)

• No dose adjustment is required when creatinine clearance is >30 mL/min. 1
• For creatinine clearance 10–30 mL/min, reduce the initial dose to 5 mg once daily (half the usual starting dose) and titrate cautiously. 1
• For hemodialysis or creatinine clearance <10 mL/min, start at 2.5 mg once daily. 1

Common Pitfalls to Avoid

• Do not dose lisinopril based on body weight in adults; the 90-kg weight is irrelevant to dosing decisions in the absence of renal impairment. 1
• Avoid underdosing: fewer than 25% of patients in real-world practice are titrated to guideline-recommended target doses, leading to suboptimal cardiovascular risk reduction. 3
• Do not combine lisinopril with an angiotensin receptor blocker (ARB) or direct renin inhibitor (aliskiren), as dual renin–angiotensin system blockade increases the risk of hyperkalemia, syncope, and acute kidney injury without added benefit. 2, 3
• Do not stop titration prematurely if blood pressure improves at lower doses; clinical trials demonstrate that reaching target doses (20–40 mg) provides maximal mortality and morbidity benefits. 2