What is the recommended initial dose and titration schedule of lisinopril for a 31‑year‑old woman with uncomplicated primary hypertension and no contraindications (e.g., pregnancy, renal artery stenosis, severe renal impairment, or angio‑edema)?

Lisinopril Dosing for a 31-Year-Old Female with Primary Hypertension

Start lisinopril 10 mg once daily and titrate to 20–40 mg once daily based on blood pressure response measured every 2–4 weeks, aiming for a target of <130/80 mmHg within 3 months. 1

Initial Dose

• The FDA-approved starting dose of lisinopril for uncomplicated hypertension in adults is 10 mg once daily. 1
• This initial dose applies to patients not taking diuretics and with normal renal function (creatinine clearance >30 mL/min). 1

Titration Schedule and Target Dose

• Reassess blood pressure every 2–4 weeks after initiating therapy or adjusting the dose. 2
• The usual maintenance dosage range is 20–40 mg per day administered as a single daily dose. 1
• Doses up to 80 mg have been studied but do not appear to provide greater antihypertensive effect than 40 mg. 1
• Titrate upward from 10 mg to 20 mg, then to 40 mg if needed, based on blood pressure response. 1

Blood Pressure Target

• Aim for a blood pressure <130/80 mmHg in this young adult to reduce long-term cardiovascular risk. 2
• The 2024 ESC guidelines recommend targeting systolic BP of 120–129 mmHg in most adults when well tolerated. 2
• Achieve the target blood pressure within 3 months of starting treatment. 2

Monitoring Requirements

• Check serum creatinine and potassium 7–14 days after initiating lisinopril or after any dose increase, as ACE inhibitors can cause hyperkalemia and acute changes in renal function. 2, 3
• Continue monitoring electrolytes and renal function at least annually once the patient is stable on maintenance therapy. 2

Combination Therapy if Monotherapy Fails

• If blood pressure remains ≥140/90 mmHg on lisinopril 40 mg daily after 4–8 weeks, add hydrochlorothiazide 12.5–25 mg once daily as second-line therapy. 2, 3, 1
• The FDA label specifically notes that if blood pressure is not controlled with lisinopril alone, a low-dose diuretic (e.g., hydrochlorothiazide 12.5 mg) may be added. 1
• Single-pill combination products are preferred when dual therapy is needed because they markedly improve medication adherence. 2

Critical Safety Considerations

• Lisinopril is absolutely contraindicated in pregnancy due to serious fetal toxicity (renal dysfunction, oligohydramnios, skull hypoplasia, fetal death). 2, 1
• This 31-year-old woman of childbearing potential must use reliable contraception while taking lisinopril, and the drug should be discontinued immediately if pregnancy is detected. 2
• Do not combine lisinopril with an ARB (e.g., losartan) or a direct renin inhibitor (aliskiren), as dual renin-angiotensin system blockade increases the risk of hyperkalemia, syncope, and acute kidney injury 2–3-fold without cardiovascular benefit. 2

Common Pitfalls to Avoid

• Do not start at 5 mg unless the patient is taking diuretics or has renal impairment (creatinine clearance <30 mL/min); the standard starting dose for uncomplicated hypertension is 10 mg. 1
• Do not stop at 10 mg if blood pressure remains elevated; the usual effective dose range is 20–40 mg daily. 1
• Do not delay titration; reassess every 2–4 weeks and adjust the dose promptly to reach target blood pressure within 3 months. 2
• Do not add a second drug before reaching the maximum effective dose (40 mg) of lisinopril, unless blood pressure is severely elevated (≥160/100 mmHg) at baseline. 3, 1