Acute Hypertension

12.5-25 mg PO; may repeat PRN

Hypertension (Alone or with Thiazide)

Initial: 25 mg PO q8-12hr, increase gradually based on response (may start lower in some patients)

Maintenance: 25-150 mg PO q8-12hr

450 mg/day maximum

Congestive Heart Failure (With Diuretics and Digitalis)

Initial: 6.25-12.5 mg PO q8hr in conjunction with cardiac glycoside and diuretic therapy

Target therapy: 50 mg q8hr

450 mg/day maximum

Left Ventricular Dysfunction After Myocardial Infarction

6.25 mg PO initially followed by 12.5 mg q8hr

Increase to 25 mg PO q8hr over next few days; THEN

Target dose: 50 mg PO q8hr

Diabetic Nephropathy

25 mg PO q8hr

Dosing Considerations

Beneficial for many patients at risk for heart disease; reduces risk of MI, stroke, diabetic nephropathy , microalbuminuria, new onset DM

Consider starting an ACE inhibitor in high-risk patients, even if no HTN or CHF

May prolong survival in CHF, may preserve renal function in DM

May help to prevent migraine HA

Good choice in hyperlipidemia patients

Requires weeks for full effect; to start, use low dose and titrate every 1-2wk

Administration

Take on an empty stomach

Acute Hypertension

12.5-25 mg PO; may repeat PRN

Hypertension (Alone or with Thiazide)

Initial: 25 mg PO q8-12hr, increase gradually based on response (may start lower in some patients)

Maintenance: 25-150 mg PO q8-12hr

450 mg/day maximum

Congestive Heart Failure (With Diuretics and Digitalis)

Initial: 6.25-12.5 mg PO q8hr in conjunction with cardiac glycoside and diuretic therapy

Target therapy: 50 mg q8hr

450 mg/day maximum

Left Ventricular Dysfunction After Myocardial Infarction

6.25 mg PO initially followed by 12.5 mg q8hr

Increase to 25 mg PO q8hr over next few days; THEN

Target dose: 50 mg PO q8hr

Diabetic Nephropathy

25 mg PO q8hr

Dosing Considerations

Beneficial for many patients at risk for heart disease; reduces risk of MI, stroke, diabetic nephropathy , microalbuminuria, new onset DM

Consider starting an ACE inhibitor in high-risk patients, even if no HTN or CHF

May prolong survival in CHF, may preserve renal function in DM

May help to prevent migraine HA

Good choice in hyperlipidemia patients

Requires weeks for full effect; to start, use low dose and titrate every 1-2wk

Administration

Take on an empty stomach

Contraindications

Hypersensitivity to ACE inhibitors

Anuria

History of ACEI-induced angioedema

Hereditary or idiopathic angioedema

Coadministration of neprilysin inhibitors (eg, sacubitril) with ACE inhibitors may increase angioedema risk; do not administer ACE inhibitors within 36 hr of switching to or from sacubitril/valsartan

Bilateral renal artery stenosis

Do not coadminister with aliskiren in patients with diabetes mellitus or with renal impairment (ie, GFR <60 mL/min/1.73 m²)

Cautions

Aortic stenosis/hypertrophic cardiomyopathy, hypotension, biliary cirrhosis or biliary obstruction, myelosuppression, electrolyte imbalance, hyperuricemia or gout, SLE, hepatic or renal impairment

Avoid concomitant use with lithium

Less effective in African-Americans

Excessive hypotension if concomitant diuretics or volume-depleted; start with 6.25 mg q8hr

Risk of hyperkalemia, especially with K+ sparing diuretics

Dual blockade of the renin angiotensin system with ARBs, ACE inhibitors, or aliskiren associated with increased risk for hypotension, hyperkalemia, and renal function changes (including acute renal failure) compared to monotherapy

Blood levels don't correlate with BP response

Food decreases absorption

ACE inhibition also causes increased bradykinin levels which putatively mediates angioedema

Coadministration with mTOR inhibitors (eg, temsirolimus, everolimus, sirolimus) may increase risk for angioedema

Intestinal angioedema, that presented with abdominal pain, reported in patients treated with ACE inhibitors

Neutropenia (<1000/mm³ with myeloid hypoplasia reported with captopril; risk is dependent on clinical status of patient

Causes false positive urine acetone

Pregnancy & Lactation