Lisinopril

FDA label

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Renal CrCl >30 mL/min: no dose adjustment. CrCl 10–30 mL/min: halve the usual initial dose (hypertension 5 mg, systolic heart failure 2.5 mg, acute MI 2.5 mg), then up-titrate as tolerated to max 40 mg/day. CrCl <10 mL/min or on hemodialysis: initial 2.5 mg QD. Not recommended in peds with GFR <30 mL/min/1.73 m².

Hepatic Undefined

Instructions

• Discontinue as soon as pregnancy is detected.
• Post-MI: continue dosing for at least 6 weeks; withdraw if prolonged hypotension (SBP <90 mmHg for >1 h) occurs.
• Hypotension after the first dose does not preclude careful subsequent titration once the hypotension is managed.
• In heart failure, the diuretic dose may need adjustment to minimize hypovolemia-driven hypotension.
• Monitor renal function and serum potassium periodically.

Contraindications

• Concomitant use with a neprilysin inhibitor (e.g., sacubitril); do not administer within 36 hours of switching to or from sacubitril/valsartan
• History of angioedema or hypersensitivity related to previous ACE inhibitor treatment
• Hereditary or idiopathic angioedema
• Co-administration with aliskiren in patients with diabetes

Cautions

• Fetal toxicity: RAS-acting drugs in the 2nd/3rd trimester reduce fetal renal function → oligohydramnios, lung hypoplasia, skull hypoplasia, anuria, hypotension, death.
• Angioedema of face, extremities, lips, tongue, glottis or larynx at any time in treatment, some fatal; discontinue promptly and monitor to full resolution. Higher rate in Black patients; increased risk with concomitant mTOR inhibitors (sirolimus, everolimus, temsirolimus) or a neprilysin inhibitor.
• Intestinal angioedema presenting as abdominal pain ± nausea/vomiting, sometimes with no prior facial angioedema and normal C-1 esterase.
• Anaphylactoid reactions during hymenoptera venom desensitization, during dialysis with high-flux membranes, and during LDL apheresis with dextran sulfate absorption.
• Impaired renal function including acute renal failure — highest risk with renal artery stenosis, CKD, severe CHF, post-MI or volume depletion; monitor periodically.
• Symptomatic hypotension, sometimes with oliguria, progressive azotemia, acute renal failure or death; monitor BP after initiation.
• Hyperkalemia — monitor serum potassium periodically.
• Cholestatic jaundice progressing to hepatic failure — monitor for jaundice or signs of liver failure.
• Less antihypertensive effect in Black than in non-Black patients.

Adverse reactions

• Hypertension: headache, dizziness, cough.
• Heart failure: hypotension, chest pain.
• Acute MI: hypotension, renal dysfunction.
• Dose-related (ATLAS, high vs low dose): dizziness 19% vs 12%, hypotension 11% vs 7%, increased creatinine 10% vs 7%, syncope 7% vs 5%, hyperkalemia 6% vs 4%.
• Hyperkalemia (K >5.7 mEq/L) in 2.2% of hypertension and 4.8% of heart failure patients; reversible minor BUN/creatinine rises.
• Fatigue, asthenia, orthostatic effects.
• GI: pancreatitis, constipation, flatulence, dry mouth, diarrhea.
• Rare: bone marrow depression, hemolytic anemia, leukopenia/neutropenia, thrombocytopenia.
• Skin: urticaria, alopecia, photosensitivity, erythema, flushing, diaphoresis, toxic epidermal necrolysis, Stevens-Johnson syndrome, pruritus.
• Special senses: visual loss, diplopia, blurred vision, tinnitus, taste and olfactory disturbances.
• Impotence; a lupus-like symptom complex (positive ANA, raised ESR, arthralgia, myalgia, fever, vasculitis, eosinophilia).

Pregnancy Can cause fetal harm — discontinue as soon as pregnancy is detected; 2nd/3rd-trimester exposure causes oligohydramnios, fetal renal failure, lung hypoplasia, skeletal/skull deformation and death. Observe exposed neonates for hypotension, oliguria and hyperkalemia.

Lactation No human milk data; present in rat milk. Advise women not to breastfeed during treatment.