Usual Adult Dose for Hypertension

Initial dose: 10 mg orally once a day; 5 mg orally once a day
Maintenance dose: 20 to 40 mg orally once a day
Maximum dose: 80 mg orally once a day

Comments:

• The initial dose is 5 mg orally once a day in patients receiving a diuretic.
• The 80 mg dose is used but does not appear to give greater effect.
• If blood pressure is not controlled with lisinopril alone, a low dose of a diuretic may be added (e.g., hydrochlorothiazide, 12.5 mg). After the addition of a diuretic, it may be possible to reduce the dose of lisinopril.

Usual Adult Dose for Congestive Heart Failure

Initial dose: 2.5 to 5 mg orally once a day
Maintenance dose: Dosage should be increased as tolerated
Maximum dose: 40 mg orally once a day

Comments:

• The diuretic dose may need to be adjusted to help minimize hypovolemia, which may contribute to hypotension. The appearance of hypotension after the initial dose of lisinopril does not preclude subsequent careful dose titration with the drug.

Usual Adult Dose for Myocardial Infarction

Initial dose: 5 mg orally (within 24 hours of the onset of acute myocardial infarction)
Subsequent doses: 5 mg orally after 24 hours, then 10 mg orally after 48 hours.
Maintenance dose: 10 mg orally once a day. Dosing should continue for at least 6 weeks.

Comments:

• Therapy should be initiated at 2.5 mg in patients with a low systolic blood pressure (less than or equal to 120 mm Hg and greater than 100 mmHg) during the first 3 days after the infarct. If prolonged hypotension occurs (systolic blood pressure less than 90 mmHg for more than 1 hour) therapy should be withdrawn.

Usual Adult Dose for Diabetic Nephropathy

Initial dose: 10 to 20 mg orally once a day
Maintenance dose: 20 to 40 mg orally once a day
Dosage may be titrated upward every 3 days

Comments:

• Not an approved indication.

Usual Geriatric Dose for Hypertension

Initial dose: 2.5 to 5 mg orally once a day
Maintenance dose: Dosages should be increased at 2.5 mg to 5 mg per day at 1 to 2 week intervals.
Maximum dose: 40 mg orally once a day

Usual Pediatric Dose for Hypertension

Pediatric patients greater than or equal to 6 years of age:
Initial dose: 0.07 mg/kg orally once a day (Maximum initial dose is 5 mg once a day)
Maintenance dose: Dosage should be adjusted according to blood pressure response at 1 to 2 week intervals.
Maximum dose: Doses above 0.61 mg/kg or greater than 40 mg have not been studied in pediatric patients

Comments:

• This drug is not recommended in pediatric patients less than 6 years old or in pediatric patients with glomerular filtration rate less than 30 mL/min.

Renal Dose Adjustments

CrCl greater than 30 mL/min: No adjustment recommended
CrCl 10 mL/min to less than or equal to 30 mL/min: Recommended initial dose is half of the usual recommended dose (i.e., hypertension, 5 mg; systolic heart failure, 2.5 mg, and acute MI, 2.5 mg. Up titrate as tolerated to a maximum of 40 mg daily)
CrCl less than 10 mL/min or on hemodialysis: Recommended initial dose is 2.5 mg orally once a day

Liver Dose Adjustments

Patients who develop jaundice or marked elevations of hepatic enzymes should discontinue therapy and receive appropriate medical treatment.

Dose Adjustments

• The antihypertensive effect may diminish toward the end of the dosing interval regardless of the administered dose, but most commonly with a dose of 10 mg or less daily. This can be evaluated by measuring blood pressure just prior to dosing to determine whether satisfactory control is being maintained for 24 hours. If it is not, an increase in dose should be considered. If blood pressure is not adequately controlled with lisinopril alone, a diuretic may be added. After the addition of a diuretic, it may be possible to reduce the dose of lisinopril.
• In all high risk patients, such as patients with ischemic heart or cerebrovascular disease, in whom excessive falls in blood pressure may lead to myocardial infarction or cerebrovascular accident the manufacturer advises treatment initiation at lower dosages.
• Dosage adjustments in the elderly should be made with particular caution.
• In patients who are currently being treated with a diuretic, symptomatic hypotension occasionally can occur following the initial dose. To reduce the likelihood of hypotension, the diuretic should, if possible, be discontinued 2 to 3 days prior to beginning therapy. Then, if blood pressure is not controlled with lisinopril alone, diuretic therapy should be resumed. If diuretic therapy cannot be discontinued, an initial dose of 5 mg should be used with careful medical supervision for several hours and until blood pressure has stabilized.

Precautions

US BOXED WARNINGS:

• FETAL TOXICITY: Angiotensin converting enzyme (ACE) inhibitor use during pregnancy can cause morbidity and death to the developing fetus. When used during the second and third trimesters, ACE inhibitors have been associated with fetal and neonatal injury, including hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, and death. Oligohydramnios has also been reported, presumably resulting from decreased fetal renal function; oligohydramnios in this setting has been associated with fetal limb contractures, craniofacial deformation, and hypoplastic lung development. Exposure to ACE inhibitors during the first trimester of pregnancy has been associated with prematurity, intrauterine growth retardation, patent ductus arteriosus, other structural cardiac malformations, and neurological malformations. When pregnancy is detected, ACE inhibitors should be discontinued as soon as possible. If no alternative to ACE inhibitor therapy is available, patients should be made aware of the risks to their fetuses and the intra-amniotic environment should be evaluated by serial ultrasound examinations. If oligohydramnios develops, this drug should be discontinued unless it is considered lifesaving for the mother. Depending on the week of pregnancy, contraction stress testing, a nonstress test, or biophysical profiling may be appropriate. Oligohydramnios may not show until after the fetus has suffered irreversible injury.

Dialysis

This drug can be removed by hemodialysis.

Other Comments

Administration advice:

• Should be given as a single daily dose.
• May be given with or without food.
• In some patients with heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with this drug. This effect is anticipated and is not usually a reason to discontinue treatment. If hypotension becomes symptomatic, a reduction of dose or discontinuation of may be necessary.

• This drug is indicated as adjunctive therapy with diuretics and digitalis for treating heart failure.
• Following first time MI, all ACE inhibitors, at comparable appropriate dosages, appear to be equally effective for reducing mortality and recurrent MI rates.
• Prior to therapy, patients at high risk of symptomatic hypotension such as patients with salt depletion with or without hyponatremia, hypovolemia or those receiving vigorous diuretic therapy should have these conditions corrected. Renal function and serum potassium should be monitored.
• If it is not feasible to discontinue diuretic therapy prior to starting lisinopril, the patient should be closely monitored for several hours following the initial dose of this drug, and until the blood pressure has stabilized. The antihypertensive effects of lisinopril and diuretics used in combination are approximately additive.
• Achievement of optimal blood pressure reduction may require 2 to 4 weeks of therapy.
• Acute myocardial infarction: in addition to this drug, patients should receive, if appropriate, standard treatments, such as thrombolytics, aspirin, and a beta-blocker.
• Antihypertensive effects of this drug are maintained during long-term therapy. Abrupt withdrawal has not been associated with a rapid increase in blood pressure, or a significant increase in blood pressure compared to pretreatment levels.

• This drug may be taken with or without food, but should be taken at the same time each day.
• This drug may impair your ability to drive or operate machinery.

Frequently asked questions

• How long after taking 5 mg lisinopril will my blood pressure drop down?
• Does lisinopril cause weight gain?
• Do ACE inhibitors make COVID-19 worse?
• Can I just stop taking lisinopril?
• What is the strength of Qbrelis (lisinopril) oral solution?