LisinoprilPA study guide

Why they happen and how to manage them

Hyperkalemia

Less angiotensin II means less aldosterone, so the kidney holds on to potassium. Management: Check potassium periodically, and more often with kidney disease, diabetes, or potassium-sparing drugs.

Cough and angioedema

ACE also breaks down bradykinin. Blocking it lets bradykinin accumulate. Management: Angioedema: stop permanently and treat the airway. Intolerable cough: switch class.

Rise in creatinine

Angiotensin II keeps glomerular pressure up when renal perfusion is low. Blocking it can drop filtration. Management: Monitor renal function and consider holding if it falls meaningfully.

First-dose hypotension

Volume-depleted patients depend more on angiotensin II for blood pressure. Management: Lower the starting dose or reduce the diuretic first.

Sources: [1][2][3]

Common and serious

Sources: [1][2][3][4][5]

Narrow therapeutic index

The label does not describe a narrow therapeutic index or direct dosing by measured blood levels of the drug.

Sources: [1]

ALT (liver enzyme)

Why

Rare cholestatic liver injury

When

If jaundice or liver symptoms appear

Act on

Stop if jaundice or marked enzyme rise

Normal

4 to 36 U/L.

Sources: [1][2]

Blood pressure

Why

Hypotension and response

When

Closely for the first 2 weeks in high-risk patients and after dose increases

Act on

After MI: withdraw if systolic BP stays below 90 mm Hg for more than 1 hour

Normal

Below 120/80 mm Hg.

Sources: [1][2][3]

Potassium

Why

Hyperkalemia

When

Periodically, and frequently with potassium-sparing diuretics

Normal

3.7 to 5.2 mEq/L.

Sources: [1][2][3]

Serum creatinine

Why

Kidney function

When

Periodically

Act on

Consider holding or stopping if kidney function falls meaningfully

Normal

0.7 to 1.3 mg/dL in men and 0.5 to 0.95 mg/dL in women.

Sources: [1][2]

Adult dose

Hypertension

Start 10 mg once daily (5 mg if already on a diuretic). Usual range 20 to 40 mg per day. Doses up to 80 mg add little effect.

Heart failure

Start 5 mg once daily (2.5 mg if serum sodium is below 130 mEq/L). Titrate up to 40 mg once daily at most.

Acute MI

First dose 5 mg within 24 hours of symptom onset, a second 5 mg dose 24 hours later, 10 mg at 48 hours, then 10 mg daily for at least 6 weeks. Start at 2.5 mg if systolic BP is above 100 and at or below 120 mm Hg in the first 3 days.

Sources: [1][2][3]

Renal adjustment

CrCl above 30 mL/min: no change. CrCl 10 to 30 mL/min: halve the usual starting dose (5 mg for hypertension, 2.5 mg for heart failure or MI), then titrate to a maximum of 40 mg daily. CrCl below 10 mL/min or on hemodialysis: start 2.5 mg once daily.

Sources: [1]

Hepatic adjustment

The label gives no hepatic dose adjustment. Stop the drug if jaundice or a marked rise in liver enzymes develops.

Sources: [1]

Boxed warning

Fetal toxicity. Drugs acting on the renin-angiotensin system can injure or kill a developing fetus. Stop lisinopril as soon as pregnancy is detected.

Sources: [1]

Contraindications

• Prior angioedema or hypersensitivity from any ACE inhibitor
• Hereditary or idiopathic angioedema
• Use with a neprilysin inhibitor such as sacubitril. Allow a 36-hour gap when changing between lisinopril and sacubitril/valsartan
• Use with aliskiren in patients with diabetes

Sources: [1]

Key interactions

Diuretics

Large first-dose drop in blood pressure. Start at a lower dose.

Potassium-sparing diuretics, potassium supplements, potassium salt substitutes

Raise the risk of hyperkalemia.

NSAIDs, including COX-2 inhibitors

Can worsen kidney function and blunt the blood pressure effect.

ARBs, other ACE inhibitors, or aliskiren (dual RAS blockade)

More hypotension, hyperkalemia, and kidney injury.

Lithium

Lithium levels and toxicity can rise.

Insulin and oral diabetes drugs

Added glucose lowering with a risk of hypoglycemia.

mTOR inhibitors or neprilysin inhibitors

Higher angioedema risk.

Sources: [1][2][3][4][5][6]

Antidote or reversal

No specific antidote. Overdose mainly causes hypotension, treated with IV normal saline. Lisinopril can be removed by hemodialysis.

Sources: [1]

Pregnancy

Can cause fetal harm, mainly with use in the second and third trimesters: reduced fetal kidney function, oligohydramnios, skull hypoplasia, and death. Stop as soon as pregnancy is detected.

Sources: [1]

Lactation

No human data. The label advises against breastfeeding during treatment.

Sources: [1]

Pediatric

Approved for hypertension from age 6. Start 0.07 mg/kg once daily (up to 5 mg), titrating to at most 0.61 mg/kg or 40 mg. Not recommended under age 6 or with GFR below 30 mL/min/1.73 m².

Sources: [1][2]

Geriatric

No age-based dose change. In a large MI trial, patients 75 and older stopped the drug for kidney problems more often (4.8% vs 1.3%).

Sources: [1]