Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor prescribed primarily for the management of hypertension, heart failure, and post-myocardial infarction care. It works by inhibiting the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, thereby promoting vasodilation and reducing peripheral arterial resistance. This mechanism not only lowers blood pressure but also decreases the workload on the heart, making it a cornerstone therapy in cardiovascular medicine. Its well-established efficacy, once-daily dosing convenience, and extensive clinical evidence base contribute to its status as a first-line treatment option in appropriate patient populations.

Features

• Pharmacological class: Angiotensin-converting enzyme (ACE) inhibitor
• Available formulations: Oral tablets in strengths of 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, and 40 mg
• Administration: Typically once daily, with or without food
• Bioavailability: Approximately 25%, with peak plasma concentrations occurring within 7 hours
• Elimination half-life: 12 hours, permitting 24-hour hemodynamic control
• Metabolism: Not metabolized by the liver; excreted unchanged primarily through the kidneys
• FDA-approved indications: Hypertension, heart failure, acute myocardial infarction

Benefits

• Provides sustained 24-hour blood pressure control with single daily dosing
• Reduces mortality and hospitalizations in patients with congestive heart failure
• Demonstrates cardioprotective effects following myocardial infarction
• Shows renal protective benefits in diabetic patients with proteinuria
• May improve endothelial function and vascular compliance
• Cost-effective generic availability improves accessibility

Common use

Lisinopril is predominantly prescribed for the management of essential hypertension, either as monotherapy or in combination with other antihypertensive agents. It is indicated for the treatment of heart failure when used concomitantly with diuretics and digitalis, improving survival and reducing symptoms of cardiac decompensation. Following acute myocardial infarction, lisinopril is administered to hemodynamically stable patients within 24 hours of onset to improve survival and reduce the incidence of heart failure. Off-label uses include diabetic nephropathy management due to its antiproteinuric effects and prophylactic migraine treatment in selected cases.

Dosage and direction

Hypertension: Initial dose typically 10 mg once daily, titrated upward to 20-40 mg daily based on blood pressure response. Maximum recommended dose: 80 mg daily.

Heart Failure: Start with 2.5-5 mg once daily under close medical supervision, increasing gradually to a target maintenance dose of 20-40 mg daily.

Acute Myocardial Infarction: Initiate with 5 mg within 24 hours of symptom onset, followed by 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg daily for 6 weeks.

Dosage adjustment required in renal impairment: CrCl 10-30 mL/min: initial dose 2.5-5 mg daily; CrCl <10 mL/min: initial dose 2.5 mg daily. Not recommended for children under 6 years or with body weight <20 kg.

Precautions

Monitor renal function and serum potassium before initiation and periodically during therapy, particularly in patients with renal artery stenosis, pre-existing renal impairment, or those taking potassium supplements. Assess blood pressure response within 2-4 weeks of initiation or dosage adjustment. Exercise caution in patients with collagen vascular disease or those receiving immunosuppressive therapy due to increased risk of neutropenia/agranulocytosis. Avoid use in pregnancy due to potential fetal harm, especially during the second and third trimesters. May cause symptomatic hypotension, especially in volume-depleted patients; correct volume depletion prior to initiation.

Contraindications

History of angioedema related to previous ACE inhibitor therapy. Concomitant use with aliskiren in patients with diabetes. Patients with hereditary or idiopathic angioedema. Hypersensitivity to lisinopril or any component of the formulation. Bilateral renal artery stenosis or stenosis in a solitary kidney. Concomitant use with sacubitril/valsartan (must discontinue lisinopril at least 36 hours before starting sacubitril/valsartan).

Possible side effect

Common (≥1%): Dizziness (6-12%), headache (5-6%), cough (4-9%), fatigue (3-5%), nausea (2-4%), diarrhea (2-3%), orthostatic hypotension (1-3%)

Less common (0.1-1%): Rash, impotence, hyperkalemia, taste disturbance, photosensitivity, chest pain

Rare (<0.1%): Angioedema, neutropenia/agranulocytosis, hepatotoxicity, pancreatitis, syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Laboratory abnormalities: Increased BUN and serum creatinine (2-3%), elevated liver enzymes, decreased hemoglobin and hematocrit

Drug interaction

Potassium-sparing diuretics/potassium supplements: Increased risk of hyperkalemia NSAIDs: May reduce antihypertensive effect and increase risk of renal impairment Lithium: Increased lithium levels and toxicity risk Diuretics: Potentiated hypotensive effect, especially with initial dose Oral hypoglycemics: Enhanced hypoglycemic effect Gold injections: Nitritoid reactions (flushing, nausea, hypotension) mTOR inhibitors: Increased risk of angioedema Aliskiren: Contraindicated in diabetic patients due to increased adverse events

Missed dose

If a dose is missed, take it as soon as remembered the same day. If it is near the time for the next dose, skip the missed dose and resume the regular dosing schedule. Do not double the dose to make up for a missed dose. Maintain consistent timing of administration to ensure stable therapeutic effect. Patients should be educated on the importance of adherence to prescribed regimen for optimal blood pressure control.

Overdose

Symptoms primarily include marked hypotension, which may progress to circulatory shock. Bradycardia, electrolyte disturbances (hyperkalemia, hyponatremia), and acute renal failure may occur. Management involves supportive care with volume expansion with normal saline for hypotension. Bradycardia may require atropine administration. Hemodialysis effectively removes lisinopril from circulation and may be indicated in severe cases. Monitor serum electrolytes and renal function closely. Angiotensin II infusion may be considered for refractory hypotension.

Storage

Store at controlled room temperature (20-25°C or 68-77°F) in original container. Protect from moisture and light. Keep tightly closed. Do not remove desiccant from bottle. Keep out of reach of children and pets. Do not use beyond the expiration date printed on packaging. Properly discard any tablets that appear discolored, cracked, or otherwise compromised.

Disclaimer

This information is for educational purposes only and does not constitute medical advice. Always consult with a qualified healthcare professional before starting, changing, or discontinuing any medication. Individual response to therapy may vary. Proper diagnosis and monitoring by a physician are essential for safe and effective treatment. Not all possible uses, interactions, or adverse effects are listed here.

Reviews

Clinical trials consistently demonstrate lisinopril’s efficacy in reducing blood pressure by 8-12 mmHg systolic and 6-8 mmHg diastolic. In the SOLVD treatment trial, lisinopril reduced mortality by 16% in heart failure patients. The GISSI-3 trial showed a 11% reduction in mortality when started within 24 hours of myocardial infarction. Real-world evidence supports maintained efficacy with long-term use, though cough (ACE inhibitor-related) remains a common reason for discontinuation. Most patients tolerate therapy well with appropriate monitoring, with sustained benefits on cardiovascular outcomes over years of treatment.