Lisinopril

Class
Antihypertensives
Subclass
Angiotensin-converting enzyme inhibitors
Substance name
Lisinopril sodium
Brand names
Zestril®
Common formulations
Tablet
Contained in
Lisinopril / hydrochlorothiazide (Zestoretic®)
Dosage and administration
Adults patients
Treatment
Hypertension
•
Start at: 10 mg PO daily
•
Maintenance: 20-40 mg PO daily
•
Maximum: 80 mg per day
Alternative
•
Start at: 5 mg PO daily
•
Maintenance: 20-40 mg PO daily
•
Maximum: 80 mg per day
Administered in combination with diuretics.
Myocardial infarction • Acute management, hemodynamically stable
•
Start at: 5 mg PO daily within 24 hours of symptoms onset and continued for 2 days
•
Maintenance: 10 mg PO daily for at least 6 weeks
CKD in patients without diabetes mellitus • Off-label
•
10-40 mg PO daily
Diabetic nephropathy • Off-label
•
10-40 mg PO daily
Posttransplant erythrocytosis • Off-label
•
5-10 mg PO daily
Adjunctive treatment
Adjunctive treatment for HF
•
Start at: 5 mg PO daily
•
Maintenance: 5-40 mg PO daily
•
Maximum: 40 mg per day
Administered in combination with diuretics and usually digoxin.
Prevention
Prevention of migraine attacks • Off-label
•
10-25 mg PO daily
Indications for use
Labeled indications
Adults
•
Treatment of hypertension
•
Treatment of myocardial infarction (acute management, hemodynamically stable)
•
Adjunctive treatment for HF
Children
•
Treatment of hypertension (in patients ≥ 6 years)
Off-label indications
Adults
•
Treatment of CKD in patients without diabetes mellitus
•
Treatment of diabetic nephropathy
•
Treatment of posttransplant erythrocytosis
•
Prevention of migraine attacks
Safety risks
Boxed warnings
Fetal toxicity
•
Do not use in pregnant patients. Discontinue lisinopril as soon as possible when pregnancy is detected.
Contraindications
Hypersensitivity to lisinopril or its components
History of ACEi-induced angioedema, hereditary angioedema, or idiopathic angioedema
Concomitant use of aliskiren in patients with diabetes
Warnings and precautions
ACE inhibitor-induced angioedema
•
Use caution in patients taking mTOR inhibitors.
ALF
•
Maintain a high level of suspicion, as an increased incidence has been reported in patients receiving lisinopril.
Anaphylactoid reactions
•
Use caution in patients on hemodialysis with high-flux membranes, desensitizing treatment with hymenoptera venom, or LDL apheresis with dextran sulfate absorption.
Hypotension
•
Use caution in patients with HF with SBP < 100 mmHg, ischemic heart disease, severe aortic stenosis, HCM, cerebrovascular disease, hyponatremia, renal dialysis, severe volume and/or salt depletion of any etiology, or taking high-dose diuretic therapy.
•
Use caution in patients undergoing major surgery or anesthesia with agents producing hypotension.
Increased serum potassium
•
Use caution in patients with renal insufficiency, diabetes mellitus, or taking potassium-sparing diuretics, potassium supplements, and/or potassium-containing salt substitutes.
Renal failure
•
Use caution in patients with renal artery stenosis, CKD, severe congestive HF, post-myocardial infarction, or volume depletion.
Specific populations
Renal impairment
CrCl > 30 mL/min
•
Use acceptable. No dose adjustment required.
CrCl 10-30 mL/min
•
Start at dose of 2.5-5 mg. Titrate to a maximum of 40 mg/day.
CrCl < 10 mL/min
•
Start at dose of 2.5 mg.
Renal replacement therapy
Continuous renal replacement
•
No guidance available.
Intermittent hemodialysis
•
Dose as in CrCl < 10 mL/min.
Peritoneal dialysis
•
Dose as in CrCl < 10 mL/min.
Hepatic impairment
Any severity
•
Use acceptable. No dose adjustment required.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: D
•
Do not use. Evidence of fetal harm in humans. Discontinue lisinopril when pregnancy is detected.
•
Use of RAAS inhibitors during the second and third trimesters can cause reduced fetal renal function leading to anuria and renal failure, oligohydramnios, fetal lung hypoplasia, and skeletal deformations, including skull hypoplasia, hypotension, and death.
Breastfeeding
Use only if benefits outweigh potential risks.
Unknown amount excreted in breastmilk.
Unknown drug levels in breastfed infants.
Adverse reactions
Very common > 10%
•
Hypotension, dizziness
Common 1-10%
•
Ascites, ↓ WBC count, ↓ blood neutrophil count, ↓ platelet count, diabetes mellitus, diaphoresis, erectile dysfunction, gout, hemolytic anemia, ↑ WBC count, ↑ serum potassium, orthostatic hypotension, photosensitivity of skin, renal failure, arthralgia, asthenia, blurred vision, chest pain, constipation, cough, diarrhea, diplopia, dry mouth, dysgeusia, fatigue, fever, flatulence, hair loss, headache, myalgia, paresthesia, photophobia, pruritus, skin flushing, skin rash, syncope, tinnitus, vertigo, visual disturbances, syndrome of inappropriate antidiuretic hormone secretion, skin erythema, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria
Unknown frequency
•
Acute liver failure, acute pancreatitis, angioedema, ↓ blood glucose, ↓ serum sodium, ↑ BUN, ↑ blood eosinophil count, ↑ liver enzymes, jaundice, liver necrosis, confusion, depression, low urine output, vasculitis
Interactions
Drug(s)
Check Interactions
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