Lisinopril

Without diuretics: start 10 mg once daily; usual range 20-40 mg once daily. If the effect wears off, particularly at 10 mg, evaluate blood pressure immediately before dosing and consider increasing the dose. Doses of 80 mg were used without additional benefit. Adding low-dose hydrochlorothiazide, such as 12.5 mg, has an additive effect; the lisinopril dose may then be reduced.

Stop an existing diuretic 2-3 days before initiation when possible; resume if needed for blood-pressure control. If it cannot be stopped, start 5 mg and supervise for at least 2 hours and until blood pressure has remained stable for an additional hour. Potassium supplements, potassium-containing salt substitutes and potassium-sparing diuretics may raise serum potassium.

Adjunct to diuretics and usually digoxin: start 5 mg once daily under observation, especially with systolic pressure below 100 mmHg. The peak blood-pressure effect occurs at 6-8 hours. Observe until stable; reduce the diuretic if possible when hypovolemic. Initial hypotension does not preclude careful retitration after it is treated. Usual source range: 5-20 mg daily.

For hemodynamically stable patients, initiate within 24 hours of symptoms: 5 mg initially, 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg daily for 6 weeks, with usual thrombolytic, aspirin and beta-blocker treatment.

The low-pressure initiation sentence in the source is written as systolic pressure '=120 mmHg' at initiation or during the first 3 days, with a 2.5 mg dose. Its comparison operator is not reconstructed here.

If systolic pressure is at or below 100 mmHg, use 5 mg daily, temporarily reducing to 2.5 mg if needed. Withdraw for systolic pressure at or below 90 mmHg persisting more than 1 hour.

Older adults have similar blood-pressure responses but approximately double Cmax/AUC; use cautious dose adjustment.

Hypertension, CrCl in mL/min:

• Above 30: usual initial 10 mg daily.
• 10-30: initial 5 mg daily.
• Below 10: initial 2.5 mg daily.

Titrate to blood-pressure response to a maximum of 40 mg daily in this renal table. The source associates the renal threshold with serum creatinine approximately 3 mg/dL and notes dialysis membrane-associated anaphylactoid reactions; interval and dose are determined by blood-pressure response.

Heart failure with sodium below 130 mEq/L, CrCl at or below 30, or serum creatinine above 3 mg/dL: begin 2.5 mg daily under close supervision.

Acute MI with serum creatinine above 2 mg/dL: use cautiously; severe-impairment adjustment was not studied in the source.

See the renal table and membrane-associated anaphylactoid-reaction warning above.