- ACRONYMS AND DEFINITIONS
- AAP - American Academy of Pediatrics
- ACE - Angiotensin converting enzyme
- CCB - Calcium channel blockers
- GFR - Glomerular filtration rate
- HCTZ - Hydrochlorothiazide
- P = drugs with pediatric dosing
Benazepril (Lotensin®)
Dosage forms
Tablet
- 5 mg
- 10 mg
- 20 mg
- 40 mg
Dosing
Hypertension (adults)
- Starting: 10 mg once daily
- Maintenance: 20 - 40 mg/day
- Max: 80 mg/day
- Consider starting dose of 5 mg if adding to a diuretic
- May give in one or two divided doses
- May take without regard to food
Hypertension (children ≥ 6 years old)
- Dosing: 0.2 mg/kg once daily
- Max: 0.6 mg/kg (max 40 mg) once daily
- See Lotensin PI [sec 2.3] for instructions on compounding a 2 mg/ml suspension
- May take without regard to food
Kidney disease (adults)
- CrCl < 30 ml/min: recommended starting dose is 5 mg a day. Maximum dose is 40 mg a day.
Liver disease
- No dose adjustment necessary
Generic / Price
- YES/$Captopril (Capoten®)
Dosage forms
Tablet
- 12.5 mg
- 25 mg
- 50 mg
- 100 mg
Dosing
Hypertension (adults)
- Starting: 25 mg two to three times a day
- Maintenance: 25 - 150 mg two to three times a day
- Max: 450 mg/day
- Increase dose at 1 - 2 week intervals
- Take 1 hour before meals. Food decreases absorption.
Hypertension (infants)
- Starting: 0.05 mg/kg/dose
- Max: 6 mg/kg/day
- May given once daily to 4 times a day
- AAP recommended dosing [2]
- Take 1 hour before meals. Food decreases absorption.
Hypertension (children)
- Starting: 0.5 mg/kg/dose
- Max: 6 mg/kg/day
- Give in three divided doses
- AAP recommended dosing [2]
- Take 1 hour before meals. Food decreases absorption.
Heart failure (adults)
- Starting: 25 mg three times a day
- Maintenance dose: 50 - 100 mg three times a day
- Increase dose at 2 week intervals
- Take 1 hour before meals. Food decreases absorption.
Diabetic nephropathy (adults)
- Maintenance dose: 25 mg three times a day
- Take 1 hour before meals. Food decreases absorption.
Kidney disease
- For patients with significant kidney disease, start at lowest dose and titrate slowly
Liver disease
- Manufacturer makes no recommendation
Generic / Price
- YES/$-$$Enalapril | Vasotec® | Epaned®
Dosage forms
Tablet
- 2.5 mg
- 5 mg
- 10 mg
- 20 mg
Solution (Epaned®)
- 1 mg/ml
- Comes in 150 ml bottle
Dosing
Hypertension (adults)
- Starting: 5 mg once daily
- Maintenance: 10 - 40 mg/day
- Max: 40 mg/day
- Consider starting dose of 2.5 mg if adding to a diuretic
- May be given in one or two divided doses
- May take without regard to food
Hypertension (children ≥ 1 month)
- Starting: 0.08 mg/kg (max 5 mg) once daily
- Max: 0.60 mg/kg/day (max 40 mg)
- May give once daily or in two divided doses
- AAP recommended dosing [2]
- See Vasotec PI for instructions on compounding a 1 mg/ml suspension
- May take without regard to food
Heart failure (adults)
- Starting: 2.5 mg twice a day
- Maintenance: 2.5 - 20 mg twice a day
- Max: 40 mg/day
- Titrate over a period of a few days or weeks
- May take without regard to food
Asymptomatic left ventricular dysfunction (adults)
- Starting: 2.5 mg twice a day
- Target: 10 mg twice a day
- Titrate as tolerated
- May take without regard to food
Kidney disease
- CrCl ≤ 30 ml/min: recommended starting dose is 2.5 mg a day
Liver disease
- Manufacturer makes no recommendation
Generic / Price
- Tablet - YES/$
- Solution (Epaned®) - YES/$$$$
Fosinopril (Monopril®)
Dosage forms
Tablet
- 10 mg
- 20 mg
- 40 mg
Dosing
Hypertension (adults)
- Starting: 10 mg once daily
- Maintenance: 20 - 40 mg/day
- Max: 80 mg/day
- May be given in one or two divided doses
- May take without regard to food
Hypertension (children ≥ 6 years old)
- Starting: 0.1 mg/kg (max 5 mg) once daily
- Max: 40 mg/day
- AAP recommended dosing [2]
- May take without regard to food
Hypertension (children ≥ 50 kg)
- Starting: 5 mg/day
- Max: 40 mg/day
- AAP recommended dosing [2]
- May take without regard to food
Heart failure (adults)
- Starting dose: 10 mg once daily
- Maintenance: 20 - 40 mg once daily
- Max: 40 mg once daily
- May take without regard to food
Kidney disease
- No dose adjustment necessary for any degree of kidney disease
Liver disease
- Drug clearance is decreased in patients with cirrhosis. Use caution.
Generic / Price
- YES/$Lisinopril | Zestril® | Prinivil® | Qbrelis®
Dosage forms
Tablet
- 2.5 mg
- 5 mg
- 10 mg
- 20 mg
- 30 mg
- 40 mg
Solution (Qbrelis®)
- 1 mg/ml
- Comes in 150 ml bottle
Dosing
Hypertension (adults)
- Starting: 10 mg once daily
- Maintenance: 20 - 40 mg once daily
- Max: 40 mg once daily
- Lower starting doses may be appropriate in patients taking diuretics
- May take without regard to food
Hypertension (children ≥ 6 years old)
- Starting: 0.07 mg/kg (max 5 mg) once daily
- Max: 0.61 mg/kg (max 40 mg) once daily
- See Prinivil PI sec 2.5 for instructions on compounding a 1 mg/ml suspension
- May take without regard to food
Heart failure (adults)
- Starting: 5 mg once daily
- Maintenance: 5 - 40 mg once daily
- Max: 40 mg once daily
- May take without regard to food
Kidney disease
- CrCl 10 - 30 ml/min: give half the recommended starting dose
- CrCl < 10 ml/min: starting dose is 2.5 mg a day
Liver disease
- Manufacturer makes no recommendation
Generic / Price
- Tablet - YES/$
- Solution (Qbrelis®) - NO/$$$$
Moexipril (Univasc®)
Dosage forms
Tablet
- 7.5 mg
- 15 mg
Dosing
Hypertension (adults)
- Starting: 7.5 mg once daily
- Maintenance: 7.5 - 30 mg/day
- Max: 60 mg/day
- Lower starting dose may be appropriate in patients taking diuretics
- May give in one or two divided doses
- Take one hour before meals. Food decreases absorption.
Kidney disease
- CrCl ≤ 40 ml/min: starting dose is 3.75 mg a day, and maximum dose is 15 mg a day
Liver disease
- Drug clearance is decreased in patients with cirrhosis. Use caution.
Generic / Price
- YES/$Perindopril (Aceon®)
Dosage forms
Tablet
- 2 mg
- 4 mg
- 8 mg
Dosing
Hypertension (adults)
- Starting: 4 mg once daily
- Maintenance: 4 - 8 mg/day
- Max: 16 mg/day
- Lower starting doses may be appropriate in the elderly and in patients taking diuretics
- May give in one or two divided doses
- May take without regard to food
Stable coronary artery disease (adults)
- Starting: 4 mg once daily for 2 weeks
- Maintenance: 8 mg once daily
- Elderly patients should be started at 2 mg once daily
- May take without regard to food
Kidney disease
- CrCl < 30 ml/min: not recommended
- For lesser degrees of renal impairment, starting dose should be 2 mg and dose should not exceed 8 mg
Liver disease
- In patients with impaired liver function, plasma concentrations of perindoprilat (active metabolite) were about 50% higher than those observed in healthy subjects. Manufacturer makes no dosage recommendation.
Generic / Price
- YES/$Quinapril (Accupril®)
Dosage forms
Tablet
- 5 mg
- 10 mg
- 20 mg
- 40 mg
Dosing
Hypertension (adults)
- Starting: 10 - 20 mg once daily
- Maintenance: 20 - 80 mg/day
- Max: 80 mg/day
- Lower starting dose may be appropriate in patients taking diuretics
- May be given in one or two divided doses
- May take without regard to food
Hypertension (pediatric - age not specified by AAP)
- Starting: 5 mg/day
- Max: 80 mg/day
- AAP recommended dosing [2]
- May take without regard to food
Heart failure (adults)
- Starting: 5 mg twice a day
- Maintenance: 10 - 20 mg twice a day
- Increase dose at 1 week intervals
- May take without regard to food
Kidney disease (adults)
- CrCl 30 - 60 ml/min: starting dose is 5 mg a day
- CrCl 10 - 30 ml/min: starting dose is 2.5 mg a day
- CrCl < 10 ml/min: no data available to make recommendation
Liver disease
- Manufacturer makes no recommendation
Generic / Price
- YES/$Ramipril (Altace®)
Dosage forms
Tablet and capsule
- 1.25 mg
- 2.5 mg
- 5 mg
- 10 mg
Dosing
Hypertension (adults)
- Starting: 2.5 mg once daily
- Maintenance: 2.5 - 20 mg/day
- Max: 20 mg/day
- May give in one or two divided doses
- May take without regard to food
Hypertension (pediatric - age not specified by AAP)
- Starting: 1.6 mg/m2/day
- Max: 6 mg/m2/day
- AAP recommended dosing [2]
- May take without regard to food
Heart failure (adults)
- Starting: 2.5 mg twice a day
- Target: 5 mg twice a day
- Increase dose at 3 weeks intervals
- May take without regard to food
Kidney disease (adults)
- CrCl < 40 ml/min: starting dose is 1.25 mg a day. Maximum dose is 5 mg a day.
Liver disease
- Drug clearance is decreased in patients with cirrhosis. Use caution.
Generic / Price
- YES/$Trandolapril (Mavik®)
Dosage forms
Tablet
- 1 mg
- 2 mg
- 4 mg
Dosing
Hypertension (adults)
- Starting (nonblack): 1 mg once daily
- Starting (black): 2 mg once daily
- Maintenance: 2 - 4 mg/day
- Max: 8 mg/day
- Lower starting dose may be appropriate in patients taking diuretics
- May be given in one or two divided doses
- May take without regard to food
Heart failure (adults)
- Starting: 1 mg once daily
- Target: 4 mg once daily
- May take without regard to food
Kidney disease
- CrCl < 30 ml/min: starting dose is 0.5 mg a day
Liver disease
- Drug clearance is decreased in patients with liver disease
- Starting dose in patients with cirrhosis is 0.5 mg a day
Generic / Price
- YES/$- ACE INHIBITOR + HCTZ
Accuretic® | Quinaretic® (quinapril + HCTZ)
Dosage forms
Tablet
- Quinapril - HCTZ
- 10 mg - 12.5 mg
- 20 mg - 12.5 mg
- 20 mg - 25 mg
Dosing
Hypertension
- Dosing: 10/12.5 mg - 40/25 mg once daily
- Max: 40/25 mg once daily
- Increase dose at intervals of 2 - 3 weeks
- May take without regard to food
Generic / Price
- YES/$Capozide® (captopril + HCTZ)
Dosage forms
Tablet
- Captopril - HCTZ
- 25 mg - 15 mg
- 25 mg - 25 mg
- 50 mg - 15 mg
- 50 mg - 25 mg
Dosing
Hypertension
- Dosing: HCTZ 25 - 50 mg/day; Captopril 25 - 150 mg/day
- May be given once daily or in divided doses
- Take one hour before meals
Generic / Price
- YES/$Lotensin HCT® (benazepril + HCTZ)
Dosage forms
Tablet
- Benazepril - HCTZ
- 5 mg - 6.25 mg
- 10 mg - 12.5 mg
- 20 mg - 12.5 mg
- 20 mg - 25 mg
Dosing
Hypertension
- Starting: 10/12.5 mg once daily
- Maintenance: 5/6.25 - 20/25 mg once daily
- Max: 20/25 mg once daily
- Increase dose at intervals of every 2 - 3 weeks
- May take without regard to food
Generic / Price
- YES/$Monopril HCT® (fosinopril + HCTZ)
Dosage forms
Tablet
- Fosinopril - HCTZ
- 10 mg - 12.5 mg
- 20 mg - 12.5 mg
Dosing
Hypertension
- Dosing: HCTZ 12.5 - 50 mg once daily; Fosinopril 10 - 80 mg once daily
- In trials, the maximum dose used was 40/37.5 mg once daily
- May take without regard to food
Generic / Price
- YES/$Other
- On average, the effect of the combination of 10 mg of fosinopril with 12.5 mg of HCTZ was similar to the effect seen with monotherapy using either 40 mg of fosinopril or 37.5 mg of HCTZ
Uniretic® (moexipril + HCTZ)
Dosage forms
Tablet
- Moexipril - HCTZ
- 7.5 mg - 12.5 mg
- 15 mg - 12.5 mg
- 15 mg - 25 mg
Dosing
Hypertension
- Dosing: HCTZ 12.5 - 50 mg/day; Moexipril 7.5 - 30 mg/day
- May be given once daily or in divided doses
- Take one hour before a meal
Generic / Price
- YES/$Vaseretic® (enalapril + HCTZ)
Dosage forms
Tablet
- Enalapril - HCTZ
- 5 mg - 12.5 mg
- 10 mg - 25 mg
Dosing
Hypertension
- Starting: 10/25 mg/day given once daily or in two divided doses
- Max: 20/50 mg/day
- Increase dose at intervals of 2 - 3 weeks
- May take without regard to food
Generic / Price
- YES/$Zestoretic® | Prinzide® (lisinopril + HCTZ)
Dosage forms
Tablet
- Lisinopril - HCTZ
- 10 mg - 12.5 mg
- 20 mg - 12.5 mg
- 20 mg - 25 mg
Dosing
Hypertension
- Dosing: HCTZ 6.25 - 50 mg/day | Lisinopril 10 - 80 mg/day
- Typically dosed once daily
- Increase dose at intervals of 2 - 3 weeks
- May take without regard to food
Generic / Price
- YES/$- ACE INHIBITOR + CCB
Lotrel® (amlodipine + benazepril)
Dosage forms
Capsule
- Amlodipine - Benazepril
- 2.5 mg - 10 mg
- 5 mg - 10 mg
- 5 mg - 20 mg
- 5 mg - 40 mg
- 10 mg - 20 mg
- 10 mg - 40 mg
Dosing
Hypertension
- Starting: 2.5 mg/10 mg once daily
- Maintenance: 2.5 mg/10 mg - 10 mg/40 mg once daily
- Max: 10 mg/40 mg once daily
- May take without regard to food
- Antihypertensive effect typically seen within 2 weeks
Generic / Price
- YES/$Prestalia® (amlodipine + perindopril)
Dosage forms
Tablet
- Perindopril - Amlodipine
- 3.5 mg - 2.5 mg
- 7 mg - 5 mg
- 14 mg - 10 mg
Dosing
Hypertension
- Starting: 3.5 mg/2.5 mg once daily
- Maintenance: 3.5 mg/2.5 mg - 14 mg/10 mg once daily
- Max: 14 mg/10 mg once daily
- Increase dose at intervals of 1 to 2 weeks
- May take without regard to food
Generic / Price
- NO/$$$$Tarka® (verapamil ER + trandolapril)
Dosage forms
Tablet
- Trandolapril - Verapamil ER
- 2 mg - 180 mg
- 1 mg - 240 mg
- 2 mg - 240 mg
- 4 mg - 240 mg
Dosing
Hypertension
- Dosing: Trandolapril is dosed at 1 - 4 mg a day given in one or two divided doses. Verapamil ER is dosed at 120 - 480 mg a day given in one or two divided doses.
- In trials, Tarka was dosed once daily
- Take with food
Generic / Price
- YES/$-$$- Kidney disease
- While ACE inhibitors are beneficial in treating and preventing kidney disease, their inhibitory effects on the RAAS system can be detrimental when kidneys are severely compensated, leading to elevations in potassium, serum creatinine, and BUN. The risk of adverse effects depends on the degree of kidney disease and concurrent medical problems (e.g. heart failure, diabetes). To help avoid these issues, ACE inhibitors should be started at the lowest dose possible and titrated slowly in patients with significant kidney disease.
- The STOP ACEi study (N=411) published in 2022 randomized patients with GFR < 30 ml/min to discontinue or continue their ACE inhibitor or ARB. The primary outcome was GFR at 3 years. At the end of the study, there was no significant difference in GFR between the groups (discontinue - 12.6 ml/min, continue - 13.3 ml/min, p=0.42). End-stage kidney disease or the initiation of renal replacement therapy occurred in 62% of discontinue patients and 56% of continue patients (HR 1.28, 95%CI [0.99 - 1.65]) [PMID 36326117].
- Benazepril (Lotensin®)
- CrCl < 30 ml/min: recommended starting dose is 5 mg a day. Maximum dose is 40 mg a day.
- Captopril (Capoten®)
- For patients with significant kidney disease, start at lowest dose and titrate slowly
- Enalapril (Vasotec®)
- CrCl ≤ 30 ml/min: recommended starting dose is 2.5 mg a day
- Fosinopril (Monopril®)
- No dose adjustment necessary for any degree of kidney disease
- Lisinopril (Zestril®, Prinivil®)
- CrCl 10 - 30 ml/min: give half the recommended starting dose
- CrCl < 10 ml/min: starting dose is 2.5 mg a day
- Moexipril (Univasc®)
- CrCl ≤ 40 ml/min: starting dose is 3.75 mg a day, and maximum dose is 15 mg a day
- Perindopril (Aceon®)
- CrCl < 30 ml/min: not recommended
- For lesser degrees of renal impairment, starting dose should be 2 mg and dose should not exceed 8 mg
- Quinapril (Accupril®)
- CrCl 30 - 60 ml/min: starting dose is 5 mg a day
- CrCl 10 - 30 ml/min: starting dose is 2.5 mg a day
- CrCl < 10 ml/min: no data available to make recommendation
- Ramipril (Altace®)
- CrCl < 40 ml/min: starting dose is 1.25 mg a day. Maximum dose is 5 mg a day.
- Trandolapril (Mavik®)
- CrCl < 30 ml/min: starting dose is 0.5 mg a day
- Liver disease dosing
- Benazepril (Lotensin®)
- No dose adjustment necessary
- Captopril (Capoten®)
- Manufacturer makes no specific recommendation
- Enalapril (Vasotec®)
- Manufacturer makes no specific recommendation
- Fosinopril (Monopril®)
- Drug clearance is decreased in patients with cirrhosis
- Use with caution in these patients
- Manufacturer makes no specific dosage recommendation
- Lisinopril (Zestril®, Prinivil®)
- Manufacturer makes no specific recommendation
- Moexipril (Univasc®)
- Drug clearance is decreased in patients with cirrhosis
- Use with caution in these patients
- Manufacturer makes no specific dosage recommendation
- Perindopril (Aceon®)
- In patients with impaired liver function, plasma concentrations of perindoprilat (active metabolite) were about 50% higher than those observed in healthy subjects
- Manufacturer makes no specific dosage recommendation
- Quinapril (Accupril®)
- Manufacturer makes no specific recommendation
- Ramipril (Altace®)
- Drug clearance is decreased in patients with cirrhosis
- Use with caution in these patients
- Manufacturer makes no specific dosage recommendation
- Trandolapril (Mavik®)
- Drug clearance is decreased in patients with liver disease
- Starting dose in patients with cirrhosis is 0.5 mg a day
- DRUG INTERACTIONS
- NOTE: The drug interactions presented here are NOT all-inclusive. Other interactions may exist. Drug interaction checkers provide the most efficient and practical way to check for interactions among multiple medications. A free interaction checker is available from Drugs.com (see Drugs.com interactions checker).
- All ACE inhibitors
- ARBs - see combining ARBs and ACE inhibitors
- Aliskiren (Tekturna®) - Aliskiren should not be prescribed with ACE inhibitors in patients with diabetes or decreased kidney function (GFR<60 ml/min)
- Diabetes medications - in rare cases, ACE inhibitors have been reported to potentiate the effects of diabetes medications. Diabetics should monitor for hypoglycemia when starting an ACE inhibitor.
- Lithium - ACE inhibitors can increase lithium levels. This combination should be avoided, or lithium levels should be checked frequently if they are taken together.
- Medications that can raise potassium levels - ACE inhibitors may raise potassium levels and cause hyperkalemia. When taken with other potassium-raising medications, the risk is increased. While it is often appropriate to combine ACE inhibitors with other potassium-raising drugs, patients and providers should be aware of the potential risks. See RAAS inhibitor-induced hyperkalemia for recommendations on addressing hyperkalemia in ACE inhibitor-treated patients.
- Examples of medications that may raise potassium levels include:
- Aldosterone antagonists (spironolactone and eplerenone)
- ARBs (valsartan, olmesartan, etc.)
- Aliskiren (Tekturna®)
- Cyclosporine (Neoral®)
- ENaC inhibitors (triamterene, amiloride)
- Finerenone (Kerendia®)
- Heparin - heparin raises potassium secondarily by inhibiting aldosterone synthesis. LMWH does not appear to have the same effect. [4]
- Penicillin G potassium injection (1 million units contains 1.68mEq of potassium)
- Potassium supplements (K-Dur®, etc)
- Tacrolimus (Prograf®)
- Trimethoprim (part of Bactrim® and Septra®)
- Voclosporin (Lupkynis®)
- mTOR inhibitors (e.g., temsirolimus, sirolimus, everolimus) - the risk of angioedema may be higher in patients taking ACE inhibitors with mTOR inhibitors
- Neprilysin inhibitors (e.g. Entresto®) - do not administer an ACE inhibitor within 36 hours of a neprilysin inhibitor. The combination may increase the risk of angioedema.
- NSAIDS (Advil®, Aleve®, ibuprofen, etc.) - NSAIDS and COX-2 inhibitors can attenuate the effect of ACE inhibitors. This is more of a concern if NSAIDS are to be taken chronically on a regular basis. (see aspirin and ace inhibitors below)
- Salt substitutes (No-Salt®, etc.) - Salt substitutes typically contain a high amount of potassium (16.4 mEq per 1/4 teaspoon). Since ACE inhibitors can raise potassium levels, caution should be used when consuming salt substitutes.
- Fosinopril (Monopril®)
- Antacids (Tums®, Maalox®, etc.) - Antacids decrease the absorption of fosinopril. Fosinopril and antacid dosing should be separated by two hours.
- Quinapril (Accupril®)
- Tetracyclines - quinapril tablets have a significant amount of magnesium. Magnesium can block tetracycline absorption. Tetracycline should be taken 1-2 hours prior to, or 4 hours after quinapril.
- Metabolism and clearance
- Only enalapril undergoes significant liver metabolism
- Enalapril (Vasotec®)
- CYP3A4 - substrate
- Captopril (Capoten®)
- P-glycoprotein - substrate
- PRICE ($) INFO
Pricing legend
- $ = 0 - $50
- $$ = $51 - $100
- $$$ = $101 - $150
- $$$$ = > $150
- Pricing based on one month of therapy at standard dosing in an adult
- Pricing based on information from GoodRX.com®
- Pricing may vary by region and availability
- BIBLIOGRAPHY
- 1 - Manufacturer's Package Insert for each drug listed
- 2 - PMID 28827377 - Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, Pediatrics (2017)
- 3 - PMID 17398202
- 4 - PMID 22560830 - Use and safety of unfractionated heparin for anticoagulation during maintenance hemodialysis, Am J Kidney Dis (2021)