Angiotensin converting enzyme inhibitors to reduce blood pressure

For general information about drugs used for blood pressure (BP) reduction, and starting and adjusting drug therapy, see Approach to drug therapy for blood pressure reduction.

Angiotensin converting enzyme inhibitors (ACEIs) are particularly useful in patients with elevated BP who also have heart failure with reduced ejection fraction (HFrEF) or kidney disease (especially diabetic nephropathy). They should not be used in patients with bilateral renal artery stenosis.

ACEIs are usually well tolerated, but sensitivity to ACEIs is more likely in patients taking high-dose diuretics, patients with hyponatraemia or renovascular hypertension, and in older patients. Consider starting at a lower dose or increasing the dosing interval in these patients.

Angioedema is an infrequent adverse effect of ACEIs; avoid ACEIs in patients with a history of angioedema.

Monitor patients taking ACEI therapy for hypotension, kidney impairment and hyperkalaemia. A small rise in serum creatinine (up to 25%) or serum potassium (within the normal range) can occur when drug therapy is started or doses are increased. This may be transient and should not necessarily prompt dose reduction or cessation of the ACEI; consider the clinical context of these changes (eg whether they have occurred in isolation, or if other signs or symptoms are present)

The combination of an ACEI or angiotensin II receptor blocker (ARB), a diuretic and an NSAID (including selective cyclo-oxygenase-2 [COX-2] inhibitors)—the ‘triple whammy’—can cause acute kidney injury. Avoid this combination, especially in patients with pre-existing kidney disease or dehydration, and in older patients.

Start ACEI therapy with a low to moderate dose and increase slowly as required. Suitable dose ranges for a patient with uncomplicated elevated BP are:

A lower starting dose than listed above is appropriate in some patients, such as older patients and patients with reduced kidney or liver function.