What is ?
Lisinopril is one of the most widely prescribed medications in the United States, belonging to a class of drugs called ACE inhibitors (angiotensin-converting enzyme inhibitors). It is primarily used to treat high blood pressure and heart failure, and to improve survival after heart attack.
How Does Lisinopril Work?
Lisinopril works by inhibiting the angiotensin-converting enzyme (ACE):
- Blocks conversion of angiotensin I to angiotensin II
- Prevents blood vessels from constricting
- Lowers blood pressure
- Reduces workload on the heart
- Decreases aldosterone secretion (reduces fluid retention)
- Protects kidneys, especially in diabetic patients
- Prevents harmful remodeling of the heart after injury
- Increases bradykinin levels (contributes to blood vessel relaxation but also causes cough)
Common Uses
Hypertension:
- First-line treatment for high blood pressure
- Effective as monotherapy or in combination
- Reduces risk of stroke, heart attack, and kidney disease
Heart Failure:
- Improves symptoms and reduces hospitalizations
- Increases survival
- Reduces progression of heart failure
- Usually combined with beta-blockers and diuretics
Post-Myocardial Infarction:
- Improves survival when started within 24 hours of heart attack
- Prevents adverse cardiac remodeling
- Reduces recurrent events
Kidney Protection
Diabetic Nephropathy:
- Slows progression of kidney disease in diabetic patients
- Reduces proteinuria (protein in urine)
- First-line therapy for kidney protection
Chronic Kidney Disease:
- Provides renoprotection regardless of diabetes status
- Slows decline in kidney function
Dosage and Administration
Lisinopril dosing varies by indication:
For Hypertension:
- Starting dose: 10 mg once daily
- Usual dose: 10-40 mg once daily
- Maximum: 80 mg daily
For Heart Failure:
- Starting dose: 2.5-5 mg once daily
- Target dose: 20-40 mg once daily
- Increase gradually as tolerated
For Post-MI:
- Starting dose: 5 mg within 24 hours, then 5 mg after 24 hours, then 10 mg after 48 hours
- Maintenance: 10 mg once daily
Administration Tips:
- Take once daily, preferably at the same time
- Can be taken with or without food
- Continue taking even if you feel well
- May take 2-4 weeks for full blood pressure effect
- Do not stop suddenly without medical advice
Important Safety Information
Who Should Not Take Lisinopril?
Avoid lisinopril if you:
- Are allergic to lisinopril or other ACE inhibitors
- Have a history of angioedema (with or without ACE inhibitor use)
- Are pregnant (especially 2nd and 3rd trimesters)
- Are taking aliskiren and have diabetes
- Have bilateral renal artery stenosis
The Dry Cough
One of the most common and bothersome side effects of lisinopril is a persistent dry cough, occurring in 10-20% of patients:
Characteristics:
- Dry, tickling, nonproductive cough
- Can occur within days or months of starting
- More common in women
- Not dangerous but can be very annoying
- Does not respond to cough suppressants
- Only cure is switching to a different medication class (usually an ARB)
When to Consider Switching:
- If cough significantly affects quality of life
- If cough persists and is bothersome
- ARBs (like losartan) provide similar benefits without causing cough
Drug Interactions
Important interactions include:
Medications Increasing Potassium:
- Potassium supplements
- Salt substitutes (contain potassium)
- Potassium-sparing diuretics (spironolactone, triamterene)
- ARBs (if combined)
- NSAIDs
Other Important Interactions:
- NSAIDs (ibuprofen, naproxen) - reduce effectiveness, increase kidney damage risk
- Diuretics - may cause excessive blood pressure drop
- Lithium - may increase lithium levels
- Aliskiren - avoid in diabetics or kidney disease
- Diabetes medications - may enhance blood sugar lowering
Pregnancy and Breastfeeding
⚠️ CRITICAL WARNING: ACE inhibitors like lisinopril can cause serious harm or death to an unborn baby if taken during the second or third trimester. If you become pregnant, stop lisinopril immediately and contact your doctor.
Pregnancy:
- Contraindicated, especially 2nd and 3rd trimesters
- Can cause kidney damage, low amniotic fluid, skull defects, death in developing fetus
- Use effective contraception if of childbearing potential
Breastfeeding:
- Present in breast milk in small amounts
- Generally considered compatible but discuss with doctor
- Monitor infant for signs of low blood pressure
Monitoring and Follow-Up
Regular monitoring is essential:
Blood Pressure:
- Check regularly at home if possible
- Target varies by individual (typically <130/80 mmHg)
Kidney Function:
- Creatinine and BUN before starting
- Recheck 1-2 weeks after starting or dose increase
- Small increase in creatinine (up to 30%) is expected and acceptable
- Monitor periodically during treatment
Potassium Levels:
- Check before starting
- Recheck 1-2 weeks after starting
- Monitor periodically, especially if risk factors present
- Target: 3.5-5.0 mEq/L
Electrolytes:
- Comprehensive metabolic panel periodically
Managing Side Effects
Dizziness and Low Blood Pressure
- Most common when starting or increasing dose
- Rise slowly from sitting or lying positions
- Stay hydrated
- Avoid alcohol
- Usually improves with time
- May need dose adjustment
Dry Cough
- Very common (10-20% of patients)
- Usually develops within first few months
- Can try continuing (sometimes improves)
- If persistent and bothersome, discuss switching to ARB
- Not dangerous, just annoying
High Potassium
- Avoid potassium supplements unless prescribed
- Limit high-potassium foods if levels elevated
- Avoid salt substitutes (contain potassium)
- More common with kidney disease, diabetes, or when combined with certain medications
First-Dose Effect
Some patients experience significant blood pressure drop with the first dose, especially if:
- Taking high-dose diuretics
- Salt-depleted or dehydrated
- Heart failure
- Elderly
Precautions:
- First dose may be given at bedtime
- Ensure adequate hydration
- Sit or lie down if dizzy
- Usually resolves with subsequent doses
Special Populations
Kidney Disease:
- Dose adjustment may be needed for severe impairment
- Provides kidney protection
- Monitor kidney function closely
- Small increase in creatinine expected and acceptable
Elderly:
- Start with lower doses
- More prone to dizziness and falls
- Monitor kidney function closely
Black Patients:
- May be less effective as monotherapy for blood pressure
- Very effective when combined with thiazide diuretic
- Still beneficial for heart failure and post-MI
Diabetics:
- Provides excellent kidney protection
- May improve insulin sensitivity
- Monitor potassium closely
Angioedema Risk
Angioedema is a rare but serious side effect:
What is it?
- Swelling of deeper layers of skin
- Most commonly affects face, lips, tongue, throat
- Can be life-threatening if airway involved
Risk Factors:
- History of angioedema (any cause)
- Black race (higher risk)
- Smoking
- Female gender
Action:
- Stop lisinopril immediately
- Seek emergency medical attention
- Never restart ACE inhibitor
- Usually switch to ARB (lower but still present risk)
Lifestyle Considerations
To maximize benefits of lisinopril:
- Follow heart-healthy DASH diet
- Reduce sodium intake (<2,300 mg daily, ideally <1,500 mg)
- Maintain healthy weight
- Exercise regularly (150 minutes/week moderate activity)
- Limit alcohol
- Don't smoke
- Manage stress
- Take medication consistently
- Monitor blood pressure at home
- Avoid NSAIDs when possible
When to Contact Your Doctor
Seek immediate medical attention if you experience:
- Swelling of face, lips, tongue, or throat
- Difficulty breathing or swallowing
- Severe dizziness or fainting
- Chest pain
- Irregular heartbeat
- Signs of high potassium (muscle weakness, slow heartbeat, tingling)
- Signs of kidney problems (decreased urination, swelling, fatigue)
- Severe allergic reaction
Contact your doctor for non-emergency issues:
- Persistent dry cough affecting quality of life
- Ongoing dizziness
- Fatigue or weakness
- Questions about blood pressure readings
- Planning pregnancy
- New medications from another doctor
- Scheduled surgery or dental work
Clinical Benefits
Extensive research demonstrates that lisinopril:
- Reduces risk of stroke by 30-40%
- Decreases heart attack risk by 20-25%
- Improves survival in heart failure by 20-30%
- Slows progression of diabetic kidney disease by 50%
- Reduces heart failure hospitalizations by 20%
- Improves survival after heart attack by 10-15%
- Provides cardiovascular protection beyond blood pressure lowering
Combination Therapy
Lisinopril is often combined with:
- Hydrochlorothiazide (HCTZ): Available as combination pill (Zestoretic, Prinzide) - enhances blood pressure control
- Amlodipine: Calcium channel blocker for additional blood pressure lowering
- Beta-blockers: For heart failure or post-MI
- Diuretics: For fluid management
Storage
Store lisinopril at room temperature (68-77°F/20-25°C) away from moisture, heat, and light. Keep in original container. Protect from excessive humidity. Keep out of reach of children.
Cost and Availability
Lisinopril is available as an affordable generic medication and is on most $4 generic medication lists. It is one of the most cost-effective antihypertensive medications available and is covered by virtually all insurance plans.
Important Reminders
- Take every day, even if you feel well (high blood pressure has no symptoms)
- Don't stop suddenly without medical advice
- Notify all healthcare providers that you take lisinopril
- Carry medical information card
- Avoid pregnancy while taking lisinopril
- Report persistent dry cough
- Monitor blood pressure at home
- Attend regular follow-up appointments
Disclaimer: This information is for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Always consult your physician or other qualified healthcare provider with any questions about a medical condition or medication.