Angiotensin-converting enzyme (ACE) inhibitors (Formulary)

TAM (Treatments and Medicines) NHS Highland
NHS Highland
  • ACE inhibitors are recommended in proteinuric renal disease and are the treatment of choice in patients with CKD and albumin:creatinine ratio greater than 30mg/mmol irrespective of blood pressure. Avoid in renal artery stenosis.
  • Titrate ACE inhibitor doses up at regular intervals to achieve target blood pressure in hypertension; see Hypertension (Guidelines). For use in secondary prevention after TIA or ischaemic stroke refer to guidance. In patients with angina, with normal left ventricular function and with neither diabetes nor hypertension, there is little added benefit in adding an ACE inhibitor. For use in secondary prevention following myocardial infarction see guidance. On initiation consider issuing a ‘Sick day rule’ card.
  • Measure U&Es prior to initiation of ACE inhibitor, repeated 1 to 2 weeks after initiation and after dosage increase. Thereafter, monitor at least annually. Stop ACE inhibitor if potassium greater than 6·0mmol/L, or serum creatinine rises by more than 30% or eGFR falls by more than 25%. Do not increase dosage of ACE inhibitor if potassium greater than 5·0mmol/L. Consider addition of low potassium diet, correction of acidosis and use of thiazide or loop diuretic if strong indication for ACE inhibitor.
  • Concomitant treatment with NSAIDs reduces efficacy and increases the risk of renal damage and should, therefore, be avoided.  Potassium-sparing diuretics or potassium supplements increase the risk of hyperkalaemia.

LISINOPRIL - (First line)

Therapy notes

Formulation and dosage details

Formulation:

Tablets 2·5mg, 5mg, 10mg, 20mg

Dosage:

Hypertension: initially 2·5mg to 10mg once daily; maintenance 10 to 20mg once daily, maximum 80mg daily.
Heart failure: initially 2·5mg once daily;increasing in steps of up to 10mg at least every 2 weeks; maximum 35mg daily.
Prophylaxis after myocardial infarction: systolic blood pressure over 120mmHg, 5mg within 24 hours, followed by further 5mg 24 hours later, then 10mg after a further 24 hours, and continuing with 10mg once daily; systolic blood pressure 100 to 120mmHg, initially 2·5mg daily increased to maintenance dose of 5mg once daily.

PERINDOPRIL ERBUMINE

Therapy notes

Perindopril erbumine may be particularly useful where difficulties arise with ACE inhibitor initiation over a prolonged period of time and where there is a high risk of first dose hypotension.

Formulation and dosage details

Formulation:

Tablets 2mg, 4mg, 8mg (= tert-butylamine)

Dosage:

Post-TIA and ischaemic stroke refer to guidance. 
Heart failure: initial dose 2mg in the morning; usual maintenance 4mg once daily (before food).
Secondary prevention in ischaemic heart disease: initially 4mg once daily if under 70 years (2mg if over) and increase to 8mg once daily after 2 weeks if tolerated. 
Hypertension: initially 4mg once daily (before food); in older people or in renal impairment, initially 2mg once daily; usual maintenance dose 4mg once daily; maximum 8mg daily. 

RAMIPRIL

Therapy notes

Prescribe the lower cost ramipril capsules in preference to the higher cost non-Formulary tablets.

Formulation and dosage details

Formulation:

Capsules 1·25mg, 2·5mg, 5mg, 10mg

Dosage:

Hypertension: initially 1·25mg once daily, usual range 2·5 to 5mg once daily, maximum 10mg once daily.
Heart failure: initially 1·25mg once daily, increased gradually, target dose 10mg daily in 1 to 2 divided doses.
Prophylaxis after myocardial infarction: initially 2·5mg twice daily, increased after 3 days to 5mg twice daily; maintenance 2·5mg to 5mg twice daily.
Prophylaxis of cardiovascular events: initially 2·5mg once daily, increased to 5mg once daily then 10mg once daily.

Editorial Information

Document Id: F044