ACE inhibitor Pregnancy: eMC §4.6: ACE inhibitors are not recommended in the first trimester and are contraindicated in the second and third trimesters of pregnancy. Exposure in the second and third trimesters is known to cause human foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia). Patients planning pregnancy should be switched to an alternative antihypertensive with an established pregnancy safety profile; stop immediately when pregnancy is diagnosed. Breast-feeding: not recommended — no information available; alternatives with better established safety are preferable, especially with a newborn or preterm infant.

Lisinopril

Brand names: Zestril, Carace

Used in: Hypertension

Lisinopril is a long-acting angiotensin-converting enzyme (ACE) inhibitor used for hypertension, heart failure, after myocardial infarction and to slow progression of diabetic nephropathy.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Hypertension: usual starting dose 10 mg once daily; usual effective maintenance dose 20 mg once daily

Route: Oral

Frequency: Once daily, at approximately the same time each day (absorption is not affected by food)

Max: 80 mg/day was the maximum dose used in long-term controlled clinical trials (hypertension). Heart failure: maximum 35 mg once daily. Renal impairment: titrate upward to a maximum of 40 mg daily.

Dose must be individualised to patient profile and blood pressure response. HYPERTENSION: patients with a strongly activated renin-angiotensin-aldosterone system (renovascular hypertension, salt/volume depletion, cardiac decompensation, severe hypertension) may have an excessive fall in BP after the first dose — start at 2.5-5 mg under medical supervision. If the desired effect is not achieved in 2-4 weeks the dose may be increased further. DIURETIC-TREATED PATIENTS: if possible stop the diuretic 2-3 days before starting; if it cannot be stopped, initiate lisinopril at 5 mg and monitor renal function and serum potassium. HEART FAILURE (adjunct to diuretics and, where appropriate, digitalis or beta-blockers): start 2.5 mg once daily under medical supervision, increase by increments of no more than 10 mg at intervals of no less than 2 weeks to the highest tolerated dose, maximum 35 mg once daily. ACUTE MYOCARDIAL INFARCTION: may be started within 24 hours of symptom onset; do not start if systolic BP is below 100 mmHg. First dose 5 mg orally, then 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg once daily; if systolic BP is 120 mmHg or less at initiation or during the first 3 days give a lower dose of 2.5 mg orally. Maintenance 10 mg once daily; if hypotension occurs (systolic BP 100 mmHg or less) a daily maintenance dose of 5 mg may be given with temporary reduction to 2.5 mg if needed; withdraw if systolic BP stays below 90 mmHg for more than 1 hour. Continue treatment for 6 weeks then re-evaluate; patients who develop heart failure symptoms should continue. RENAL COMPLICATIONS OF TYPE 2 DIABETES (hypertensive patients with incipient nephropathy): 10 mg once daily, increased to 20 mg once daily if needed to achieve sitting diastolic BP below 90 mmHg. PAEDIATRIC: the SPC gives a weight-banded hypertension regimen for children aged 6-16 years with a lower starting dose or increased dosing interval where renal function is decreased, and states doses above 0.61 mg/kg (or in excess of 40 mg) have not been studied — verify against a children's formulary before prescribing to under-18s. NOTE: comparator symbols (< / >) were lost in the source text extraction — verify all thresholds against the current SPC.

Dose adjustments

Renal

eMC §4.2 Table 1 — starting dose based on creatinine clearance: less than 10 ml/min (including patients on dialysis) 2.5 mg/day; 10-30 ml/min 2.5-5 mg/day; 31-80 ml/min 5-10 mg/day. Dosage and/or frequency should be adjusted to blood-pressure response and may be titrated upward until blood pressure is controlled, to a maximum of 40 mg daily. In acute MI and in diabetic nephropathy with renal impairment (creatinine clearance below 80 ml/min), the initial dose should be adjusted per Table 1.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to lisinopril, to any of the excipients, or to any other ACE inhibitor
History of angioedema associated with previous ACE inhibitor therapy
Hereditary or idiopathic angioedema
Concomitant use with sacubitril/valsartan — must not be initiated earlier than 36 hours after the last dose of sacubitril/valsartan
Second and third trimesters of pregnancy
Concomitant use with aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR below 60 ml/min/1.73 m2)

Side effects

Dizziness and headache — common
Cough — common; rhinitis uncommon
Orthostatic effects including hypotension — common
Diarrhoea and vomiting — common; nausea, abdominal pain and indigestion uncommon
Renal dysfunction — common; hyperkalaemia and increases in blood urea, serum creatinine and liver enzymes — uncommon
Angioedema of the face, extremities, lips, tongue, glottis and/or larynx — rare
Rash and pruritus — uncommon

Interactions

Sacubitril/valsartan (neprilysin inhibitor) — contraindicated; observe a 36-hour washout in either direction (eMC §4.3)
Aliskiren-containing products — contraindicated in diabetes mellitus or renal impairment (eMC §4.3)
Diuretics — risk of symptomatic hypotension on initiation; stop the diuretic 2-3 days beforehand if possible or start lisinopril at 5 mg with close supervision; monitor renal function and serum potassium (eMC §4.2; openFDA Drug Interactions)
NSAIDs including selective COX-2 inhibitors — in elderly, volume-depleted or renally impaired patients, co-administration may cause deterioration of renal function including acute renal failure (usually reversible) (openFDA Drug Interactions)
Other antihypertensive agents — additive blood-pressure lowering effect

Clinical monograph

How it works

It inhibits ACE, reducing conversion of angiotensin I to the vasoconstrictor angiotensin II and decreasing aldosterone secretion, which lowers vascular resistance and reduces sodium and water retention.

Prescribing in practice

It is contraindicated in pregnancy and in anyone with a history of ACE-inhibitor-associated angioedema, which can be life-threatening if it affects the airway.
First-dose hypotension can occur, especially in volume-depleted patients or those on high-dose diuretics, so initiation should be cautious in these groups.
It can cause hyperkalaemia and a persistent dry cough, the latter being a common reason for switching to an ARB.

Monitoring

Check renal function and serum potassium before starting and after initiation or dose increase, and monitor blood pressure for response.

Counselling the patient

Stop the medicine and seek urgent help if your lips, tongue, face or throat swell.
A persistent dry cough is a known side effect; tell your doctor if it is troublesome.
Do not take this medicine if you are or could become pregnant.

Evidence & guidelines

ACE inhibitors such as lisinopril are recommended first-line in NICE guidance for hypertension in younger or diabetic patients and for heart failure with reduced ejection fraction, with mortality benefit shown across major heart-failure and post-infarction trials.

Reference: NICE NG136/NG106; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways