Lisinopril: clinical use

Prescribing considerations

• Assess volume depletion, hypotension, renal impairment, renovascular disease and concomitant diuretic or potassium-raising therapy before initiation.
• Use particular caution with haemodynamically significant aortic or mitral stenosis, hypertrophic cardiomyopathy, severe or unstable heart failure and recent kidney transplantation.
• Renal elimination is reduced in kidney impairment; prescribing must be individualised to renal function and clinical response.
• Explain that angioedema may first occur after months or years of apparently uneventful ACE-inhibitor use.

Contraindications and cautions

• Hypersensitivity to lisinopril, an excipient or another ACE inhibitor.
• Previous ACE-inhibitor-associated angioedema, or hereditary or idiopathic angioedema.
• Second or third trimester of pregnancy.
• Concurrent sacubitril/valsartan treatment or failure to observe its required washout period.
• Concurrent aliskiren in diabetes or renal impairment below the product-specific GFR threshold.

Monitoring

• Before treatment: blood pressure, eGFR or serum creatinine, potassium and sodium.
• Recheck blood pressure, renal function and electrolytes after initiation or changes, with earlier review for higher-risk patients.
• Repeat assessment during acute illness or whenever renal perfusion may be compromised.
• Once stable, continue periodic renal function and electrolyte monitoring according to indication, comorbidity and interacting medicines.

Clinical pharmacology

Lisinopril is an active, non-prodrug ACE inhibitor. It lowers angiotensin II and aldosterone activity, is not metabolised and is eliminated unchanged in urine. Renal impairment increases exposure; haemodialysis can remove it.

Formulation and product differences

• Selected Zestril tablets are uncoated; only the scored lowest-strength tablet is documented as divisible into equal parts.
• The selected oral solution is clear, colourless and orange-flavoured, with a graduated oral syringe.
• The oral solution contains parabens that may cause delayed allergic reactions and is essentially sodium-free.
• Store the selected oral solution below 25°C and use within 30 days after opening; selected tablets should not be stored above 30°C.

Oral solution

Route: Oral

Strengths: 1 mg/mL

Tablet

Route: Oral

Strengths: 2.5 mg, 5 mg, 10 mg, 20 mg