Here in this blog, we will discuss one of the ACE inhibitors, known as lisinopril: an antihypertensive, ACE inhibitor drug commonly sold by the brand names Prinivil, Qbrelis, or Zestril.
Nurses should not confuse lisinopril with fosinopril, Prinivil with Plendil, Pravachol, Prevacid, Prilosec, Proventil, or Restoril, or Zestril with Desyrel, Restoril, Vistaril, Zetia, or Zostrix. Also, do not confuse lisinoprils combination from Zestoretic with Prilosec. Before administering the drug, counter-check to ensure you are giving the right drug.
Lisinopril comes as a combination with a diuretic to lower blood pressure in the form of lisinopril/ hydrochlorothiazide (Prinzide/Zestoretic) in the dosage 10 millirams (mg)/12.5 mg, 20 mg/12.5 mg, and 20 mg/25 mg respectively.
Indications of Lisinopril
Lisinopril is used to lower high blood pressure not well controlled by other drugs. It treats hypertension in adults and children older than six years. Lisinopril is also used as an adjunctive therapy to reduce the signs and symptoms of systolic heart failure. It is also given in the treatment of acute myocardial infarction within 24 hours in hemodynamically stable patients to improve survival.
Lisinopril is available as an oral solution under the brand name Qbrelis in 1 mg/milliliter (ml) and tablets in 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, and 40 mg strengths.
Contraindications and Precautions
Lisinopril use is contraindicated in patients hypersensitive to it or other ACE inhibitors, having a history of angioedema with ACE inhibitors or idiopathic or hereditary angioedema, concomitant use with aliskiren in patients with diabetes, or co-administration with or within 36 hours of switching to or from a neprilysin inhibitor such as sacubitril.
Lisinopril has a black box warning during pregnancy as it can harm the fetus. Its use should be stopped as soon as the pregnancy is known because it can cause fetal injury and mortality.
Lisinopril should be used with caution in patients with renal impairment, unstented unilateral or bilateral renal artery stenosis, volume depletion, ischemic heart disease, cerebrovascular disease, severe aortic stenosis, hypertrophic cardiomyopathy, heart failure, systolic blood pressure less than 100 millimeters of mercury (mmHg), patients dependent on dialysis, hyponatremia, during or immediately after major surgery and with concomitant use of potassium supplements.
Action
Lisinopril is a competitive inhibitor of angiotensin-converting enzymes. It prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. It may inhibit angiotensin II at local vascular and renal sites, decrease plasma angiotensin II, increase plasma renin activity, and decrease aldosterone secretion, hence lowering blood pressure.
When given orally, the onset of lisinopril tablets occurs in a maximum of one hour, reaches the peak in six hours, has a duration of action of 24 hours, and is incompletely absorbed from the gastrointestinal tract. Lisinopril has a 25% protein binding and is excreted primarily through urine, unchanged, or removed by hemodialysis. Moreover, it has a half-life of 12 hours and is increased in patients with renal impairment.
Interactions
Lisinopril can interact with some drugs. With aliskiren, the hyperkalemic effects may be increased, resulting in hyperkalemia. Therefore, dose adjustment is necessary when lisinopril and aliskiren are given together. Moreover, keep an eye on the patients serum potassium levels.
Lisinopril may increase the potential for allergic reactions to allopurinol and increase the adverse effects of angiotensin receptor blockers, such as losartan, valsartan, or telmisartan, and others such as lithium and sacubitril.
Herbal preparations with hypertensive effects, such as licorice and yohimbine, and hypotensive effects, such as garlic, ginger, and ginkgo biloba, may alter the effects of lisinopril. Therefore, their concomitant administration should be avoided.
Lisinopril may increase serum blood urea nitrogen (BUN), alkaline phosphatase, bilirubin, creatinine, potassium, alanine transaminase (ALT), and aspartate aminotransferase (AST) levels and decrease serum sodium. It may also cause a positive antinuclear antibodies (ANA) titer.
Dosage of Lisinopril
Lisinopril is initially given as 2.5 to 10 mg once daily to treat hypertension in older adults. Evaluate response every 4-6 weeks and titrate the dose in one-step increments. For example, increase the daily dose by doubling it and then monitor the blood pressure. Lisinopril can be given up to 40 mg once daily to older adults.
For children over six years of age or older, the initial dose of lisinopril is 0.07 mg/kilogram (kg) once daily and can be given up to a maximum of 5 mg. Titrate the dose every 1-2 weeks. The maximum dose is 0.6 mg/kg/day or 40 mg/day.
For heart failure, the dose of lisinopril for adults and the elderly is initially 2.5 to 5 mg/day, which could be increased by no more than 10 mg/day at intervals of at least two weeks to a target dose of 20 to 40 mg once daily.
For acute myocardial infarction, lisinopril is given to improve survival in older adults in a dose of 2.5 to 5 mg initially. Then, titrate slowly to 10 mg/day or higher if tolerated.
When creatinine clearance is less than 30 ml/minute in patients with renal impairment, titrate to the patients need, depending on blood pressure control, and avoid the use in children. For hypertension in renal-impaired patients, the initial dose is 5 mg when creatinine clearance is 10 to 30 ml/minute and 2.5 mg when the creatinine clearance is less than 10 ml/minute or the patient is dialysis dependent.
The initial dose of lisinopril is 2.5 mg in patients with heart failure who have creatinine clearance less than 30ml/min or serum creatinine clearance greater than 3 mg/dL.
For acute myocardial infarction, the initial dose of lisinopril is 2.5 mg when the creatinine clearance is less than 30 ml/min.
Side Effects
Lisinopril's common side effects include headache, dizziness, and postural hypotension. Occasional side effects include chest discomfort, fatigue, rash, abdominal pain, nausea, diarrhea, upper respiratory infection, palpitations, tachycardia, peripheral edema, insomnia, paresthesia, confusion, constipation, dry mouth, and muscle cramps.
A common and bothersome side effect of lisinopril is a cough that occurs because of the accumulation of substances P and bradykinin. If your patient complains of a dry, lingering cough, you may need to change their blood pressure medication. Often, angiotensin receptor blockers help lower high blood pressure.
Adverse Effects
The adverse or toxic effects of lisinopril include excessive hypotension or first-dose syncope, especially in patients with heart failure or severe salt or volume depletion, angioedema, and hyperkalemia. In patients with collagen vascular disease such as scleroderma or systemic lupus erythematosus, it can cause agranulocytosis and neutropenia. Patients with a history of renal disease may develop nephrotic syndrome with lisinopril therapy.
Nursing Considerations
With lisinopril therapy, the following nursing considerations should be kept in mind.
Baseline Assessment
Before starting lisinopril, obtain a basic metabolic panel, especially serum BUN, creatinine, sodium, potassium, glomerular filtration rate (GFR), and creatinine clearance. Moreover, blood pressure and apical pulse should be obtained before each dose in addition to regular monitoring. Be alert to fluctuations and manage accordingly.
In patients with renal impairment, autoimmune disease, or those taking drugs that affect leukocytes or immune response, complete blood count and differential counts should be obtained before starting therapy and every 2-3 weeks after starting therapy.
Take the patient's complete medical history. Remember to ask about the history of aortic stenosis, cardiac disease, and renal impairment or stenosis.
Intervention and Evaluation
When the therapy has started, monitor blood pressure, renal function tests, white blood cells (WBCs), and serum potassium. If any of these parameters deviate from the normal, inform the physician promptly.
Assess the patient for edema and auscultate the lungs for rales. Monitor input and output and check the patients weight daily with lisinopril therapy. Also, keep an eye on daily patterns of bowel activity and stool consistency. If dizziness occurs, help the patient ambulate. Moreover, if excessive blood pressure reduction occurs, place the patient in the supine position, with feet slightly elevated.
Patient and Family Teaching
Teaching patients and their caregivers to take special care with lisinopril therapy is essential, as the drug can lower blood pressure. Tell the following points to them:
To combat the hypotensive effects of lisinopril, slowly move from lying to standing. Getting into a sitting position from lying and then standing is better. Make sure you are slow in your movement. Standing up fast from a lying position can lead to severe orthostatic hypotension, causing dizziness and vision blackout.
Limit alcohol intake, as it can negate the effects of lisinopril, leading to poor blood pressure control. Make sure to report to the emergency room if you have diarrhea, vomiting, diaphoresis, swelling of lips, face, and tongue, or difficulty breathing with a persistent cough. These symptoms can indicate anaphylaxis, a life-threatening condition.
Limit salt intake, as it can increase blood pressure and may not let lisinopril control it well. Make sure to drink plenty of water and keep yourself hydrated. Report to your physician if a decrease in urinary output or dark-colored urine occurs with swelling of hands and feet.
The Bottom Line
Lisinopril is an essential ACE inhibitor that helps keep blood pressure under control, preventing heart attacks and strokes. In some cases, it might need to be changed with other drugs because of the persistent dry cough it causes as a side effect.
Compel your patients to attend their follow-up visits with their provider, monitor their blood pressure, and report to the emergency room if their blood pressure is higher than 120/80 mmHg.
About the Author:
Mariya Rizwan is an experienced pharmacist who has been working as a medical writer for four years. Her passion lies in crafting articles on topics ranging from Pharmacology, General Medicine, Pathology to Pharmacognosy.
Mariya is an independent contributor to CEUfast's Nursing Blog Program. Please note that the views, thoughts, and opinions expressed in this blog post are solely of the independent contributor and do not necessarily represent those of CEUfast. This blog post is not medical advice. Always consult with your personal healthcare provider for any health-related questions or concerns.
If you want to learn more about CEUfasts Nursing Blog Program or would like to submit a blog post for consideration, please visit https://ceufast.com/blog/submissions.
