ACE inhibitor start
Starting doses, titration targets, and monitoring essentials for ACE inhibitors.
Last reviewed January 5, 2026
Contraindications
- Avoid if there is prior ACE inhibitor-associated angioedema.
- Avoid in known pregnancy.
- Defer initiation during significant hypotension, volume depletion, or unresolved acute illness.
Dosing
Ramipril
- Starting dose
- 2.5 mg once daily
- Typical titration / target
- Double every 2-4 weeks to 10 mg daily
- Monitoring / notes
- Check creatinine and potassium 7-14 days after start and dose changes.
Lisinopril
- Starting dose
- 10 mg once daily
- Typical titration / target
- Titrate to 20-40 mg daily
- Monitoring / notes
- Avoid in pregnancy; watch for cough and angioedema.
Perindopril
- Starting dose
- 4 mg once daily
- Typical titration / target
- Titrate to 8 mg daily
- Monitoring / notes
- Hold during dehydration or acute illness (sick day rules).
| Medication (generic) | Starting dose | Typical titration / target | Monitoring / notes |
|---|---|---|---|
| Ramipril | 2.5 mg once daily | Double every 2-4 weeks to 10 mg daily | Check creatinine and potassium 7-14 days after start and dose changes. |
| Lisinopril | 10 mg once daily | Titrate to 20-40 mg daily | Avoid in pregnancy; watch for cough and angioedema. |
| Perindopril | 4 mg once daily | Titrate to 8 mg daily | Hold during dehydration or acute illness (sick day rules). |
Renal and hepatic considerations
- Review baseline renal function and potassium before initiation.
- Do not combine with an ARB. Reduced eGFR alone is not a reason to discontinue a tolerated ACE inhibitor; evaluate the creatinine trend, potassium, BP, and indication.
- Expect up to a 30% rise in creatinine; larger rises need reassessment.
- Use extra caution with advanced CKD, acute kidney injury risk, or concurrent nephrotoxic exposure.
Pregnancy and lactation cautions
- ACE inhibitors are contraindicated in pregnancy; stop promptly and switch to a pregnancy-compatible option if pregnancy occurs.
- Discuss contraception and preconception planning before initiation when relevant.
- During lactation, confirm agent-specific compatibility and infant monitoring requirements.
Monitoring checkpoints
- Recheck creatinine and potassium 7-14 days after initiation and after dose changes.
- Reinforce home BP monitoring and follow-up within 4-6 weeks.
- Review adverse effects (cough, dizziness, angioedema warning signs) at each contact.
Stop or escalate criteria
- Stop immediately and escalate urgently for angioedema symptoms.
- Stop and reassess if creatinine rises more than expected, clinically significant hyperkalemia develops, or symptomatic hypotension occurs.
- Escalate to specialist support when BP remains uncontrolled after sequential optimization.
References
- Hypertension Canada 2025 primary-care guideline (opens in a new tab)
- KDIGO 2024 CKD guideline executive summary (opens in a new tab)
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