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Lisinopril oral

Updated 2 Feb 2023 | ACE inhibitors


Oral formulations of lisinopril as lisinopril dihydrate

Drugs List

  • lisinopril 10mg tablets
  • lisinopril 2.5mg tablets
  • lisinopril 20mg tablets
  • lisinopril 5mg tablets
  • lisinopril 5mg/5ml oral solution sugar-free
  • ZESTRIL 10mg tablets
  • ZESTRIL 20mg tablets
  • ZESTRIL 5mg tablets
  • Therapeutic Indications


    Acute myocardial infarction if given within 24 hours of onset of symptoms
    Congestive heart failure
    Diabetic nephropathy

    Unlicensed Uses



    Doses should be individualised according to patient profile and blood pressure response.


    The usual recommended starting dose is 10mg once daily.

    Patients with a strongly activated renin-angiotensin-aldosterone system (in particular, renovascular hypertension, salt and/or volume depletion, cardiac decompensation, or severe hypertension) may experience an excessive blood pressure fall following the initial dose. A starting dose of 2.5mg to 5mg is recommended in such patients and the initiation of treatment should take place under medical supervision.

    The usual effective maintenance dose is 20mg daily administered as a single daily dose. In general, if the desired therapeutic effect cannot be achieved in 2 to 4 weeks on a certain dose level, the dose can be increased.

    The recommended maximum dose is 80mg daily.

    Patients already on diuretic therapy should, if possible, have the diuretic treatment dosage lowered or discontinued at least 24 hours before starting lisinopril but may be resumed later if required. The manufacturers recommend if possible the diuretic should be discontinued 2 to 3 days before starting treatment. Therapy should be initiated at 5mg in patients where diuretic therapy cannot be suspended. Monitor renal function and serum potassium in these patients.

    Heart failure
    As an adjunct to treatment with non-potassium sparing diuretics with/without digitalis or with beta-blockers.
    To be initiated under close medical supervision.

    Initially 2.5mg daily.
    The dose may then be increased gradually (increments of no greater than 10mg at intervals of no less than 2 weeks) according to the patients response up to a maximum of 35mg daily if tolerated.

    Acute myocardial infarction
    Initial dose (first 3 days after infarction)
    Treatment may be started within 24 hours of the onset of symptoms.
    In patients with a normal blood pressure: the first dose should be 5mg, then another 5mg 24 hours after the first dose, then 10mg 48 hours after the first dose and then 10mg once daily thereafter.
    Patients with a low systolic blood pressure (100 to 120mmHg) should be initiated on 2.5mg daily, this may be increased to a maintenance dose of 5mg daily.
    Patients with systolic blood pressure below 100mmHg - do not initiate treatment.

    Maintenance dose
    10mg once daily.
    If hypotension occurs (systolic blood pressure 100mmHg or less), a daily maintenance dose of 5mg may be given with temporary reductions to 2.5mg if needed.
    If prolonged hypotension occurs (systolic blood pressure less than 90mmHg for more than one hour), therapy with lisinopril should be discontinued.
    Treatment should continue for 6 weeks then the patient should be re-evaluated. Patients who develop heart failure should continue with lisinopril.

    Diabetic nephropathy
    Initially 2.5mg to 5mg once daily, adjusted to a maintenance dose of 10mg to 20mg daily to keep diastolic blood pressure below 90mmHg.


    The recommended dose is as for adults unless there is evidence of renal impairment (See Dosage; Adults).


    Children aged over 16 years: (See Dosage; Adults).
    Children aged 6 to 16 years weighing 50kg or more: Initial dose is 5mg once daily, adjusted to a maximum of 40mg daily.
    Children aged 6 to 16 years weighing 20kg to 50kg: Initial dose is 2.5mg once daily, adjusted to a maximum of 20mg daily.
    Children aged below 6 years: Contraindicated.

    The following alternative dosing schedules may be suitable:

    Diabetic nephropathy (under specialist supervision) (unlicensed)
    Children aged 12 to 18 years: Initially 5mg once daily. The usual maintenance dose is 10mg to 20mg once daily. Maximum dose is 80mg once daily.

    Heart failure (adjunct) (under specialist supervision) (unlicensed)
    Children aged 12 to 18 years: Initially 2.5mg once daily. Increase in steps no greater than 10mg at intervals of at least 2 weeks up to maximum of 35mg once daily.

    Proteinuria in nephritis; Hypertension (under specialist supervision) (unlicensed)
    Children aged 12 to 18 years: Initially 5mg once daily. The usual maintenance dose is 10mg to 20mg once daily. Maximum dose is 80mg once daily.
    Children aged 6 to 12 years: Initially 70micrograms/kg (up to a maximum of 5mg) once daily. Increase in intervals of 1 to 2 weeks to maximum 600 micrograms/kg (or 40mg) once daily.

    Patients with Renal Impairment

    Use with caution in adult patients with a creatinine clearance below 80ml/minute.
    Starting doses:
    Patients with a creatinine clearance of 31 to 80ml/minute: 5mg to 10mg daily.
    Patients with a creatinine clearance of 10 to 30ml/minute: 2.5mg to 5mg daily.
    Patients with a creatinine clearance of less than 10ml/minute (including patients on dialysis): 2.5mg daily
    The dose may be titrated to a maximum of 40mg daily.

    The Renal Drug Handbook suggests the following:
    Glomerular filtration rate of 50ml/minute and below: Initial dose of 2.5mg daily. Titrate to response.

    Use with caution in patients with renal impairment, especially in the presence of severe congestive heart failure and renal artery stenosis, as there is an increased risk of side effects. Renal function and serum electrolytes must be monitored before and during treatment in all patients. Consult a specialist if renal dysfunction significantly decreased as a result of treatment with lisinopril. If renal dysfunction (serum creatinine exceeding 265micromol/l or a doubling from pre-treatment levels - whichever is greater) develops during treatment with lisinopril, the physician should consider withdrawal of therapy.

    Not recommended in paediatric patients with severe renal impairment (GFR below 30ml/minute/1.73 square metre) as there is inadequate data available.
    Children aged 6 to 16 years: When used to treat hypertension a lower starting dose or increased dosing interval should be considered.

    Additional Dosage Information

    Concomitant diuretics: ACE inhibitors can cause a very rapid fall in blood pressure in volume-depleted patients. Treatment should be initiated with very low doses. If the dose of diuretic is greater than 80mg furosemide daily or equivalent, the ACE inhibitor should be initiated under close supervision and in some patients the dose of diuretic may need to be reduced or the diuretic discontinued at least 24 hours beforehand (may not be possible in heart failure - risk of pulmonary oedema). The manufacturers recommend if possible the diuretic should be discontinued 2 to 3 days before starting treatment. If high-dose diuretic therapy can not be stopped, close observation is recommended for at least 2 hours or until blood pressure has stabilised.


    Children under 6 years
    Within 36 hours of discontinuing a sacubitril containing product
    Cardiogenic shock
    Haemodialysis with high flux membranes
    Haemodynamic instability
    Hereditary angioneurotic oedema
    Hypotension - if treating myocardial infarction
    Idiopathic angioneurotic oedema
    Renal artery stenosis
    Renal impairment in children under 18 years where eGFR <30ml/min/1.73m sq

    Precautions and Warnings

    Children aged 6 to 18 years
    Desensitisation therapy
    Aortic stenosis
    Cerebral ischaemia
    Collagen vascular disease
    Hypertrophic cardiomyopathy
    Ischaemic heart disease
    Left ventricular outflow obstruction
    Mitral stenosis
    Peripheral vascular disease
    Renal impairment - creatinine clearance below 80ml/min
    Renovascular disorder
    Severe renin-dependent hypertension
    Uncontrolled cardiac failure

    Adjustment of hypoglycaemic therapy may be necessary in diabetes mellitus
    Anaesthetist should be made aware patient is taking this medication
    Patients with primary aldosteronism may not benefit from this treatment
    Reduce dose in patients with creatinine clearance below 80ml/min
    Advise ability to drive/operate machinery may be affected by side effects
    Advise patient that first dose hypotension may occur
    Afro-Caribbean or black patients may show reduced response
    Correct volume and/or salt depletion before initiating therapy
    Exclude renovascular disorder before treatment
    Not all available brands are licensed for all age groups
    Place patient in supine position if severe hypotension occurs
    Evaluate renal function before and during treatment
    Monitor serum electrolytes before and during treatment
    Consider monitoring white blood cell counts in collagen vascular disease
    Monitor serum potassium regularly
    Advise patient to report symptoms of infection immediately
    Higher incidence of angioedema in black patients
    Increased risk of hyperkalaemia with K+ suppl. and K+ sparing diuretic
    Withdraw before apheresis
    Withdraw before desensitisation
    Advise patient to seek advice at first indications of pregnancy
    Discontinue if jaundice or other evidence of hepatic impairment occurs
    Discontinue if laryngeal stridor/angioedema of face/tongue or glottis
    Discontinue or reduce dose if renal impairment worsens
    Dosage must be individualised for each patient, especially children
    Not licensed for all indications in all age groups
    Advise patient not to take NSAIDs unless advised by clinician
    Hypotensive effect enhanced by alcohol
    Advise on problems of salt substitutes/high intake of potassium-rich food
    Female: Ensure adequate contraception during treatment

    Initiate treatment with caution in patients receiving diuretics.

    Renal function must be monitored before and during treatment in all patients. Although ACE inhibitors have a specialised role in the management of some forms of renal disease, they also occasionally cause impairment of renal function which may be progressive and severe. The elderly are at particular risk. If renal dysfunction (serum creatinine exceeding 265micromol/l or a doubling from pre-treatment levels - whichever is greater) develops during treatment with lisinopril, the physician should consider withdrawal of therapy. Renal failure has been associated with ACE inhibitors and has been mainly observed in patients with severe congestive heart failure or underlying renal disease including renal artery stenosis. If recognised promptly and treated, renal failure is usually reversible. Use with caution in patients with bilateral renal artery stenosis or with stenosis of an artery to a solitary functioning kidney.

    Angioedema of the extremities, face, lips, tongue, glottis and/or larynx may occur at any time during treatment with ACE inhibitors and in some cases can be fatal. In all cases, lisinopril should be discontinued promptly and appropriate treatment and monitoring instituted to ensure complete resolution of symptoms prior to dismissing the patient. Patients may require prolonged observation since treatment with antihistamines and corticosteroids may not be sufficient. Patients with a history of angioedema unrelated to ACE inhibitors may be at increased risk of angioedema while receiving an ACE inhibitor.

    Pregnancy and Lactation


    Lisinopril is contraindicated in pregnancy.

    Lisinopril is not teratogenic in mice, rats and rabbits with doses below 55, 33 and 0.15 times, respectively, the maximum recommended human daily dose. However, the use of ACE inhibitors is not recommended during the first trimester of pregnancy. Foetal exposure to lisinopril after the first trimester has been associated with teratogenicity and severe toxicity, similar to that seen with captopril and enalapril. The cause of this toxicity is thought to be due to foetal hypotension and decreased renal blood flow. Lisinopril may lead to in utero renal failure due to the prevention of conversion of angiotensin I to angiotensin II. Prolonged hypotension may follow as the primary method of removal of this drug is via the kidneys and impairment of this system in the newborn prevents elimination of the drug (Briggs, 2011).

    ACE inhibitors are contraindicated during the second and third trimesters of pregnancy as exposure during these trimesters is known to induce human foetal toxicity (renal dysfunction, oligohydramnios, pulmonary hypoplasia, patent ductus arteriosus, delay in skull ossification, hypoxia, renal tubular dysgenesis, neonatal toxicity and even death). Severe and sometimes fatal anuria in the foetus and in the newborn have been observed and is thought to be caused by the compromise of the foetal renal system. Foetal renal failure resulting from in utero exposure to ACE inhibitors has been reported where dialysis has been required shortly after birth. Evidence of a risk of teratogenicity after first trimester exposure is conflicting, however, the MHRA recommends that a risk cannot be excluded. The MHRA states that the use of ACE inhibitors in late pregnancy has been associated with adverse effects on the kidney and other congenital anomalies, therefore ACE inhibitors should not be used at any stage during of pregnancy unless absolutely necessary and only then after the potential risks and benefits have been discussed with the patient. Spontaneous abortions and premature births have also been reported following administration with ACE inhibitors.

    If exposure has occurred in the first trimester a detailed ultrasound diagnosis is advisable. Exposure to an ACE inhibitor during pregnancy is not an indication for either invasive diagnostic procedures or termination of pregnancy. In cases involving long term prenatal therapy in the second and/ or third trimesters, the foetus should be monitored for the potential development of oligohydramnios, and foetal growth should be assessed with detailed ultrasound scans (Schaefer, 2007). Infants whose mothers have taken ACE inhibitors should be closely monitored for hypotension and renal dysfunction.

    Unless treatment with an ACE inhibitor is considered absolutely essential, women who are planning to become pregnant should be switched to an alternative drug with an established safety record. Guidelines advise that women who are taking ACE for chronic hypertension in pregnancy, or are planning pregnancy, are told that there is an increased risk of congenital abnormalities if these drugs are taken and other antihypertensive treatments should be discussed and offered.

    The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( ) or if this is unavailable at the backup site ( ).


    Lisinopril is contraindicated in breastfeeding.

    It is unknown whether lisinopril is excreted in human milk, however, because of its low molecular weight its passage into breast milk should be expected. The drug is excreted in the milk of lactating rats. Hale states that no paediatric concerns have been reported following the use of lisinopril. Schaefer (2007) comments that accidental prescribing of lisinopril does not require limiting of breastfeeding but therapy should be changed. Guidelines advise that women who still need antihypertensive treatment in the post natal period are informed that there is insufficient evidence on the safety in babies receiving breast milk from a mother taking ACE inhibitors other than enalapril and captopril.

    The MHRA concludes that although ACE inhibitors are not generally recommended for use by breastfeeding mothers they are not all absolutely contraindicated and some may be prescribed if treatment is considered essential, however ACE inhibitors should not be used by breastfeeding mothers in the first few weeks after delivery because of possible profound neonatal hypotension particularly in preterm infants. The MHRA has stated that lisinopril is not recommended during breastfeeding. If ACE inhibitor therapy is considered essential for the mother the use of captopril, enalapril or quinapril may be considered when the infant is older. The infant should be carefully followed up for signs of hypotension should ACE inhibitor treatment be deemed necessary. Hale (2014) suggests that the newborn is also observed for weakness.

    Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
    Specialist advice is available from the UK Drugs in Lactation Advisory Service at

    Side Effects

    Abdominal pain
    Accelerated erythrocyte sedimentation
    Acute renal failure
    Allergic alveolitis
    Altered liver function tests
    Autoimmune disorders
    Blood urea increased
    Bone marrow depression
    Cerebrovascular accident
    Decrease in haematocrit
    Decrease in haemoglobin
    Depressive symptoms
    Dry mouth
    Eosinophilic pneumonia
    Erythema multiforme
    Haemolytic anaemia
    Hepatic failure
    Hypersensitivity reactions
    Inappropriate secretion of antidiuretic hormone
    Increase in antinuclear antibodies (ANA)
    Mood changes
    Myocardial infarction
    Olfactory senses altered
    Orthostatic hypotension
    Raynaud's phenomenon
    Renal impairment
    Serum bilirubin increased
    Serum creatinine increased
    Sleep disturbances
    Stevens-Johnson syndrome
    Taste disturbances
    Toxic epidermal necrolysis


    It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

    The following number will direct the caller to the relevant local centre (0844) 892 0111

    Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( ) or if this is unavailable at the backup site ( ).

    Further Information

    Last Full Review Date: October 2015

    Reference Sources

    Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

    Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

    Martindale: The Complete Drug Reference (online) London: Brayfield A (ed). Pharmaceutical Press Accessed on 15 October 2015.

    Medications and Mothers' Milk, Sixteenth Edition (2014) Hale, T and Rowe, H, Hale Publishing, Plano, Texas.

    Summary of Product Characteristics: Lisinopril 2.5mg tablets. Actavis UK Ltd.Revised July 2015.
    Summary of Product Characteristics: Lisinopril 5mg tablets. Actavis UK Ltd. Revised July 2015.
    Summary of Product Characteristics: Lisinopril 10mg tablets. Actavis UK Ltd. Revised July 2015.
    Summary of Product Characteristics: Lisinopril 20mg tablets. Actavis UK Ltd. Revised July 2015.

    Summary of Product Characteristics: Lisinopril 1mg/1ml tablets. Essential Pharmaceuticals Ltd. Revised July 2015.

    Summary of Product Characteristics: Zestril 2.5mg, 5mg, 10mg and 20mg tablets. AstraZeneca UK Ltd. Revised May 2015.

    The Renal Drug Handbook. Fourth Edition (2014) ed. Ashley, C and Dunleavy, A, Radcliffe Publishing Ltd, London.

    MHRA Drug Safety Update: Volume 2, Issue 10, May 2009.
    Last accessed: 15 October, 2015.

    MHRA Drug Safety Update: Volume 1, Issue 5, December 2007
    Last accessed: 15 October, 2015.

    National Institute for Health and Clinical excellence (NICE) clinical guidance 107: Hypertension in pregnancy. Issue date August 2010
    Available at:
    Last accessed: 15 October, 2015.

    NICE Evidence Services Available at: Last accessed: 25 August 2017

    US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
    Available at:
    Lisinopril. Last Revised: 7 September, 2013.
    Last accessed: 15 October, 2015.

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