ACE inhibitors · Cardiovascular
Lisinopril
Zestril® · Prinivil®(brand names vary by market)
The ACE inhibitor that needs no activation, which matters in liver failure.
Mechanism
The only common ACE inhibitor that is active as given rather than a prodrug: no hepatic conversion step between the tablet and the effect.
Open the interactive pathwayIndications
- Hypertension
- Heart failure with reduced ejection fraction
- Post myocardial infarction
- Diabetic nephropathy
Formulations
Dosing concepts
Hepatic impairment
Because it is not a prodrug, its effect does not depend on liver conversion; that is the one situation where the choice within the class is a real one.
Renal impairment
Renally cleared, so the starting dose falls as clearance does.
Concepts, not prescribing instructions. Practice numbers live in current references and local protocols.
Pharmacokinetics
- Bioavailability
- ~25%, unaffected by food
- Half-life
- ~12 h
- Elimination
- renal: Excreted unchanged; no hepatic metabolism at all
- Protein binding
- Negligible
Adverse effects
- Dry coughcommon
- Hyperkalemiacommon & serious
- Acute kidney injury when volume-depleteserious
- AngioedemaseriousHigher reported rates in patients of African ancestry.
Contraindications & precautions
Contraindications
- Pregnancy
- Prior ACE inhibitor angioedema
- Bilateral renal artery stenosis
Precautions
- Renal impairment
- Volume depletion
- Concurrent potassium-raising drugs
Interactions
- ACE inhibitors / ARBs + Potassium-sparing diuretics, K supplements, salt substitutescautionAdditive hyperkalemia, worst with renal impairment layered on top.
- ACE inhibitor / ARB + diuretic + NSAID (the 'triple whammy')avoidAcute kidney injury, classically in a dehydrated older adult who bought ibuprofen for a sore knee.
- ACE inhibitors / ARBs / thiazides + LithiumcautionLithium toxicity: tremor, confusion, ataxia, renal injury.
Monitoring
Creatinine and potassium
Baseline and after every change · 1 to 2 weeks after starting or increasing
Blood pressure
Effect
Counselling points
- Once daily, with or without food.
- Report a persistent dry cough; it is treatable by changing the drug.
- Seek urgent help for any swelling of the face, lips or tongue.
- Avoid potassium-containing salt substitutes.
Clinical pearls
- No prodrug step and no protein binding makes it the most predictable member of its class, which is why it appears so often in trials.
- Angioedema can appear after years of uneventful use. Duration of therapy is no reassurance at all.
References & review
- Lisinopril product monograph (consult the current version for your market) (monograph)
- Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed. (reference-work)
Last reviewed 2026-08-16 · jurisdiction: global · drug information changes; verify against current references before practice use.