ACE Inhibitor Comparison Table – Med Ed 101

ACE Inhibitors have been a workhorse in managing blood pressure for years. While lisinopril is the most commonly used agent that I see in practice, I thought it would be helpful to put together an ACE Inhibitor Comparison table to share with the audience and highlight some important differences. If you’d like more information on ACE inhibitors and lisinopril in general, check out this podcast episode.

HTN Dosing Indications Half-Life Elimination Miscellaneous
Lisinopril 20-40mg/day HTN, HF, Post-STEMI; Off-label: Migraine ppx, NSTEMI ACS, Proteinuric CKD, nephropathy, Posttransplant erythrocytosis 12 hours Renal Available in combination with HCTZ
Enalapril 5-40mg/day HTN, HF, Post-STEMI; Off-label: Migraine ppx, NSTEMI ACS, Proteinuric CKD, nephropathy, Posttransplant erythrocytosis 2-11 hours Primarily Renal and significant fecal QD-BID dosing

Available in combination with HCTZ

Ramipril 2.5-20mg/day HTN, CV risk reduction, HF; Off-label: STEMI and NSTEMI ACS, proteinuric CKD, nephropathy 13-17 hours Primarily Renal and significant fecal QD or BID dosing
Captopril 25-150mg TID HTN, HF, Post-MI ACS, diabetic nephropathy; Off-label: primary aldosteronism 2 hours Renal AE: Altered sense of taste

BID-TID dosing

Available in combination with HCTZ

Benazepril 20-40mg/day HTN 10-11 hours Renal Available in combination with amlodipine, HCTZ
Perindopril 4-16mg QD HTN, Stable coronary artery disease; Off-label: HFrEF 30-120 hours Renal Available in combination with amlodipine
Quinapril 20-80mg QD HTN, HFrEF 3 hours Renal Available in combination with HCTZ
Fosinopril 10-40mg QD HTN, HFrEF; Off-label: HIV associated nephropathy 12 hours Renal and fecal Available in combination with HCTZ
Trandolapril 2-4mg QD HTN, Post-MI HF/LVD; Off-label: HFrEF 6-10 hours Primarily fecal and significant renal Available in combination with verapamil
Moexipril 7.5-30mg/day HTN 1.5-10 hours Primarily fecal and minor renal QD-BID dosing

Available in combination with HCTZ

ACE Inhibitor Comparison Table

Half-Life Differences of ACE Inhibitors

The first major difference is half-life and how that relates to the frequency of dosing. A medication like captopril has a very short half-life and needs to be dosed multiple times per day. This is not good when talking about a medication that a patient is likely going to be taking for years. The shorter the half-life the more likely we are to encounter blood pressure fluctuations as well.

Adverse Effects

In general, the ACE inhibitors have very little variation in adverse effects. Cough, hyperkalemia, renal impairment, and angioedema are the most commonly associated adverse effects and the ones you are likely to see on your board exams and in practice. The one unique adverse effect that occurs with captopril and generally not with other ACE Inhibitors is taste alterations.

Elimination

ACE Inhibitors are primarily eliminated one of two ways. In the ACE Inhibitor Comparison Chart above, you can see these drugs can be eliminated in the urine (renal) or in the feces. What is very nice about ACE inhibitors is that we don’t typically need to worry about metabolic breakdown and interactions through CYP enzymes.

This table was put together by Amy Van Loon, PharmD Candidate.

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  • September 18, 2023