ACE Inhibitor Comparison Table

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

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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