Key takeaways:
Angiotensin-converting enzyme (ACE) inhibitors are a common type of blood pressure medication. They’re also used to treat other conditions like heart failure. Examples of ACE inhibitors include lisinopril (Zestril) and benazepril (Lotensin).
ACE inhibitors are generally considered similarly effective and cause similar side effects.
Don’t stop taking your ACE inhibitor without talking to your medical care team. Stopping an ACE inhibitor can cause dangerous side effects, like increased blood pressure.
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Angiotensin-converting enzyme (ACE) inhibitors are medications that treat high blood pressure (hypertension) and other medical conditions. The generic names of oral ACE inhibitors end in “-pril,” making them easy to recognize. Lisinopril (Zestril, Qbrelis) is one example. Here, we’ll cover exactly what an ACE inhibitor is and eight important facts you should know if you take one of these medications.
What is an ACE inhibitor?
ACE inhibitors are a group of blood pressure medications. But ACE inhibitors are used for more than just hypertension. We’ll cover several of their uses in the next section. Examples of oral ACE inhibitors include:
Lisinopril
Benazepril (Lotensin)
Enalapril (Vasotec)
Captopril
Fosinopril
Quinapril
Ramipril (Altace)
Moexipril
Trandolapril
How do ACE inhibitors work?
ACE inhibitors work by targeting the body’s renin-angiotensin-aldosterone (RAAS) system. More specifically, they prevent the formation of angiotensin II.
Angiotensin II is a protein that causes blood vessels to constrict (tighten), which can cause high blood pressure and other health problems. ACE inhibitors decrease blood pressure by lowering angiotensin II levels, which helps relax the blood vessels.
1. ACE inhibitors treat more than just hypertension
ACE inhibitors are FDA approved to treat hypertension. But several ACE inhibitors are also approved for other reasons, including:
Heart failure: When taken in combination with other medications, ACE inhibitors can reduce the risk of death from heart failure for some people.
After a heart attack: ACE inhibitors can reduce the risk of death in people who’ve recently had a heart attack.
To reduce the risk of heart attack, stroke, or death related to a cardiac event: ACE inhibitors can reduce the risk of these events in people who have certain health conditions like diabetes, hypertension, or high cholesterol.
Kidney problems: ACE inhibitors are first-choice options to treat kidney problems caused by diabetes (diabetic nephropathy).
Even if an ACE inhibitor isn’t FDA approved for a particular condition, it might still be prescribed “off-label.” This is when a medication is prescribed for a purpose that it isn’t FDA approved for.
Usually, there’s some research showing that the medication is effective in treating the specific condition. For example, captopril is the only ACE inhibitor that’s approved to treat diabetic nephropathy. But several other ACE inhibitors are prescribed for this as well.
2. Not all ACE inhibitors are taken the same way
Most ACE inhibitors are taken by mouth. But some are taken once a day while others may be taken as often as 3 times a day.
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This is because some ACE inhibitors don’t last as long in the body as others. For example, captopril is usually taken 2 to 3 times a day because it leaves the body more quickly than other ACE inhibitors. But some medications like lisinopril are usually only taken once daily. Other ACE inhibitors, such as benazepril and enalapril, are taken 1 to 2 times a day.
If you’re prescribed an ACE inhibitor, make sure you closely follow your prescriber’s instructions on how to take it. For example, captopril should be taken on an empty stomach at least 1 hour before a meal. Taking captopril with food can decrease its absorption and cause it not to work as well. Other ACE inhibitors, such as lisinopril, aren’t typically affected by food and can be taken without regard to meals.
3. ACE inhibitors are usually considered similarly effective
Whether one ACE inhibitor is best for you depends on what health condition you’re treating, your medical history, and other personal factors.
Overall, one ACE inhibitor isn’t better than another. Though some ACE inhibitors have been studied more than others, this doesn’t necessarily make one ACE inhibitor preferable over another.
When deciding which ACE inhibitor is best for you, your prescriber may consider factors such as:
Dosing frequency: If you prefer to only take one dose of your ACE inhibitor per day, lisinopril or benazepril may be a good option.
Formulations: If you have trouble swallowing pills, an ACE inhibitor that comes as an oral liquid (like lisinopril or enalapril) may be best.
Other health issues you have: Many ACE inhibitors are processed in the liver, which helps them start working. But lisinopril and captopril are exceptions. They don’t require liver involvement, so they may be better options for people with liver problems.
4. Don’t stop taking an ACE inhibitor without talking to your healthcare provider
If you’re interested in stopping your ACE inhibitor, talk to your medical care team first. Stopping an ACE inhibitor can cause your blood pressure to increase. And some research has shown that it can increase the risk of death.
But there are some situations where stopping your ACE inhibitor may be necessary. It’s rare but possible to develop kidney problems after taking an ACE inhibitor. Sometimes you may need to stop treatment to prevent long-term damage. But you should always talk to your prescriber first.
5. You could develop a cough, but there are other medication options if you do
A dry cough is one of the most common ACE inhibitor side effects. This may be a result of ACE inhibitors causing two proteins — bradykinin and substance P — to build up in the body. Higher levels of these proteins cause the airway to tighten and can lead to a dry, persistent cough.
You can develop a dry cough at any time after starting an ACE inhibitor. It’s not necessarily dangerous, but it can be bothersome. A dry cough caused by ACE inhibitors may improve over time, even if you continue taking the medication. But it could take several weeks to months. In other cases, the only way to make the cough go away is to stop your ACE inhibitor.
Let your prescriber know if you experience a dry cough while taking an ACE inhibitor. They may recommend that you try a different medication. A common alternative to ACE inhibitors are angiotensin II receptor blockers (ARBs) like losartan (Cozaar) and valsartan (Diovan). ARBs work similarly to ACE inhibitors, but they’re much less likely to cause a cough.
6. ACE inhibitors can cause some rare but serious side effects
ACE inhibitors are usually well-tolerated. More common (but mild) side effects include dizziness and the dry cough discussed above. But some people may experience more serious side effects. These are rare, but they may warrant emergency care.
Angioedema is one of the most serious ACE inhibitor side effects. This is swelling of the face, lips, and tongue that can be life-threatening if not treated. Some people, including Black people women, and smokers, may be more likely to develop angioedema. And if you have a history of hereditary or idiopathic angioedema, you should avoid taking ACE inhibitors.
Another potentially serious side effect of ACE inhibitors is high potassium levels (hyperkalemia). Hyperkalemia is often mild, but it can be severe if your potassium is extremely high. This can lead to an abnormal heart rhythm (arrhythmia). Your prescriber will monitor your potassium levels while you’re taking an ACE inhibitor. So be sure to stay on top of your regular appointments.
7. ACE inhibitors have possible drug interactions
Taking ACE inhibitors can result in a wide range of drug interactions. So, before you start taking an ACE inhibitor, give your prescriber and pharmacist a list of all the medications and supplements you take. This will help them check for interactions.
While this isn’t a comprehensive list, ACE inhibitors can interact with:
ARBs: Taking ARBs with ACE inhibitors increases the risk of side effects. That’s also true for Entresto (sacubitril / valsartan), which contains an ARB (valsartan).
Aliskiren (Tekturna): This medication should be avoided when taking an ACE inhibitor, especially in people who have diabetes or moderate to severe kidney disease.
Thiazide and loop diuretics: When taken with ACE inhibitors, diuretics (“water pills”) may cause blood pressure to fall too low. This includes thiazides like hydrochlorothiazide (Microzide) and loop diuretics like furosemide (Lasix).
Potassium-sparing diuretics: This type of diuretic, which includes spironolactone (Aldactone), can increase potassium levels. Your prescriber may monitor your potassium levels more closely if you take these medications.
Nonsteroidal anti-inflammatory drugs (NSAIDs): These pain relievers, such as ibuprofen (Advil, Motrin), can be hard on your kidneys. Negative kidney effects may be more likely when you combine ACE inhibitors and NSAIDs.
8. Don’t take an ACE inhibitor if you’re pregnant
If you’re pregnant or trying to become pregnant, you shouldn’t take an ACE inhibitor. All ACE inhibitors carry a boxed warning — the FDA’s strictest warning for medications — for their potential to cause harm to a fetus when used during pregnancy.
Let your prescriber know immediately if you’re planning to become pregnant, or you become pregnant, while taking an ACE inhibitor. They’ll likely recommend switching to a different blood pressure medication.
The bottom line
Angiotensin-converting enzyme (ACE) inhibitors are used to treat high blood pressure (hypertension) and heart failure. They’re also recommended after a heart attack to lower the risk of death. Additionally, they have several off-label uses. Individual ACE inhibitors are generally considered similarly effective and have similar side effects. So one usually isn’t preferred over another.
ACE inhibitors are typically well-tolerated. But side effects, such as dry cough and dizziness, can happen. These are usually mild. More seriously, angioedema or extremely high potassium levels (hyperkalemia) can occur. These severe side effects require emergency care.
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References
Berkey, F. J., et al. (2021). Does the risk of ACE-I–induced angioedema differ between Black and non-Black patients. Evidence-Based Practice.
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de Boer, I. H., et al. (2022). KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney International.
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