Pharmacologic, Pharmacokinetic, and Therapeutic Differences among ACE Inhibitors

Angiotensin-converting enzyme (ACE) inhibitors are a heterogeneous group of agents, and important pharmacologic, pharmacokinetic, and therapeutic differences among them must be understood to obtain optimal therapy. For patients with severe liver disease, lisinopril and captopril are not prodrugs (e.g., do not require hepatic activation), and lisinopril has almost solely renal elimination. Enalaprilat, the intravenous formulation of enalapril, is the only intravenously available ACE inhibitor and can be given to patients with severe liver dysfunction as it is also not a prodrug. Fosinopril is the only drug with compensatory dual routes of elimination, and it does not require dosage adjustment in patients with reduced renal function, as other ACE inhibitors do. Captopril and moexipril have potential drug-food interactions and are the only agents that should be spaced from meals. The ACE inhibitors also differ in their dialyzability, half-life, lipophilicity, trough:peak ratios, approved indications, and therapeutic information available for many indications.