ACE-I / ARB Equivalent Doses
Cross-convert ACE inhibitors and angiotensin-receptor blockers with HF target-dose flags.
- Switching a patient from an ACE-I to an ARB after cough or angioedema
- Cross-mapping a home agent to one on the inpatient formulary
- Reconciling a HFrEF patient's outpatient dose against guideline-directed targets
- Sanity-checking that an "every other day" dose ordered for AKI matches what was intended
- Lisinopril, enalapril, captopril, ramipril are most common in the US; ramipril and perindopril dominate elsewhere. Cross-conversions trip people up at international transitions of care.
- HFrEF target doses are not the same as HTN target doses. A patient on 10 mg lisinopril for blood pressure is at half the HFrEF target — uptitrate when tolerated.
- Don't combine ACE-I + ARB. ONTARGET buried that idea; the only narrow exception is some proteinuric CKD on a renal protocol, and even there it has fallen out of favor.
- Cough swap. ACE-I cough resolves within 1–4 weeks of stopping. Switching to losartan or another ARB at an equivalent dose typically resolves it without losing renoprotective / cardiovascular benefit.
- Angioedema swap is more cautious. ARBs have lower angioedema risk but it is not zero — many clinicians monitor closely or avoid altogether after a serious ACE-I event.
- Renal dose check. Lisinopril, enalapril, perindopril require renal-dose adjustment in advanced CKD; ARBs vary.
ACE/ARB conversions are routine at every transition of care. The error mode isn't usually mathematical — it's substituting at "BP-equivalent" dose when the indication is actually heart failure, and stopping there instead of titrating to target.
| Lisinopril | 20mg/day | daily | HF target 40 mg |
| Enalapril | 20mg/day | BID | HF target 40 mg |
| Ramipril | 10mg/day | daily–BID | HF target 10 mg |
| Captopril | 100mg/day | TID | HF target 150 mg |
| Benazepril | 20mg/day | daily | |
| Perindopril | 8mg/day | daily | HF target 8 mg |
| Losartan | 50mg/day | daily–BID | HF target 150 mg |
| Valsartan | 160mg/day | daily–BID | HF target 320 mg |
| Telmisartan | 80mg/day | daily | |
| Candesartan | 16mg/day | daily | HF target 32 mg |
| Irbesartan | 300mg/day | daily | |
| Olmesartan | 40mg/day | daily |
ACE-I and ARB are not interchangeable
- ACE-I cause cough (~10%) and angioedema (rare but life-threatening); ARBs largely do not.
- Do not combine ACE-I + ARB except in unusual circumstances — increased risk of AKI and hyperkalemia without mortality benefit (ONTARGET).
- For HFrEF, ARNI (sacubitril/valsartan) is now preferred over ACE-I/ARB monotherapy when tolerated (PIONEER-HF, PARADIGM-HF).
- HF target doses (shown when applicable) come from trial-validated regimens — uptitrate slowly.
Frequently asked
What is the equivalent dose of losartan to lisinopril?
A common conversion is lisinopril 20 mg/day ≈ losartan 50 mg/day for blood pressure. The equivalency is approximate — individual responses vary, and ARBs and ACE-Is are not pharmacologically identical. After a switch for ACE-I cough, BP is typically rechecked and titrated within 1–2 weeks.
Is enalapril 10 mg the same as lisinopril 10 mg?
For total daily dose, roughly yes — lisinopril 20 mg/day ≈ enalapril 20 mg/day total. But enalapril is dosed BID (10 mg twice daily) while lisinopril is once daily. The PK profiles differ; substituting mg-for-mg without changing the schedule produces peak / trough variability the once-daily formulation avoids.
Should I switch my patient from an ACE-I to an ARB if they get a cough?
Yes — ACE-I cough resolves with discontinuation, and ARBs do not produce the same cough because they do not raise bradykinin. A standard equivalent ARB dose is appropriate. Monitor potassium and creatinine after the switch as you would for any RAAS change.
Can I combine an ACE-I and an ARB?
Generally no. ONTARGET (NEJM 2008) showed no mortality benefit from the combination but a substantial increase in hyperkalemia, hypotension, and AKI. Combination therapy has been removed from major HF and HTN guidelines except in very narrow circumstances under specialist management.
What is the heart-failure target dose for lisinopril?
The ATLAS trial used 32.5–35 mg/day (rounded to 40 mg in practice) as the high-dose target — substantially higher than typical antihypertensive doses. Under-dosing in HFrEF is one of the most common reasons patients fail to achieve trial-level mortality benefit.
Should I switch a HFrEF patient on lisinopril to ARNI?
If they tolerate ACE-I or ARB and have HFrEF (LVEF ≤40%), yes — current AHA/ACC/HFSA HF guidelines recommend ARNI (sacubitril/valsartan) over ACE-I/ARB monotherapy for HFrEF when tolerated. Wait at least 36 hours after the last ACE-I dose before starting sacubitril/valsartan to avoid angioedema.