====== Fosinopril ======

Fosinopril is a long-acting ACE inhibitor used in hypertension and heart failure.

It is unique among ACE inhibitors because it undergoes both hepatic and renal elimination.

Class:
→ [[cardio:raas:acei|ACE Inhibitors]]

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===== Mechanism of Action =====

• Inhibits Angiotensin-Converting Enzyme (ACE)
• ↓ Angiotensin II
• ↓ Aldosterone
• ↑ Bradykinin

Net Effects:
• ↓ Systemic vascular resistance
• ↓ Blood pressure
• ↓ Ventricular remodeling
• ↓ Sodium retention

Mechanism identical to other ACE inhibitors.

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===== Unique Features =====

• Prodrug → converted to fosinoprilat
• Dual elimination (hepatic + renal)
• Less dose adjustment required in mild-to-moderate renal impairment compared to other ACE inhibitors

This dual clearance is its major distinguishing feature.

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===== Indications =====

==== Hypertension ====
• Effective once-daily ACE inhibitor

→ [[cardio:hypertension:start|Hypertension Module]]

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==== Heart Failure (HFrEF) ====
• Mortality benefit expected as class effect
• Used similarly to other ACE inhibitors

→ [[cardio:heart_failure:start|Heart Failure Module]]

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===== Dosing =====

Hypertension:
• Start: 10 mg once daily
• Usual range: 10–40 mg once daily
• Max: 40 mg daily

Heart Failure:
• Start: 5–10 mg once daily
• Titrate as tolerated

Once-daily dosing.

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===== Pharmacokinetics =====

• Prodrug → activated in liver
• Eliminated via both liver and kidneys
• Half-life ~12 hours

Because of dual clearance, less accumulation in isolated renal impairment compared to purely renally cleared ACE inhibitors.

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===== Adverse Effects =====

Class Effects:
• Dry cough
• Hyperkalemia
• Hypotension
• Angioedema (rare)
• Mild creatinine elevation

No major differences in side-effect profile.

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===== Monitoring =====

Monitor:
• Serum creatinine
• Potassium

Recheck labs 1–2 weeks after initiation or dose change.

Mild creatinine increase (<30%) is expected.

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===== Contraindications =====

• Pregnancy
• History of ACE inhibitor–induced angioedema
• Bilateral renal artery stenosis

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===== Clinical Pearls =====

✔ Unique dual hepatic + renal elimination  
✔ Useful when renal function is reduced  
✔ Once-daily dosing  
✔ No proven superiority over other ACE inhibitors  
✔ Monitor potassium and renal function  

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Related:

→ [[cardio:raas:acei|ACE Inhibitors]]
→ [[cardio:raas:lisinopril|Lisinopril]]
→ [[cardio:heart_failure:start|Heart Failure Module]]
→ [[cardio:start|Return to CV Modules]]