ACE Inhibitors and Antipsychotic Medications: Drug Interactions

Clinical Management Recommendations

The American Heart Association recommends monitoring blood pressure, including orthostatic measurements, at baseline, after initiating either medication, after dose increases, and periodically during maintenance therapy, as well as assessing volume status before initiating ACE inhibitors, in patients taking antipsychotics and ACE inhibitors 1
The American College of Cardiology suggests starting ACE inhibitors at low doses (e.g., captopril 6.25 mg three times daily, enalapril 2.5 mg twice daily, lisinopril 2.5-5 mg once daily) when used with antipsychotics, and titrating gradually to target doses used in clinical trials, monitoring for hypotension at each step 1, 2

The European Society of Cardiology notes that ACE inhibitors remain first-line therapy for heart failure with reduced ejection fraction, even in patients taking antipsychotics, and that the cardiovascular benefits of ACE inhibitors in appropriate indications outweigh the interaction risks when properly managed 1, 3, 4, 5
The American Heart Association recommends considering the use of high-potency antipsychotics, such as risperidone, to minimize additive hypotensive effects when combining with ACE inhibitors 1