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Introduction
This article provides a step-by-step approach to counselling a patient on angiotensin-converting enzyme (ACE) inhibitors in an OSCE setting.
Opening the consultation
Wash your hands and don PPE if required.
Introduce yourself including your name and role.
Confirm the patient’s name and date of birth.
Explain the reason for the consultation: “Today, I’d like to talk to you about a medication called angiotensin-converting enzyme inhibitors, also known as ACE inhibitors. Would that be okay?”
It is important to establish good rapport and an open line of communication: “If you have any questions at any point, or if something is not clear, please feel free to interrupt and ask me.”
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to ask questions (this is often referred to as ‘chunking and checking’).
Ideas, concerns and expectations
A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can provide insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
It can sometimes be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three areas below.
Ideas
- “Have you heard of ACE inhibitors before?”
- “What do you know about ACE inhibitors?”
- “Do you know the reasons why people may take an ACE inhibitor?”
Concerns
- “Do you have any particular worries about starting an ACE inhibitor?”
Expectations
- “Is there anything in particular you hoped we would cover today relating to ACE inhibitors?”
Patient history
Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focused history early in the consultation.
This should include exploration of the patient’s symptoms and management of their condition, including trials of previous medications and their impact, compliance and adverse effects.
Understanding the patient’s care so far will help you tailor any advice and personalise the information for their specific situation.
Contraindications
Review the patient’s medical history to identify any contraindications, and medication history to identify potential interactions that may prohibit the use of ACE inhibitors.
ACE inhibitors prevent efferent vasoconstriction, a homeostatic mechanism that maintains renal perfusion, and should therefore be avoided in patients with severe bilateral renal artery stenosis (or severe stenosis of the artery supplying a single functioning kidney).1 Due to their effect on renal function, it is important to monitor urea and electrolytes (U&Es) before starting treatment.
As ACE inhibitors reduce systemic blood pressure, caution should be exercised when also taking other antihypertensive agents or if the patient already has systemic hypotension.
Sodium and potassium concentrations may be affected, so caution should also be taken in patients with hyponatraemia or those taking drugs that may cause hyperkalaemia.2-3
What are ACE inhibitors and when are they used?
ACE inhibitors are medications that affect the renin-angiotensin system, which has roles in heart failure, hypertension, nephropathy and secondary prevention of cardiovascular disease.
Commonly used ACE inhibitors include ramipril, lisinopril, enalapril, captopril, quinapril and fosinopril.2
Their mode of action involves preventing the conversion of angiotensin I to angiotensin II, thereby reducing the action of angiotensin II on the type 1 and 2 angiotensin II receptors. ACE inhibitors also inhibit the breakdown of the vasodilator bradykinin.
This leads to a reduction in sympathetic activation of the cardiovascular system, causing reduced vasoconstriction and reduced sodium and water retention. Cardiac cell growth triggered by angiotensin II, which can lead to heart remodelling, is also reduced.1, 4
Example
“ACE inhibitors are a type of medication that can be used to lower blood pressure. They work by widening the blood vessels and reducing the amount of salt and water in the body. In addition to lowering blood pressure, they also have a benefit for long-term heart and kidney health.”
How to take ACE inhibitors
Overview
ACE inhibitors are most commonly available in tablet or capsule form, but can also be found in liquid form.
They are typically prescribed as a once-a-day dose, however, to increase tolerability, this can be split into two divided doses.2
The starting and maximum doses of ACE inhibitors are generally different. The starting doses tend to differ by indication and the specific medication (e.g. ramipril 1.25 mg – 2.5 mg), although the majority of patients will begin with a low dose and titrate to effect.
For hypertension, this would be until a target blood pressure is reached (unless already at the maximum licensed dose), but for most other indications, the intention is to increase to the maximum tolerated dose.2-3, 5
Missed dose
If a dose is missed, the patient should take it as soon as they remember. However, if it is the next day, the missed dose should be skipped.
Only the prescribed total daily dose should be taken, as taking more would increase the risk of hypotension and kidney injury.
Sick day rules
The impact of ACE inhibitors on renal function is most significant in those with reduced renal perfusion, which can occur transiently with illnesses such as infectious gastroenteritis.
Therefore, it is important to advise patients to seek medical attention as they may need to stop taking the medication.
It is typically safe to restart the medication at the previously established dose once the patient is asymptomatic and eating and drinking normally.2, 5
Check the patient’s understanding
It is important to “chunk and check” with the patient at this point to ensure they understand how to take an ACE inhibitor.
Example
“You should take your ACE inhibitor as prescribed every day. It can be taken with or without food.”
“ACE inhibitors are initially prescribed at a low dose and gradually increased until the maximum dose you can tolerate is reached. This is based upon side effects and blood tests.”
“ACE inhibitors can be used alone as a treatment for high blood pressure, however, if they do not fully control this, further medications can be added as needed.”
“It is best to review the response after about 2 weeks by rechecking your blood pressure. If the numbers are not to target, we can try increasing the dose or, if already at the maximum dose, adding another medication.”
“If you miss a dose, take it as soon as you remember. But if you don’t remember until the next day, skip the missed dose and just take your usual daily amount. Do not take extra to make up for a missed dose.”
“It is important that you take your ACE inhibitor every day, and this is likely to continue long term. If you are unwell with anything like vomiting and diarrhoea, it is important to seek medical attention as you may need to stop taking the medication for the duration of your illness.”
“Is there anything you aren’t clear on and would like me to go over again? If not, would you mind repeating back to me your understanding of ACE inhibitors and how you should take them?”
Monitoring
A patient should be followed up 1-2 weeks after starting an ACE inhibitor or increasing the dose.
For patients with existing chronic kidney disease, aged over 60 years, with relevant comorbidities (such as diabetes mellitus or peripheral arterial disease), or those taking a combination of treatments with diuretics or mineralocorticoid receptor antagonists, this review should be performed after 5-7 days.3
A review should include rechecking of U&Es, monitoring blood pressure and identifying any side effects. If everything is satisfactory, the dose can be titrated upwards until the target response or dose is reached, ensuring monitoring is done at each step.
When starting or increasing the dose of ACE inhibitors, it is normal to experience a slight increase in creatinine and potassium levels. A decrease in eGFR of <25%, an increase in serum creatinine of <30% or a potassium of <5.0 mmol/L are all satisfactory to allow for continued prescribing of an ACE inhibitor.5
Once the patient is on the target dose and stable, U&Es should continue to be monitored during ongoing treatment. The frequency varies depending on the indication and other co-morbidities. For example, in hypertension this would be annually, but in heart failure it would be every 6 months, and in higher stages of CKD this would be even more frequent.3, 5
Example
“You will need a review and blood tests 1-2 weeks after starting the medication to ensure that there is no significant impact on your kidney function and to monitor for any side effects. Any further increase in dose would be monitored the same way.”
“Once the target dose has been reached, the frequency will drop, and usually blood tests once per year are satisfactory”.
“You should contact your doctor at any time if you are concerned.”
Side effects and interactions
As with all medication, there are side effects associated with ACE inhibitor use.
Educating patients about what to expect when starting an ACE inhibitor, as well as signs of serious side effects and the importance of seeking prompt medical attention should these develop, is an important part of ACE inhibitor counselling.
Side effects can be both class and dose-dependent and could often be resolved by a reduction in dose; this would therefore mean that a patient is at their maximum tolerated dose of an ACE inhibitor.
Common side effects of ACE inhibitors include:
- Hypotension
- Deterioration in renal function
- Cough
- Hyperkalaemia
- Rash
Less common, but serious side effects include:
- Angioedema
- Pancreatitis
Impact of bradykinin
Both cough and angioedema are considered to be related to the accumulation of bradykinin, which ACE inhibitors prevent from breaking down. These side effects usually occur within the first week of taking an ACE inhibitor, but can occur within hours or even after many years of taking the medication.4
The risk of these is greatly reduced, but not zero, by switching to an angiotensin-II receptor antagonist. Development of angioedema with one ACE inhibitor would contraindicate the use of the whole class for that patient.
Interactions
Many prescribed medications can interact with ACE inhibitors to cause adverse effects; therefore, it is important to advise patients to discuss new medications, including over-the-counter medications, with a healthcare professional.
The most important considerations are related to renal function and the co-prescription of nephrotoxic agents (such as NSAIDs or diuretics) or drugs that can increase serum potassium (such as mineralocorticoid receptor antagonists), which would necessitate further monitoring of U&Es.
Although a desired effect, hypotension is another key interaction and therefore, patients’ tolerance should be assessed closely when starting another medication that could lower blood pressure (e.g. calcium channel blockers or beta-blockers).2, 5
Example
“You may experience mild side effects when starting or increasing the dose of ACE inhibitors. Most commonly, this may be symptoms like feeling lightheaded, due to low blood pressure.”
“Another common side effect is a dry cough, for which it is important to seek medical attention. There are many other causes of a cough, but if these are ruled out and the cough is troublesome, the ACE inhibitor is likely the cause and a different class of medication can be used.”
“Very rarely, ACE inhibitors can cause something called angioedema. This is swelling of the soft tissues, usually of the mouth and face, which can be life-threatening. If this occurs, you should call 999 for an ambulance.”
“Not all patients who take ACE inhibitors experience side effects, but it’s good to be aware of them before you start.”
“There are also side effects that you would not have symptoms of, but that require monitoring through blood tests, such as an impact on your kidney function or the balance of salts in the body. Due to this, it is important that you attend blood tests in the advised time frame so that we can ensure the medication is prescribed safely.”
“When taking an ACE inhibitor, it’s important to speak to a healthcare professional before starting any new medication, including over-the-counter ones, as some drugs can interact and affect your kidneys, potassium levels, or blood pressure.”
Lifestyle advice
It is important to educate patients taking ACE inhibitors about how lifestyle can affect their experience with the medication.
Symptoms of hypotension, such as dizziness, can increase the risk of accidents when driving or operating heavy machinery. They should also be made aware that it is not advised to drink alcohol whilst taking ACE inhibitors, as this can increase the hypotensive effect.
When hypertension is the indication, it is important to reiterate the benefits of diet and exercise in controlling the condition. If these changes lower blood pressure, this could cause symptoms of hypotension and permit a reduction in medication dosing.
It is important to advise the patient that if they become pregnant, they should inform their doctor right away, as this could have implications for the safety of medication, monitoring requirements in pregnancy and risk of pregnancy complications.
Example
“If you experience side effects such as dizziness, you should avoid driving or operating machinery. Your doctor might recommend an alternative medication or reduce the dose so that you do not experience these side effects.”
“Medication does not mean that lifestyle changes such as diet and exercise are no longer important. If you can lower your blood pressure through these means, we could reduce or even stop medication in the future, so it is important to attend regular medication reviews.”
“It is important to inform your doctor if you become pregnant or are planning to become pregnant whilst taking ACE inhibitors, as they can cause harm to the baby. It is important not to suddenly stop, as instead an alternative medication should be used to control your blood pressure, and your pregnancy is likely to require extra monitoring.”
“Would you be able to repeat back to me your understanding of how you should take your ACE inhibitors and what to do if you experience bothersome or serious side effects? We can go through it again if you would like.”
Closing the consultation
Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the consultation.
Finally, thank the patient for their time and offer them a leaflet summarising the key information related to ACE inhibitors.
Dispose of PPE appropriately and wash your hands.
Editor
Dr Jess Speller
References
- Brown NJ, Vaughan DE. Angiotensin-Converting Enzyme Inhibitors. Circulation. 1998. Available from: [LINK].
- BNF. Drugs affecting the renin-angiotensin system. 2025. Available from: [LINK].
- NICE CKS. Heart failure – chronic. 2025. Available from: [LINK].
- Messerli FH, Bangalore S, Bavishi C, et al. Angiotensin-Converting Enzyme Inhibitors in Hypertension: To Use or Not to Use? Journal of the American College of Cardiology. Available from: [LINK].
- NICE CKS. Hypertension. 2025. Available from: [LINK].
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