blood pressure than ACE inhibitors such as lisinopril, although convincing evidence is lacking that these drugs differ in their effect on morbidity or mortality in such persons. Kidney problems In patients with moderate to severe kidney disease, lisinopril and other ACE inhibitors are superior to angiotensin II receptor blockers and other antihypertensive drugs for prevention of death, fatal cardiac events, and kidney injury. Dose reduction may be required when creatinine clearance is less than or equal to 30mL/min. Since lisinopril is removed by dialysis, dosing changes must also be considered for people on dialysis. Pregnancy and breastfeeding Animal and human data have revealed evidence of lethal harm to the embryo and teratogenicity associated with ACE inhibitors. No controlled data in human pregnancy are available. Birth defects have been associated with use of lisinopril in any trimester. Death and increased toxicity to the fetus and newly born child have been reported with the use of lisinopril in the second and third trimesters. The label states, "When pregnancy is detected, discontinue Zestril as soon as possible." The manufacturer recommends mothers should not breastfeed while taking this medication because of the current lack of safety data. Contraindications Lisinopril is contraindicated in people who have a history of angioedema (hereditary or idiopathic) or who have diabetes and are taking aliskiren. Adverse effects The incidence of adverse effects varies according to which disease state the patient is being treated for. People taking lisinopril for the treatment of hypertension may experience the following side effects: Headache (3.8%) Dizziness (3.5%) Cough (2.5%) Persons with the ACE I/D genetic polymorphism may be at higher risk for ACE inhibitor-associated cough. Difficulty swallowing or breathing (signs of angioedema), allergic reaction (anaphylaxis) Hyperkalemia (2.2% in adult clinical trials) Fatigue (1% or more) Diarrhea (1% or more) Some severe skin reactions have been reported rarely, including toxic epidermal necrolysis and Stevens–Johnson syndrome; causal relationship has not been established. People taking lisinopril for the treatment of myocardial infarction may experience the following side effects: Hypotension (5.3%) Kidney dysfunction (1.3%) People taking lisinopril for the treatment of heart failure may experience the following side effects: Hypotension (3.8%) Dizziness (12% at low dose – 19% at high dose) Chest pain (2.1%) Fainting (5–7%) Hyperkalemia (3.5% at low dose – 6.4% at high dose) Difficulty swallowing or breathing (signs of angioedema), allergic reaction (anaphylaxis) Fatigue (1% or more) Diarrhea (1% or more) Some severe skin reactions