Lisinopril is a widely prescribed ACE inhibitor used to manage high blood pressure, heart failure, and post-heart attack recovery in the UK. Many patients taking lisinopril also have metabolic conditions such as diabetes or obesity, which are known risk factors for non-alcoholic fatty liver disease (NAFLD). This has led to questions about whether lisinopril itself can cause fatty liver. Understanding the relationship between medications and liver health is important for safe, effective treatment. This article examines the evidence on lisinopril and fatty liver disease, explains how both conditions develop, and provides guidance on when to seek medical advice.

What Is Lisinopril and How Does It Work?

Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor widely prescribed in the United Kingdom for the management of hypertension (high blood pressure) and heart failure. It is also used following myocardial infarction (heart attack) to improve survival rates and reduce the risk of further cardiovascular events. Lisinopril has an established safety profile and is recommended by NICE guidelines for the treatment of various cardiovascular conditions.

For hypertension, NICE NG136 recommends ACE inhibitors (or angiotensin receptor blockers) as first-line treatment for adults under 55 years of age, or for those with type 2 diabetes or chronic kidney disease regardless of age. For adults aged 55 and over, or those of African or Caribbean family origin of any age, a calcium-channel blocker is usually offered first-line unless there is evidence of heart failure or intolerance.

The drug works by inhibiting the angiotensin-converting enzyme, which is responsible for converting angiotensin I to angiotensin II—a potent vasoconstrictor. By blocking this conversion, lisinopril causes blood vessels to relax and widen (vasodilation), thereby reducing blood pressure and decreasing the workload on the heart. This mechanism also helps to reduce fluid retention and improve cardiac output in patients with heart failure.

Common effects and considerations include:

• Reduction in both systolic and diastolic blood pressure

• Improved cardiac function in heart failure patients

• Renal protective effects, particularly in diabetic nephropathy

• Once-daily dosing, which supports medication adherence

Like all medications, lisinopril can cause adverse effects. The most frequently reported include a persistent dry cough (occurring in approximately 10–15% of patients), dizziness, headache, and fatigue. More serious but rare adverse effects include angioedema (swelling of the face, lips, or throat), hyperkalaemia (elevated potassium levels), and renal impairment.

Important safety information:

• Angioedema is a medical emergency requiring immediate attention (call 999). If you develop facial swelling, lip swelling, or difficulty breathing, seek urgent help and do not take further doses. ACE inhibitors must be avoided in future.

• Pregnancy: Lisinopril is contraindicated in pregnancy and should be stopped if you are planning pregnancy or become pregnant. Discuss alternative treatments with your GP. Breastfeeding is not recommended whilst taking lisinopril.

• Monitoring: Your GP will arrange blood tests to check your kidney function (eGFR) and potassium levels within 1–2 weeks of starting lisinopril or changing the dose, and then periodically based on your individual risk. Routine liver function tests are not required unless clinically indicated.

Patients should be advised to report any unusual symptoms promptly to their GP or healthcare provider. Suspected side effects can also be reported via the MHRA Yellow Card Scheme at www.mhra.gov.uk/yellowcard or via the Yellow Card app.

Understanding Fatty Liver: Causes and Risk Factors

Fatty liver disease, medically termed hepatic steatosis, occurs when excess fat accumulates in liver cells. This condition has become increasingly prevalent in the UK, affecting an estimated one in three adults to some degree. Fatty liver disease is broadly categorised into two main types: non-alcoholic fatty liver disease (NAFLD) and alcohol-related liver disease (ARLD). NAFLD is now the most common cause of chronic liver disease in developed countries and is closely associated with metabolic syndrome.

The pathophysiology of fatty liver involves the accumulation of triglycerides within hepatocytes (liver cells). In NAFLD, this occurs without significant alcohol consumption and is strongly linked to insulin resistance. When the liver cannot process fats efficiently, or when there is an excessive supply of fatty acids from the diet or adipose tissue, fat begins to accumulate. Over time, this can progress from simple steatosis to non-alcoholic steatohepatitis (NASH), which involves inflammation and liver cell damage, potentially leading to fibrosis, cirrhosis, or hepatocellular carcinoma.

Key risk factors for developing fatty liver disease include:

• Obesity and overweight status – particularly central (abdominal) adiposity

• Type 2 diabetes mellitus – insulin resistance is a major driver

• Dyslipidaemia – elevated triglycerides and low HDL cholesterol

• Metabolic syndrome – a cluster of conditions including hypertension, abnormal cholesterol, and increased waist circumference

• Alcohol consumption – UK Chief Medical Officers advise keeping alcohol intake within 14 units per week to reduce health risks; there is no completely safe level. Risk of alcohol-related liver disease increases with higher intakes and with binge drinking patterns.

• Certain medications – including corticosteroids, tamoxifen, valproate, amiodarone, and some antiretroviral drugs

Many individuals with fatty liver disease remain asymptomatic in the early stages, with the condition often detected incidentally through blood tests showing elevated liver enzymes or during abdominal imaging for other reasons. As the disease progresses, patients may experience fatigue, right upper quadrant discomfort, or hepatomegaly (enlarged liver).

NICE NG49 recommends lifestyle modification as the cornerstone of management, focusing on weight loss (aiming for 7–10% body weight reduction if overweight or obese), dietary changes, increased physical activity, and management of associated metabolic conditions. In primary care, risk stratification using non-invasive fibrosis scores (such as FIB-4 or the NAFLD Fibrosis Score) helps identify patients who may have advanced fibrosis. The Enhanced Liver Fibrosis (ELF) test may be used as recommended by NICE DG34 to further assess fibrosis risk. Patients with high-risk scores or indeterminate results with concerning features should be referred to hepatology for specialist assessment.

When to Seek Medical Advice About Liver Health

Recognising when to seek medical attention regarding liver health is crucial for early detection and management of liver conditions. Many liver diseases, including fatty liver, develop silently without obvious symptoms in their initial stages. However, certain signs and symptoms warrant prompt evaluation by a healthcare professional.

You should contact your GP if you experience:

• Persistent fatigue or unexplained weakness that interferes with daily activities

• Yellowing of the skin or whites of the eyes (jaundice)

• Dark urine or pale-coloured stools

• Persistent abdominal pain or discomfort, particularly in the right upper quadrant

• Unexplained weight loss or loss of appetite

• Nausea and vomiting that persists

• Easy bruising or bleeding

• Swelling in the legs, ankles, or abdomen (ascites)

• Confusion or difficulty concentrating (which may indicate hepatic encephalopathy)

If you are taking lisinopril or any other regular medication and notice abnormal symptoms, it is important to discuss these with your GP rather than stopping medication abruptly. Routine monitoring is particularly important for patients on long-term ACE inhibitor therapy. Your GP will arrange blood tests to check your kidney function (U&Es and eGFR) and potassium levels within 1–2 weeks of starting lisinopril or changing the dose, and then periodically based on your individual risk factors. Liver function tests (LFTs) are not routinely required for lisinopril unless there are clinical reasons to check them, such as symptoms or abnormal results from other investigations.

Patients with known risk factors for liver disease—such as obesity, diabetes, excessive alcohol use, or a family history of liver conditions—should be proactive about liver health screening. NICE NG49 recommends that individuals with metabolic risk factors undergo assessment for NAFLD. If liver blood tests remain abnormal for more than six months, or if non-invasive fibrosis scores (FIB-4 or NAFLD Fibrosis Score) suggest high risk, or if the ELF test indicates advanced fibrosis, referral to hepatology is appropriate.

Seek urgent medical attention (call 999 or attend A&E) if you develop:

• Severe abdominal pain

• Vomiting blood or passing black, tarry stools

• Severe confusion or altered consciousness

• Signs of severe allergic reaction, including facial swelling, lip swelling, or difficulty breathing

Regular health checks and open communication with your healthcare team enable early identification of potential liver problems and appropriate intervention before serious complications develop.

Can Lisinopril Cause Fatty Liver Disease?

There is no established causal link between lisinopril use and the development of fatty liver disease based on current medical evidence and regulatory data from the MHRA, EMA, and published clinical literature. Lisinopril is not listed among medications known to cause drug-induced steatosis or steatohepatitis. The drug is not metabolised and is excreted unchanged in the urine by the kidneys; significant hepatic metabolism does not occur, which reduces the likelihood of direct liver toxicity.

ACE inhibitors, including lisinopril, are generally considered safe from a hepatic perspective. Liver-related adverse effects associated with ACE inhibitors are rare and typically manifest as transient elevations in liver enzymes (transaminases) rather than fatty infiltration. When hepatotoxicity does occur with ACE inhibitors, it usually presents as cholestatic or hepatocellular injury rather than steatosis. Such cases are rare or very rare and are usually reversible upon discontinuation of the medication.

Important safety information: The Summary of Product Characteristics (SmPC) for ACE inhibitors includes a class warning that cholestatic jaundice and hepatitis can occur rarely. If you develop jaundice (yellowing of the skin or eyes) or marked elevation of liver enzymes whilst taking lisinopril, stop the medication and seek urgent medical review.

It is important to recognise that patients prescribed lisinopril often have underlying conditions—such as hypertension, diabetes, cardiovascular disease, and metabolic syndrome—that are themselves independent risk factors for developing NAFLD. This creates a potential for confounding, where the association between medication use and fatty liver may reflect the underlying disease rather than a drug effect. Studies examining the relationship between ACE inhibitors and liver health have not demonstrated an increased risk of fatty liver disease. Some observational research has suggested potential protective effects of ACE inhibitors on liver fibrosis progression in patients with existing NAFLD, though this remains an area of ongoing investigation and is not proven.

Key points regarding lisinopril and liver health:

• Lisinopril does not cause fatty liver disease according to current evidence

• Routine liver function monitoring is not specifically required for lisinopril unless clinically indicated

• Any elevation in liver enzymes should prompt clinical evaluation to identify the underlying cause

• Patients with pre-existing liver disease can generally use lisinopril safely, though individual assessment is necessary

• If jaundice or marked liver enzyme elevation occurs, stop lisinopril and seek urgent medical review

If you are taking lisinopril and have concerns about liver health or have been diagnosed with fatty liver disease, discuss this with your GP. They can assess whether your fatty liver is related to metabolic factors, alcohol use, or other causes, and provide appropriate management advice. Do not stop taking lisinopril without medical guidance, as abrupt discontinuation can lead to loss of blood pressure control and increased cardiovascular risk. Your healthcare provider can review your complete medication profile and risk factors to develop an individualised treatment plan that addresses both your cardiovascular and liver health needs.

Frequently Asked Questions