Enalapril is a medication used to treat various cardiovascular conditions, primarily high blood pressure (hypertension) and congestive heart failure. It belongs to a class of drugs known as angiotensin-converting enzyme (ACE) inhibitors. Enalapril works by inhibiting the action of the angiotensin-converting enzyme, which is involved in regulating blood pressure and fluid balance in the body.

Angiotensin-converting enzyme inhibitor enalapril (Epaned, Renitec) is used to treat individuals with hypertension, heart failure, and proteinuria.

Enalapril (Epaned, Renitec) Uses:

• Asymptomatic left ventricular dysfunction:
  • lessens the risk of developing heart failure and decreases hospitalisation for people with low ejection failure due to heart failure.
• Heart Failure:
  • Utilized for symptomatic heart failure
  • Guideline recommendations: The American College of Cardiology/American Heart Association's (ACC/AHA) 2013 Heart Failure Guidelines advise using ACE inhibitors in conjunction with other medical therapies that follow the guidelines to stop the progression of heart failure (HF) and reduced ejection fraction in asymptomatic patients with or without a history of myocardial infarction (Stage B HF) or to treat patients with symptomatic HF and reduced ejection fraction to reduce illness and mortality (Stage C HFrEF).

Hypertension:

• Management of hypertension.
  • Guideline recommendations:
    • In the absence of comorbidities (such as cerebrovascular disease, chronic kidney disease, diabetes, heart failure, ischemic heart disease, etc.), the 2017 Guideline for the Avoidance, Discovery, Evaluation, and Managing of High Blood Pressure in Adults suggests that thiazide-like diuretics or dihydropyridine calcium channel blockers may be preferred options due to improved cardiovascular endpoints (eg, prevention of heart failure and stroke).
    • ARBs and ACE inhibitors are also suitable for monotherapy.
    • Combination therapy is initially favoured in patients at high risk (stage 2 hypertension or atherosclerotic cardiovascular disease [ASCVD] risk 10%) and may be necessary to achieve blood pressure objectives.
• Off Label Use of Enalapril in Adults:
  • Non–ST-elevation acute coronary syndrome
  • Steady coronary artery disease
  • ST-elevation acute coronary syndrome
  • Aldosteronism (diagnosis)
  • Bartter's syndrome
  • Hypertension secondary to scleroderma renal crisis
  • Hypertensive crisis
  • Idiopathic edema
  • Postmyocardial infarction for avoidance of ventricular failure

Enalapril (Epaned, Renitec) Dose in Adults

Note: If a person has low sodium levels in their blood, not enough fluid in their body, severe heart failure, kidney problems, or takes water pills, they should take a lower starting dose of enalapril. This is to make sure the medication is safe and effective for them.

Enalapril (Epaned, Renitec) Dose in the treatment of Asymptomatic left ventricular dysfunction:

• When treating asymptomatic left ventricular dysfunction with enalapril, the usual starting dose is 2.5 milligrams taken by mouth twice a day.
• If the patient can tolerate it well, the dose can be gradually increased until they reach the target dose of 10 milligrams taken twice a day.
• The maximum daily dose should not exceed 20 milligrams.
• This dosing strategy helps improve the condition of the heart in patients with asymptomatic left ventricular dysfunction.

Enalapril (Epaned, Renitec) Dose in the treatment of Heart failure:

• In the treatment of heart failure with enalapril, the typical starting dose is 2.5 milligrams taken orally twice a day.
• This dose can be increased gradually, typically over 1-2 week intervals, as tolerated by the patient.
• The maximum daily dose should not exceed 40 milligrams.
• The goal is to reach a target dose of 10 to 20 milligrams taken twice a day.
• This stepwise approach to dosing helps manage heart failure effectively and minimize the risk of side effects.

Enalapril (Epaned, Renitec) Dose in the treatment of Hypertension:

• Initial Dose: Start with 5 milligrams of enalapril taken orally once a day.
• Dose Adjustment: The dose can be adjusted based on how the patient responds to the medication. This adjustment should be done gradually, typically at 1- to 2-week intervals. The goal is to achieve effective blood pressure control.
• Maximum Dose: The maximum daily dose of enalapril for hypertension is 40 milligrams, which can be taken in 1 or 2 divided doses.

Additionally, if a person is switching from intravenous (IV) enalaprilat to oral enalapril therapy, the conversion guidelines are as follows:

• If not taking diuretics at the same time, start with enalapril 5 milligrams orally once a day.
• If taking diuretics and responding well to enalaprilat (IV form) at a dose of 0.625 milligrams every 6 hours, start with enalapril 2.5 milligrams orally once a day. Further adjustments can be made as needed.

Enalapril (Epaned, Renitec) Dose in Childrens

Note: If a person has low sodium levels, not enough fluid in their body, severe heart failure, kidney problems, or takes water pills, they should start with a lower dose of enalapril. This lower dose is safer for them.

Enalapril (Epaned, Renitec) Dose in Heart failure:

For infants, children, and adolescents with heart failure, the dosing of enalapril is based on their body weight.

• Initial Dose: Start with 0.1 milligrams per kilogram of body weight per day. This initial dose should be divided into 1 to 2 doses throughout the day.
• Dose Adjustment: After the initial dose, the healthcare provider may increase the dose gradually over a period of 2 weeks if needed. The maximum dose should not exceed 0.5 milligrams per kilogram of body weight per day.
• Average Effective Dose: On average, for the improvement of congestive heart failure (CHF) in children, a dose of 0.36 milligrams per kilogram of body weight per day was found to be effective. However, some individuals have been treated with doses as high as 0.94 milligrams per kilogram of body weight per day.

Enalapril (Epaned, Renitec) Dose in the treatment of Hypertension:

For infants, children, and adolescents with hypertension (high blood pressure), the dosing of enalapril is based on their body weight.

• Initial Dose: Start with 0.08 milligrams per kilogram of body weight once daily. The maximum initial dose should not exceed 5 milligrams.
• Dose Adjustment: The healthcare provider will adjust the dose based on the child's blood pressure readings. The goal is to find the right dose that effectively controls blood pressure.
• Maximum Dose: It's important to note that doses exceeding 0.58 milligrams per kilogram (or more than 40 milligrams) have not been studied in children and adolescents for hypertension. Therefore, it's recommended to stay within the prescribed dose range and not exceed these limits.

Enalapril (Epaned, Renitec) Dose in Proteinuria and nephrotic syndrome: Oral:

For the treatment of proteinuria, especially in conditions like nephrotic syndrome, dosing of enalapril in children and adolescents is based on limited data.

Fixed Dosing:

• Children aged 7 years and older and adolescents can be given a fixed dose of 2.5 to 5 milligrams per day. This dosing was reported in a retrospective study in pediatric patients who had normal blood pressure. It can be used either as monotherapy or in combination with prednisone.
• In a case series involving three adolescents with sickle cell anemia nephropathy, an initial dose of 5 milligrams per day was used. In one patient, the dose was increased to 7.5 milligrams per day.

Weight-Directed Dosing:

• For children and adolescents, an initial dose of 0.2 milligrams per kilogram of body weight per day is recommended. This dose can be adjusted based on the individual's response, typically at 4- to 12-week intervals.
• The dosing range for weight-directed dosing is 0.2 to 0.6 milligrams per kilogram of body weight per day.
• The maximum daily dose should not exceed 20 milligrams.
• It's important to note that the effectiveness of enalapril in reducing proteinuria appears to be dose-dependent, meaning that the higher the dose, the greater the effect on proteinuria.
• If enalapril is used in combination with another medication that blocks angiotensin (like an angiotensin receptor blocker or ARB), lower doses (0.1 to 0.16 milligrams per kilogram per day) have been reported.

Enalapril Pregnancy Risk Category: D

• Enalapril and similar drugs that affect the renin-angiotensin system can be very harmful to a developing baby if taken during pregnancy.
• They should be stopped as soon as pregnancy is detected because they can lead to serious problems like underdeveloped lungs, skeletal issues, and even the death of the baby.
• These drugs can also cause low levels of amniotic fluid, which is important for the baby's growth.
• If a baby is exposed to these drugs before birth, they should be closely monitored for problems like high potassium levels, low blood pressure, and reduced urine output.
• In some cases, treatments like blood transfusions or dialysis might be needed to help the baby.
• For pregnant women, there are safer options to treat high blood pressure or chronic heart failure, and ACE inhibitors like enalapril are generally not recommended during pregnancy.

Enalapril use during breastfeeding:

• Enalapril and its active form, enalaprilat, can be found in breast milk.
• When we calculate how much of the medication a nursing infant would receive, it's about 1.1% of the dose that's considered therapeutic for an infant.
• In general, medications are considered safe for breastfeeding if the amount passed to the baby through breast milk is less than 10% of a therapeutic dose.
• In this case, the amount of enalapril in breast milk is below that threshold.
• However, it's important to note that because there is a possibility of serious side effects in breastfed infants, especially when the mother takes a high dose of enalapril, the decision to continue breastfeeding or stop should be made carefully, taking into consideration the mother's need for treatment.

Enalapril (Epaned, Renitec) Dose in Kidney Disease:

Normal Kidney Function (Creatinine Clearance >30 mL/minute):

• No dosage adjustment is necessary.

Reduced Kidney Function (Creatinine Clearance ≤30 mL/minute):

• Initial dose: 2.5 milligrams once daily.
• The dose can be increased as needed, but the maximum daily dose should not exceed 40 milligrams.

Heart Failure Patients with Elevated Serum Creatinine (>1.6 mg/dL):

• Initial dose: 2.5 milligrams once daily, which can be increased to twice daily as needed.
• The dose can be further increased in 2.5 milligram increments at intervals of at least 4 days, but the maximum daily dose should not exceed 40 milligrams.

Hemodialysis Patients:

• Enalapril is moderately dialyzable (20% to 50%).
• On dialysis days, the initial dose is 2.5 milligrams after dialysis.
• The dose on non-dialysis days should be adjusted based on blood pressure response.

Conversion from IV Enalaprilat to Oral Enalapril Therapy:

• If the person's kidney function is relatively normal (Creatinine Clearance >30 mL/minute), they can initiate enalapril at 5 milligrams once daily.
• If kidney function is reduced (Creatinine Clearance ≤30 mL/minute), they can initiate enalapril at 2.5 milligrams once daily.

Alternate Recommendations (Aronoff 2007):

• If the person's Glomerular Filtration Rate (GFR) is greater than 50 mL/minute, no dosage adjustment is necessary.
• If GFR is between 10 to 50 mL/minute, administer 50% to 100% of the usual dose.
• If GFR is less than 10 mL/minute, administer only 25% of the usual dose.
• For individuals on peritoneal dialysis, administer only 25% of the usual dose.

Dose in Liver disease:

• In patients with severe liver problems, there is generally no need to adjust the dosage of enalapril.
• Although the conversion of enalapril to its active form, enalaprilat, may be slower or less effective in these patients due to liver impairment, the actual effects of the medication on blood pressure and other factors do not seem to be significantly changed.
• However, it's crucial for individuals with severe liver issues to be monitored closely by their healthcare provider to ensure that the medication is working as expected and to watch for any potential side effects or complications.

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Note: Data from trials on hypertension and heart failure make up frequency ranges. Patients with CHF frequently have higher rates of side effects. But the incidence of unfavourable

Common Side Effects of Enalapril (Epaned, Renitec):

• Renal:
  • Increased serum creatinine

Less Common Side Effects of Enalapril (Epaned, Renitec):

• Cardiovascular:
  • Hypotension
  • Chest Pain
  • Orthostatic Effect
  • Orthostatic Hypotension
  • Syncope
• Central Nervous System:
  • Fatigue
  • Headache
  • Dizziness
• Dermatologic:
  • Skin Rash
• Gastrointestinal:
  • Anorexia
  • Nausea
  • Constipation
  • Dysgeusia
  • Vomiting
  • Abdominal Pain
  • Diarrhea
• Neuromuscular & Skeletal:
  • Weakness
• Renal:
  • Renal Insufficiency
• Respiratory:
  • Bronchitis
  • Cough
  • Dyspnea

Contraindications to Enalapril (Epaned, Renitec):

Enalapril should not be used in individuals who have:

• Hypersensitivity: An allergy or severe sensitivity to enalapril or any component of the medication.
• Angioedema: A history of angioedema (a severe swelling of deeper layers of the skin) related to previous treatment with an ACE inhibitor.
• Idiopathic or Hereditary Angioedema: Known idiopathic (of unknown cause) or hereditary angioedema.
• Concomitant Use with Aliskiren: Taking enalapril along with aliskiren is contraindicated in patients with diabetes mellitus.
• Coadministration with Neprilysin Inhibitors: Using enalapril in combination with, or within 36 hours of switching to or from, a neprilysin inhibitor such as sacubitril is not recommended.

In Canada, there is an additional contraindication:

• Concomitant Use with Aliskiren-Containing Drugs: Enalapril should not be taken with aliskiren-containing medications in patients with moderate-to-severe renal impairment (where the glomerular filtration rate is less than 60 mL/minute/1.73 m²).

It's important to note that there is a possibility of cross-sensitivity to ACE inhibitors due to similarities in chemical structure and pharmacologic actions, although documented cases of this are limited.

Warnings and precautions

Angioedema

• Angioedema, although rare, can occur at any time during treatment with ACE inhibitors like enalapril, especially after the first dose.
• It can involve swelling of the head and neck, which may potentially block the airway, or it can affect the intestines, leading to abdominal pain.
• It's important to note that African-Americans may have a higher risk of angioedema.
• The risk can also be increased if ACE inhibitors are used in combination with certain other medications like mTOR inhibitors (e.g., everolimus) or neprilysin inhibitors (e.g., sacubitril).
• If angioedema occurs, especially if it affects the tongue, glottis, or larynx and poses a risk of airway obstruction, close and frequent monitoring is essential.
• Patients with a history of airway surgery may be at a higher risk of airway blockage in case of angioedema.
• Aggressive and prompt management is crucial in such cases.
• Enalapril should not be used in patients with a history of idiopathic or hereditary angioedema or previous angioedema related to ACE inhibitor therapy, as it is contraindicated in these individuals.

Cholestatic jaundice

• One rare but serious side effect associated with ACE inhibitors like enalapril is cholestatic jaundice.
• This condition can lead to a blockage in the flow of bile from the liver, resulting in jaundice (yellowing of the skin and eyes).
• In some cases, cholestatic jaundice can progress to a severe liver condition called fulminant hepatic necrosis, which can be fatal.
• If a person taking enalapril experiences a significant increase in liver enzymes or develops jaundice, it's important to discontinue the medication immediately.
• These symptoms should be reported to a healthcare provider promptly for evaluation and appropriate management.

Cough:

• One side effect associated with ACE inhibitors like enalapril is a dry, persistent cough.
• This cough is typically nonproductive (meaning it doesn't produce mucus) and often starts within the first few months of starting the medication.
• Fortunately, this cough usually goes away within 1 to 4 weeks after discontinuing the ACE inhibitor.
• However, before discontinuing the medication, other possible causes of cough should be considered and ruled out, especially in patients with heart failure who may have pulmonary congestion contributing to coughing.

Hematologic effects

• Hematologic effects, such as changes in blood cell counts, have been associated with ACE inhibitors like captopril.
• This can include neutropenia (a low white blood cell count) with myeloid hypoplasia and agranulocytosis, as well as anemia (low red blood cell count) and thrombocytopenia (low platelet count).
• Patients with impaired kidney function are at a higher risk of developing neutropenia, and those with both kidney impairment and collagen vascular diseases like systemic lupus erythematosus are at an even greater risk.
• To monitor for these potential blood-related issues, healthcare providers should periodically check the complete blood count (CBC) with a differential (which looks at the different types of white blood cells) in patients at risk.
• If any abnormalities are detected, appropriate action should be taken to address and manage them.

Hyperkalemia:

• Taking ACE inhibitors like enalapril can sometimes lead to a condition called hyperkalemia, where there is too much potassium in the blood.
• Risk factors for this include kidney problems, diabetes, and using potassium-sparing diuretics, supplements, or salts.
• It's important to be cautious when using these agents together and to keep a close watch on potassium levels through monitoring.

Hypersensitivity reactions

• Hypersensitivity reactions, including anaphylactic or anaphylactoid reactions, can sometimes happen with ACE inhibitors like enalapril.
• In some rare cases, severe anaphylactoid reactions have been observed during hemodialysis using certain high-flux dialysis membranes or during low-density lipoprotein apheresis with dextran sulfate cellulose.
• There have also been isolated reports of anaphylactoid reactions in patients receiving sensitization treatment with hymenoptera (bee or wasp) venom while taking ACE inhibitors.
• It's important to be aware of these potential reactions and to seek immediate medical attention if any signs of a severe allergic reaction occur while taking this medication.

Hypotension/syncope

• ACE inhibitors like enalapril can sometimes cause symptomatic low blood pressure, leading to feelings of dizziness or even fainting, which is known as syncope.
• This is more likely to happen, especially with the first few doses, in patients who have low blood volume (volume-depleted).
• It's important to correct any volume depletion before starting the medication.
• Close monitoring of the patient's blood pressure is necessary, especially when starting or increasing the dose.
• If low blood pressure occurs, the healthcare provider may need to adjust the dose, but this is usually not a reason to stop using ACE inhibitors, particularly in patients with heart failure where lowering blood pressure can be beneficial.
• The rate at which blood pressure is lowered should be appropriate for the patient's clinical condition.

Renal function deterioration:

• In some cases, using ACE inhibitors like enalapril can lead to a decline in kidney function or an increase in serum creatinine levels, especially in patients with conditions like renal artery stenosis or heart failure where kidney blood flow relies on angiotensin II for constriction of blood vessels.
• This deterioration in kidney function may lead to reduced urine output, acute kidney failure, and higher levels of waste products in the blood (azotemia).
• Small increases in serum creatinine may happen when starting the medication, but discontinuation is typically considered only if there is ongoing and significant worsening of kidney function.

Aortic stenosis

• In individuals with severe aortic stenosis, the use of ACE inhibitors like enalapril should be approached with caution.
• These medications can potentially reduce coronary perfusion, which means they might affect the blood supply to the heart muscle and lead to ischemia (inadequate blood flow).
• Therefore, it's important for healthcare providers to carefully consider the risks and benefits of using ACE inhibitors in patients with severe aortic stenosis and to closely monitor their condition during treatment.

Ascites:

• The use of ACE inhibitors like enalapril should generally be avoided in patients with ascites caused by cirrhosis or refractory ascites.
• If there is a compelling reason to use these medications in such patients, it's crucial to monitor their blood pressure and kidney function very closely.
• This close monitoring is necessary to prevent the rapid development of kidney failure, which can occur in these individuals.
• Healthcare providers should weigh the potential benefits and risks carefully before prescribing ACE inhibitors in patients with ascites due to cirrhosis and exercise caution in their management.

Cardiovascular disease

• When starting therapy with ACE inhibitors like enalapril in patients with ischemic heart disease or cerebrovascular disease, it's essential to closely monitor these individuals.
• A potential side effect of ACE inhibitors is low blood pressure, which can have serious consequences such as heart attacks (MI) or strokes.
• If a patient experiences a drop in blood pressure, fluid replacement may be necessary to restore it to a safer level, and then therapy can be resumed.
• However, if hypotension (low blood pressure) recurs or becomes problematic, it may be necessary to discontinue ACE inhibitor therapy.
• Careful observation and management are crucial to balance the potential benefits of the medication against the risk of low blood pressure in these patients.

Collagen vascular disease:

• In patients with collagen vascular diseases, especially when there is also kidney impairment, the use of ACE inhibitors like enalapril should be approached with caution.
• These individuals may have an increased risk of experiencing hematologic toxicity (problems with blood cells).

Hypertrophic cardiomyopathy with outflow tract obstruction (HCM)

• In patients with hypertrophic cardiomyopathy (HCM) who also have outflow tract obstruction, the use of ACE inhibitors like enalapril should be approached with caution.
• These medications can reduce the heart's afterload, which may worsen symptoms associated with HCM in these patients.

Renal artery stenosis

• In patients with unstented unilateral (one-sided) or bilateral (both sides) renal artery stenosis (narrowing of the arteries that supply the kidneys with blood), the use of ACE inhibitors like enalapril should be approached with caution.
• In cases of unstented bilateral renal artery stenosis, it's typically avoided unless the potential benefits significantly outweigh the risks.
• This is because using ACE inhibitors in such patients can increase the risk of kidney function deterioration.

Renal impairment

• In individuals with preexisting kidney problems, ACE inhibitors like enalapril should be used cautiously.
• It may be necessary to adjust the dosage of the medication based on the degree of renal insufficiency.
• It's important to avoid rapid increases in dosage, as this could potentially worsen renal function.

Enalapril: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Risk Factor C (Monitor therapy)
Alfuzosin	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Amphetamines	May lessen the effectiveness of antihypertensive agents.
Angiotensin II	The therapeutic efficacy of angiotensin II may be enhanced by angiotensin-converting enzyme inhibitors.
Antipsychotic Agents (Second Generation [Atypical])	Antipsychotic drugs' hypotensive effects may be enhanced by blood pressure-lowering medications (Second Generation [Atypical]).
Aprotinin	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
AzaTHIOprine	AzaTHIOprine's myelosuppressive effects may be enhanced by angiotensin-converting enzyme inhibitors.
Barbiturates	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Benperidol	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Brigatinib	May lessen the effectiveness of antihypertensive agents. Antihypertensive Agents' bradycardic action may be strengthened by brutinib.
Brimonidine (Topical)	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Dapoxetine	The impact of angiotensin-converting enzyme inhibitors on hyperkalemia may be enhanced.
Dexmethylphenidate	Can lessen an antihypertensive drug's therapeutic impact.
Diazoxide	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Dipeptidyl Peptidase-IV Inhibitors	May worsen angiotensin-converting enzyme inhibitors' toxic or severe effects. Particularly, there may be a higher incidence of angioedema.
Drospirenone	Drospirenone's hyperkalemic impact may be enhanced by angiotensin-converting enzyme inhibitors.
DULoxetine	The hypotensive impact of DULoxetine may be enhanced by blood pressure lowering medications.
Eplerenone	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Everolimus	May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. Particularly, there may be a higher incidence of angioedema.
Ferric Gluconate	Angiotensin-Converting Enzyme Inhibitors might make ferric gluconate more harmful or poisonous.
Ferric Hydroxide Polymaltose Complex	Ferric Hydroxide Polymaltose Complex may have a more negative or toxic effect when taken with angiotensin-converting enzyme inhibitors. In particular, there may be an elevated risk for angioedema or allergic responses.
Gelatin (Succinylated)	Ferric Hydroxide Polymaltose Complex may have a more negative or toxic effect when taken with angiotensin-converting enzyme inhibitors. In particular, there may be an elevated risk for angioedema or allergic responses.
Gold Sodium Thiomalate	Gold Sodium Thiomalate may have a more negative or toxic effect when used with angiotensin-converting enzyme inhibitors. Nitritoid responses are more likely now, it has been noted.
Heparin	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Heparins (Low Molecular Weight)	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Herbs (Hypertensive Properties)	May lessen the effectiveness of antihypertensive agents.
Herbs (Hypotensive Properties)	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Hypotension-Associated Agents	The hypotensive action of hypotension-associated agents may be strengthened by blood pressure lowering medications.
Icatibant	May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.
Levodopa-Containing Products	Levodopa-Containing Products' hypotensive effects may be strengthened by blood pressure-lowering medications.
Loop Diuretics	May strengthen angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by loop diuretics.
Lormetazepam	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Methylphenidate	May lessen the effectiveness of antihypertensive agents.
Molsidomine	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Naftopidil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nicergoline	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nicorandil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nicorandil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nitroprusside	Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside.
Nonsteroidal Anti-Inflammatory Agents	Nonsteroidal Anti-Inflammatory Agents' negative/toxic effects may be increased by angiotensin-converting enzyme inhibitors. In particular, the combination may cause a marked decline in renal function. Angiotensin-Converting Enzyme Inhibitors' antihypertensive effects may be lessened by nonsteroidal anti-inflammatory drugs.
Pentoxifylline	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Pholcodine	Pholcodine's hypotensive impact may be strengthened by blood pressure lowering medications.
Phosphodiesterase 5 Inhibitors	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Potassium Salts	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Potassium-Sparing Diuretics	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Pregabalin	Angiotensin-Converting Enzyme Inhibitors may intensify Pregabalin's negative/toxic effects. Particularly, there may be a higher incidence of angioedema.
Prostacyclin Analogues	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Quinagolide	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Racecadotril	May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. In particular, this combination may make angioedema more likely.
Ranolazine	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Salicylates	May intensify angiotensin-converting enzyme inhibitors' nephrotoxic effects. The therapeutic benefit of angiotensin-converting enzyme inhibitors may be reduced by salicylates.
Sirolimus	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger..
Tacrolimus (Systemic)	Angiotensin-Converting Enzyme Inhibitors may enhance the hyperkalemic effect of Tacrolimus (Systemic).
Temsirolimus	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Thiazide and Thiazide-Like Diuretics	May increase the angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by thiazide and thiazide-like diuretics.
TiZANidine	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Tolvaptan	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Trimethoprim	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Yohimbine	May lessen the effectiveness of antihypertensive agents.
Risk Factor D (Consider therapy modification)
Aliskiren	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects. Angiotensin-Converting Enzyme Inhibitors' hypotensive effects may be strengthened by aliskiren. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be made worse by aliskiren. Treatment: It is not advised for diabetic patients to take aliskiren along with ACEIs or ARBs. Combination therapy should be avoided in other patients, especially when CrCl is less than 60 mL/min. If combined, keep a close eye on your blood pressure, potassium, and creatinine levels.
Allopurinol	Angiotensin-Converting Enzyme Inhibitors might make Allopurinol more likely to cause allergic or hypersensitive reactions.
Amifostine	Amifostine's hypotensive impact may be strengthened by blood pressure lowering medications. Treatment: Blood pressure-lowering drugs need to be avoided for 24 hours before amifostine is administered when used at chemotherapeutic doses. Amifostine should not be given if blood pressure lowering treatment cannot be stopped.
Angiotensin II Receptor Blockers	May worsen angiotensin-converting enzyme inhibitors' toxic or severe effects. Angiotensin-Converting Enzyme Inhibitors' serum levels may rise in response to angiotensin II receptor blockers. Management: According to US labelling, it is not advisable to take telmisartan and ramipril. It is unclear whether another ACE inhibitor and ARB combo would be any safer. When possible, take into account alternatives to the mix.
Grass Pollen Allergen Extract (5 Grass Extract)	Grass pollen allergen extract may have a more negative or toxic effect if angiotensin-converting enzyme inhibitors are used (5 Grass Extract). With regard to grass pollen allergen extract, ACE inhibitors may specifically enhance the likelihood of a severe allergic reaction (5 Grass Extract).
Iron Dextran Complex	Angiotensin-Converting Enzyme Inhibitors might make Iron Dextran Complex more harmful or poisonous. Patients taking an ACE inhibitor may be more susceptible to events of the anaphylactic variety. Management: Adhere strictly to the instructions for iron dextran administration, including the use of a test dose before the initial therapeutic dose and the availability of resuscitation tools and qualified people.
Lanthanum	May lower angiotensin-converting enzyme inhibitors' serum concentration. Angiotensin-converting enzyme inhibitors should be given at least two hours before or after lanthanum.
Lithium	The serum concentration of lithium may rise in response to angiotensin-converting enzyme inhibitors. Management: After adding an ACE inhibitor, lithium dosage decreases will probably be required. Following the addition or discontinuation of concurrent ACE inhibitor therapy, carefully monitor the patient's response to lithium.
Obinutuzumab	The hypotensive effects of blood pressure-lowering medications may be strengthened. Management: Take into account temporarily stopping blood pressure-lowering drugs 12 hours before the start of the obinutuzumab infusion and keeping them off until 1 hour after the infusion is finished.
Sodium Phosphates	The nephrotoxic impact of sodium phosphates may be enhanced by angiotensin-converting enzyme inhibitors. In particular, there may be an increased risk of acute phosphate nephropathy. Treatment: You might want to temporarily stop taking ACEIs or look into alternatives to the oral sodium phosphate bowel preparation in order to prevent this combo. Maintaining appropriate hydration and properly monitoring renal function should be done if the combination cannot be avoided.
Urapidil	Angiotensin-Converting Enzyme Inhibitors may interact with them through an unidentified method. Avoid taking urapidil and ACE inhibitors simultaneously as a management strategy.
Risk Factor X (Avoid combination)
Bromperidol	May lessen blood pressure lowering agents' hypotensive effects. The hypotensive impact of bromperidol may be enhanced by blood pressure lowering medications.
Sacubitril	The negative or hazardous effects of sacubitril may be increased by angiotensin-converting enzyme inhibitors. In particular, this combination may raise the risk of angioedema.

Monitoring parameters:

• Blood Pressure: Regularly check blood pressure to ensure it's within the desired range for your specific condition.
• Serum Creatinine and Potassium: Monitor levels of serum creatinine and potassium in your blood. Changes in these levels may require adjustments to your treatment.
• Collagen Vascular Disease and Renal Impairment: If you have collagen vascular disease (a group of autoimmune diseases) and/or kidney problems, periodic monitoring of your complete blood count (CBC) with differential (looking at different types of blood cells) may be necessary.

Heart Failure:

• Renal Function and Serum Potassium: Within 1 to 2 weeks after starting enalapril for heart failure, and regularly afterward, your healthcare provider will assess your renal (kidney) function and serum potassium levels. This is especially important if you have preexisting issues like low blood pressure, low sodium levels, diabetes, kidney problems, or if you take potassium supplements.

Hypertension:

• Blood Pressure Targets (ACC/AHA 2017):
  • If you have confirmed hypertension and known cardiovascular disease (CVD) or a high risk of CVD (greater than 10% 10-year risk), your target blood pressure is recommended to be below 130/80 mm Hg.
  • If you have confirmed hypertension without markers of increased CVD risk, a target blood pressure below 130/80 mm Hg may be reasonable.
• Diabetes and Hypertension (ADA 2019):
  • For patients aged 18 to 65 without CVD and a 10-year CVD risk of less than 15%, the recommended target blood pressure is below 140/90 mm Hg.
  • If you are aged 18 to 65 with known CVD or a 10-year CVD risk greater than 15%, a target blood pressure below 130/80 mm Hg may be appropriate if it's safe for you.
  • For patients over 65, the target blood pressure is typically below 140/90 mm Hg, but in very complex or poor health, it may be below 150/90 mm Hg.

These monitoring guidelines help ensure that your treatment with enalapril is safe and effective for your specific medical condition.

How to administer Enalapril (Epaned, Renitec)?

• You can take enalapril by mouth without needing to consider whether you've eaten or not.
• It can be taken with or without food.

Mechanism of action of Enalapril (Epaned, Renitec):

• Enalapril is a medication that competes with angiotensin-converting enzyme (ACE) in the body.
• It works by blocking ACE's action, which normally converts angiotensin I into angiotensin II.
• Angiotensin II is a powerful substance that constricts blood vessels.
• When you take enalapril, it lowers the levels of angiotensin II in your body.
• This, in turn, leads to an increase in plasma renin activity (an enzyme related to blood pressure regulation) and a decrease in the secretion of aldosterone (a hormone that affects salt and water balance).
• The overall effect is a reduction in blood pressure and less strain on the heart.

Onset of Action:

• It starts to work in approximately 1 hour after taking the medication.

Peak Effect:

• The maximum effect is usually reached at 4 to 6 hours after taking it.

Duration:

• Its effects typically last for 12 to 24 hours.

Absorption:

• Enalapril is absorbed by the body in the range of 55% to 75%.

Protein Binding:

• About 50% of enalapril binds to proteins in the blood.

Metabolism:

• Enalapril is a prodrug, which means it needs to be transformed in the liver to become active.
• It is converted into its active form, enalaprilat, through hepatic biotransformation.

Half-life Elimination:

• Enalapril has a half-life of about 2 hours in healthy adults, but it can be longer in individuals with congestive heart failure (CHF), ranging from 3.4 to 5.8 hours.
• Enalaprilat, the active metabolite, has a half-life of approximately 35 hours in adults and can vary in neonates and children.

Time to Peak, Serum:

• After taking enalapril orally, it reaches peak serum levels within 0.5 to 1.5 hours.
• Enalaprilat, the active form, reaches its peak serum levels at 3 to 4.5 hours.

Excretion:

• The drug is primarily excreted in the urine (about 61%), with a smaller portion excreted in the feces (approximately 33%).

International Brand Names of Enalapril:

• Epaned
• Vasotec
• ACT Enalapril
• APO-Enalapril
• JAMP Enalapril
• MAR-Enalapril
• MYLAN-Enalapril
• NOVO-Enalapril
• PMS-Enalapril
• PRO-Enalapril-10
• PRO-Enalapril-2.5
• PRO-Enalapril-20
• PRO-Enalapril-5
• RAN-Enalapril
• RIVA-Enalapril
• SANDOZ Enalapril
• SIG-Enalapril
• TARO-Enalapril
• TEVA-Enalapril
• Acapril
• Acebitor
• Acetec
• Acetensil
• Alapren
• Amprace
• Analept
• Anapril
• Anapril S Minitab
• Angiotec
• Angonic
• Antens
• Apridal
• Auspril
• Bajaten
• Baripril
• Bealipril
• Beartec
• Benalipril
• Berlipril
• Biocronil
• Bonapress
• BQL
• Converten
• Corodil
• Crinoren
• Dabonal
• Danssan
• Dynapril
• Ednyt
• Elfonal
• Enace
• Enahexal
• Enalagamma
• Enalap
• Enalapril
• Enaloc
• Enam
• Enap
• Enap i.v.
• Enap [inj.]
• Enaprel
• Enapren
• Enapril
• Enaprin
• Enaril
• Enatec
• Enazil
• Enbid-20
• Enetil
• Enpril
• Entab
• Envas
• Eril
• Ezapril
• Glioten
• Grifopil
• Herten
• Hypace
• Hyperil
• Hypril
• Hytrol
• Iecatec
• Ileveran
• Innovace
• Invoril
• Istopril
• Kalpiren
• KaparlonS
• Korandil
• Lapril
• Lenipril
• Lotrial
• Macpril
• Meipril
• Naprilate
• Naprilene
• Narapril
• Neopril
• Nuril
• Olivin
• Perisafe
• Pres
• Presil
• Prilace
• Rapril
• Renacardon
• Renallapin
• Renite
• Renite XL
• Renitec
• Renitek
• Reniten
• Renivace
• Sintec
• Tenace
• Tenaten
• Unipril
• Vasonorm
• Vasopress
• Vasopril
• Xanef

Enalapril Brand Names in Pakistan:

Enalapril Maleate Tablets 5 Mg in Pakistan
Acelar	Pharmevo (Pvt) Ltd.
Cardace	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Cardil	Himont Pharmaceuticals (Pvt) Ltd.
Cardiotec	Wilsons Pharmaceuticals
Coniuren	Gray`S Pharmaceuticals
Cortec	Nabiqasim Industries (Pvt) Ltd.
Enace	Atco Laboratories Limited
Enetec	Alliance Pharmaceuticals (Pvt) Ltd.
Enpril	Bryon Pharmaceuticals (Pvt) Ltd.
Hipril	Raazee Theraputics (Pvt) Ltd.
Japril	Jawa Pharmaceuticals(Pvt) Ltd.
Lopritol	Unipharma (Pvt) Ltd.
Medipril	Medicaids Pakistan (Pvt) Ltd.
Napril	Caylex Pharmaceuticals (Pvt) Ltd.
Renitec	Obs
Stadelant	Meezab International
Zepres	Continental Chemical Company (Pvt) Ltd.

 

Enalapril Maleate Tablets 10 Mg in Pakistan
Acelar	Pharmevo (Pvt) Ltd.
Alphrin	Qureshi Pharma (Pvt) Ltd.
Amotac	Mass Pharma (Private) Limited
Cardace	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Cardil	Himont Pharmaceuticals (Pvt) Ltd.
Cardiotec	Wilsons Pharmaceuticals
Coniuren	Gray`S Pharmaceuticals
Cortec	Nabiqasim Industries (Pvt) Ltd.
Cortec Plus	Nabiqasim Industries (Pvt) Ltd.
Enace	Atco Laboratories Limited
Enetec	Alliance Pharmaceuticals (Pvt) Ltd.
Enpril	Bryon Pharmaceuticals (Pvt) Ltd.
Hipril	Raazee Theraputics (Pvt) Ltd.
Japril	Jawa Pharmaceuticals(Pvt) Ltd.
Laporide	Usawa Pharmaceuticals
Maxpril	Makson Pharmaceuticals
Napril	Caylex Pharmaceuticals (Pvt) Ltd.
Redopril	Novartis Pharma (Pak) Ltd
Renitec	Obs
Shozupril	W & Ali Sons Pharmaceuticals
Zepres	Continental Chemical Company (Pvt) Ltd.

 

Enalapril Maleate Tablets 20 Mg in Pakistan
Maxpril	Makson Pharmaceuticals
Renitec	Obs
Stadelant	Meezab International
Zepres	Continental Chemical Company (Pvt) Ltd.

Enalapril is a medication used to treat various cardiovascular conditions, primarily high blood pressure (hypertension) and congestive heart failure. It belongs to a class of drugs known as angiotensin-converting enzyme (ACE) inhibitors. Enalapril works by inhibiting the action of the angiotensin-converting enzyme, which is involved in regulating blood pressure and fluid balance in the body.

Angiotensin-converting enzyme inhibitor enalapril (Epaned, Renitec) is used to treat individuals with hypertension, heart failure, and proteinuria.

Enalapril (Epaned, Renitec) Uses:

• Asymptomatic left ventricular dysfunction:
  • lessens the risk of developing heart failure and decreases hospitalisation for people with low ejection failure due to heart failure.
• Heart Failure:
  • Utilized for symptomatic heart failure
  • Guideline recommendations: The American College of Cardiology/American Heart Association's (ACC/AHA) 2013 Heart Failure Guidelines advise using ACE inhibitors in conjunction with other medical therapies that follow the guidelines to stop the progression of heart failure (HF) and reduced ejection fraction in asymptomatic patients with or without a history of myocardial infarction (Stage B HF) or to treat patients with symptomatic HF and reduced ejection fraction to reduce illness and mortality (Stage C HFrEF).

Hypertension:

• Management of hypertension.
  • Guideline recommendations:
    • In the absence of comorbidities (such as cerebrovascular disease, chronic kidney disease, diabetes, heart failure, ischemic heart disease, etc.), the 2017 Guideline for the Avoidance, Discovery, Evaluation, and Managing of High Blood Pressure in Adults suggests that thiazide-like diuretics or dihydropyridine calcium channel blockers may be preferred options due to improved cardiovascular endpoints (eg, prevention of heart failure and stroke).
    • ARBs and ACE inhibitors are also suitable for monotherapy.
    • Combination therapy is initially favoured in patients at high risk (stage 2 hypertension or atherosclerotic cardiovascular disease [ASCVD] risk 10%) and may be necessary to achieve blood pressure objectives.
• Off Label Use of Enalapril in Adults:
  • Non–ST-elevation acute coronary syndrome
  • Steady coronary artery disease
  • ST-elevation acute coronary syndrome
  • Aldosteronism (diagnosis)
  • Bartter's syndrome
  • Hypertension secondary to scleroderma renal crisis
  • Hypertensive crisis
  • Idiopathic edema
  • Postmyocardial infarction for avoidance of ventricular failure

Enalapril (Epaned, Renitec) Dose in Adults

Note: If a person has low sodium levels in their blood, not enough fluid in their body, severe heart failure, kidney problems, or takes water pills, they should take a lower starting dose of enalapril. This is to make sure the medication is safe and effective for them.

Enalapril (Epaned, Renitec) Dose in the treatment of Asymptomatic left ventricular dysfunction:

• When treating asymptomatic left ventricular dysfunction with enalapril, the usual starting dose is 2.5 milligrams taken by mouth twice a day.
• If the patient can tolerate it well, the dose can be gradually increased until they reach the target dose of 10 milligrams taken twice a day.
• The maximum daily dose should not exceed 20 milligrams.
• This dosing strategy helps improve the condition of the heart in patients with asymptomatic left ventricular dysfunction.

Enalapril (Epaned, Renitec) Dose in the treatment of Heart failure:

• In the treatment of heart failure with enalapril, the typical starting dose is 2.5 milligrams taken orally twice a day.
• This dose can be increased gradually, typically over 1-2 week intervals, as tolerated by the patient.
• The maximum daily dose should not exceed 40 milligrams.
• The goal is to reach a target dose of 10 to 20 milligrams taken twice a day.
• This stepwise approach to dosing helps manage heart failure effectively and minimize the risk of side effects.

Enalapril (Epaned, Renitec) Dose in the treatment of Hypertension:

• Initial Dose: Start with 5 milligrams of enalapril taken orally once a day.
• Dose Adjustment: The dose can be adjusted based on how the patient responds to the medication. This adjustment should be done gradually, typically at 1- to 2-week intervals. The goal is to achieve effective blood pressure control.
• Maximum Dose: The maximum daily dose of enalapril for hypertension is 40 milligrams, which can be taken in 1 or 2 divided doses.

Additionally, if a person is switching from intravenous (IV) enalaprilat to oral enalapril therapy, the conversion guidelines are as follows:

• If not taking diuretics at the same time, start with enalapril 5 milligrams orally once a day.
• If taking diuretics and responding well to enalaprilat (IV form) at a dose of 0.625 milligrams every 6 hours, start with enalapril 2.5 milligrams orally once a day. Further adjustments can be made as needed.

Enalapril (Epaned, Renitec) Dose in Childrens

Note: If a person has low sodium levels, not enough fluid in their body, severe heart failure, kidney problems, or takes water pills, they should start with a lower dose of enalapril. This lower dose is safer for them.

Enalapril (Epaned, Renitec) Dose in Heart failure:

For infants, children, and adolescents with heart failure, the dosing of enalapril is based on their body weight.

• Initial Dose: Start with 0.1 milligrams per kilogram of body weight per day. This initial dose should be divided into 1 to 2 doses throughout the day.
• Dose Adjustment: After the initial dose, the healthcare provider may increase the dose gradually over a period of 2 weeks if needed. The maximum dose should not exceed 0.5 milligrams per kilogram of body weight per day.
• Average Effective Dose: On average, for the improvement of congestive heart failure (CHF) in children, a dose of 0.36 milligrams per kilogram of body weight per day was found to be effective. However, some individuals have been treated with doses as high as 0.94 milligrams per kilogram of body weight per day.

Enalapril (Epaned, Renitec) Dose in the treatment of Hypertension:

For infants, children, and adolescents with hypertension (high blood pressure), the dosing of enalapril is based on their body weight.

• Initial Dose: Start with 0.08 milligrams per kilogram of body weight once daily. The maximum initial dose should not exceed 5 milligrams.
• Dose Adjustment: The healthcare provider will adjust the dose based on the child's blood pressure readings. The goal is to find the right dose that effectively controls blood pressure.
• Maximum Dose: It's important to note that doses exceeding 0.58 milligrams per kilogram (or more than 40 milligrams) have not been studied in children and adolescents for hypertension. Therefore, it's recommended to stay within the prescribed dose range and not exceed these limits.

Enalapril (Epaned, Renitec) Dose in Proteinuria and nephrotic syndrome: Oral:

For the treatment of proteinuria, especially in conditions like nephrotic syndrome, dosing of enalapril in children and adolescents is based on limited data.

Fixed Dosing:

• Children aged 7 years and older and adolescents can be given a fixed dose of 2.5 to 5 milligrams per day. This dosing was reported in a retrospective study in pediatric patients who had normal blood pressure. It can be used either as monotherapy or in combination with prednisone.
• In a case series involving three adolescents with sickle cell anemia nephropathy, an initial dose of 5 milligrams per day was used. In one patient, the dose was increased to 7.5 milligrams per day.

Weight-Directed Dosing:

• For children and adolescents, an initial dose of 0.2 milligrams per kilogram of body weight per day is recommended. This dose can be adjusted based on the individual's response, typically at 4- to 12-week intervals.
• The dosing range for weight-directed dosing is 0.2 to 0.6 milligrams per kilogram of body weight per day.
• The maximum daily dose should not exceed 20 milligrams.
• It's important to note that the effectiveness of enalapril in reducing proteinuria appears to be dose-dependent, meaning that the higher the dose, the greater the effect on proteinuria.
• If enalapril is used in combination with another medication that blocks angiotensin (like an angiotensin receptor blocker or ARB), lower doses (0.1 to 0.16 milligrams per kilogram per day) have been reported.

Enalapril Pregnancy Risk Category: D

• Enalapril and similar drugs that affect the renin-angiotensin system can be very harmful to a developing baby if taken during pregnancy.
• They should be stopped as soon as pregnancy is detected because they can lead to serious problems like underdeveloped lungs, skeletal issues, and even the death of the baby.
• These drugs can also cause low levels of amniotic fluid, which is important for the baby's growth.
• If a baby is exposed to these drugs before birth, they should be closely monitored for problems like high potassium levels, low blood pressure, and reduced urine output.
• In some cases, treatments like blood transfusions or dialysis might be needed to help the baby.
• For pregnant women, there are safer options to treat high blood pressure or chronic heart failure, and ACE inhibitors like enalapril are generally not recommended during pregnancy.

Enalapril use during breastfeeding:

• Enalapril and its active form, enalaprilat, can be found in breast milk.
• When we calculate how much of the medication a nursing infant would receive, it's about 1.1% of the dose that's considered therapeutic for an infant.
• In general, medications are considered safe for breastfeeding if the amount passed to the baby through breast milk is less than 10% of a therapeutic dose.
• In this case, the amount of enalapril in breast milk is below that threshold.
• However, it's important to note that because there is a possibility of serious side effects in breastfed infants, especially when the mother takes a high dose of enalapril, the decision to continue breastfeeding or stop should be made carefully, taking into consideration the mother's need for treatment.

Enalapril (Epaned, Renitec) Dose in Kidney Disease:

Normal Kidney Function (Creatinine Clearance >30 mL/minute):

• No dosage adjustment is necessary.

Reduced Kidney Function (Creatinine Clearance ≤30 mL/minute):

• Initial dose: 2.5 milligrams once daily.
• The dose can be increased as needed, but the maximum daily dose should not exceed 40 milligrams.

Heart Failure Patients with Elevated Serum Creatinine (>1.6 mg/dL):

• Initial dose: 2.5 milligrams once daily, which can be increased to twice daily as needed.
• The dose can be further increased in 2.5 milligram increments at intervals of at least 4 days, but the maximum daily dose should not exceed 40 milligrams.

Hemodialysis Patients:

• Enalapril is moderately dialyzable (20% to 50%).
• On dialysis days, the initial dose is 2.5 milligrams after dialysis.
• The dose on non-dialysis days should be adjusted based on blood pressure response.

Conversion from IV Enalaprilat to Oral Enalapril Therapy:

• If the person's kidney function is relatively normal (Creatinine Clearance >30 mL/minute), they can initiate enalapril at 5 milligrams once daily.
• If kidney function is reduced (Creatinine Clearance ≤30 mL/minute), they can initiate enalapril at 2.5 milligrams once daily.

Alternate Recommendations (Aronoff 2007):

• If the person's Glomerular Filtration Rate (GFR) is greater than 50 mL/minute, no dosage adjustment is necessary.
• If GFR is between 10 to 50 mL/minute, administer 50% to 100% of the usual dose.
• If GFR is less than 10 mL/minute, administer only 25% of the usual dose.
• For individuals on peritoneal dialysis, administer only 25% of the usual dose.

Dose in Liver disease:

• In patients with severe liver problems, there is generally no need to adjust the dosage of enalapril.
• Although the conversion of enalapril to its active form, enalaprilat, may be slower or less effective in these patients due to liver impairment, the actual effects of the medication on blood pressure and other factors do not seem to be significantly changed.
• However, it's crucial for individuals with severe liver issues to be monitored closely by their healthcare provider to ensure that the medication is working as expected and to watch for any potential side effects or complications.

---

Note: Data from trials on hypertension and heart failure make up frequency ranges. Patients with CHF frequently have higher rates of side effects. But the incidence of unfavourable

Common Side Effects of Enalapril (Epaned, Renitec):

• Renal:
  • Increased serum creatinine

Less Common Side Effects of Enalapril (Epaned, Renitec):

• Cardiovascular:
  • Hypotension
  • Chest Pain
  • Orthostatic Effect
  • Orthostatic Hypotension
  • Syncope
• Central Nervous System:
  • Fatigue
  • Headache
  • Dizziness
• Dermatologic:
  • Skin Rash
• Gastrointestinal:
  • Anorexia
  • Nausea
  • Constipation
  • Dysgeusia
  • Vomiting
  • Abdominal Pain
  • Diarrhea
• Neuromuscular & Skeletal:
  • Weakness
• Renal:
  • Renal Insufficiency
• Respiratory:
  • Bronchitis
  • Cough
  • Dyspnea

Contraindications to Enalapril (Epaned, Renitec):

Enalapril should not be used in individuals who have:

• Hypersensitivity: An allergy or severe sensitivity to enalapril or any component of the medication.
• Angioedema: A history of angioedema (a severe swelling of deeper layers of the skin) related to previous treatment with an ACE inhibitor.
• Idiopathic or Hereditary Angioedema: Known idiopathic (of unknown cause) or hereditary angioedema.
• Concomitant Use with Aliskiren: Taking enalapril along with aliskiren is contraindicated in patients with diabetes mellitus.
• Coadministration with Neprilysin Inhibitors: Using enalapril in combination with, or within 36 hours of switching to or from, a neprilysin inhibitor such as sacubitril is not recommended.

In Canada, there is an additional contraindication:

• Concomitant Use with Aliskiren-Containing Drugs: Enalapril should not be taken with aliskiren-containing medications in patients with moderate-to-severe renal impairment (where the glomerular filtration rate is less than 60 mL/minute/1.73 m²).

It's important to note that there is a possibility of cross-sensitivity to ACE inhibitors due to similarities in chemical structure and pharmacologic actions, although documented cases of this are limited.

Warnings and precautions

Angioedema

• Angioedema, although rare, can occur at any time during treatment with ACE inhibitors like enalapril, especially after the first dose.
• It can involve swelling of the head and neck, which may potentially block the airway, or it can affect the intestines, leading to abdominal pain.
• It's important to note that African-Americans may have a higher risk of angioedema.
• The risk can also be increased if ACE inhibitors are used in combination with certain other medications like mTOR inhibitors (e.g., everolimus) or neprilysin inhibitors (e.g., sacubitril).
• If angioedema occurs, especially if it affects the tongue, glottis, or larynx and poses a risk of airway obstruction, close and frequent monitoring is essential.
• Patients with a history of airway surgery may be at a higher risk of airway blockage in case of angioedema.
• Aggressive and prompt management is crucial in such cases.
• Enalapril should not be used in patients with a history of idiopathic or hereditary angioedema or previous angioedema related to ACE inhibitor therapy, as it is contraindicated in these individuals.

Cholestatic jaundice

• One rare but serious side effect associated with ACE inhibitors like enalapril is cholestatic jaundice.
• This condition can lead to a blockage in the flow of bile from the liver, resulting in jaundice (yellowing of the skin and eyes).
• In some cases, cholestatic jaundice can progress to a severe liver condition called fulminant hepatic necrosis, which can be fatal.
• If a person taking enalapril experiences a significant increase in liver enzymes or develops jaundice, it's important to discontinue the medication immediately.
• These symptoms should be reported to a healthcare provider promptly for evaluation and appropriate management.

Cough:

• One side effect associated with ACE inhibitors like enalapril is a dry, persistent cough.
• This cough is typically nonproductive (meaning it doesn't produce mucus) and often starts within the first few months of starting the medication.
• Fortunately, this cough usually goes away within 1 to 4 weeks after discontinuing the ACE inhibitor.
• However, before discontinuing the medication, other possible causes of cough should be considered and ruled out, especially in patients with heart failure who may have pulmonary congestion contributing to coughing.

Hematologic effects

• Hematologic effects, such as changes in blood cell counts, have been associated with ACE inhibitors like captopril.
• This can include neutropenia (a low white blood cell count) with myeloid hypoplasia and agranulocytosis, as well as anemia (low red blood cell count) and thrombocytopenia (low platelet count).
• Patients with impaired kidney function are at a higher risk of developing neutropenia, and those with both kidney impairment and collagen vascular diseases like systemic lupus erythematosus are at an even greater risk.
• To monitor for these potential blood-related issues, healthcare providers should periodically check the complete blood count (CBC) with a differential (which looks at the different types of white blood cells) in patients at risk.
• If any abnormalities are detected, appropriate action should be taken to address and manage them.

Hyperkalemia:

• Taking ACE inhibitors like enalapril can sometimes lead to a condition called hyperkalemia, where there is too much potassium in the blood.
• Risk factors for this include kidney problems, diabetes, and using potassium-sparing diuretics, supplements, or salts.
• It's important to be cautious when using these agents together and to keep a close watch on potassium levels through monitoring.

Hypersensitivity reactions

• Hypersensitivity reactions, including anaphylactic or anaphylactoid reactions, can sometimes happen with ACE inhibitors like enalapril.
• In some rare cases, severe anaphylactoid reactions have been observed during hemodialysis using certain high-flux dialysis membranes or during low-density lipoprotein apheresis with dextran sulfate cellulose.
• There have also been isolated reports of anaphylactoid reactions in patients receiving sensitization treatment with hymenoptera (bee or wasp) venom while taking ACE inhibitors.
• It's important to be aware of these potential reactions and to seek immediate medical attention if any signs of a severe allergic reaction occur while taking this medication.

Hypotension/syncope

• ACE inhibitors like enalapril can sometimes cause symptomatic low blood pressure, leading to feelings of dizziness or even fainting, which is known as syncope.
• This is more likely to happen, especially with the first few doses, in patients who have low blood volume (volume-depleted).
• It's important to correct any volume depletion before starting the medication.
• Close monitoring of the patient's blood pressure is necessary, especially when starting or increasing the dose.
• If low blood pressure occurs, the healthcare provider may need to adjust the dose, but this is usually not a reason to stop using ACE inhibitors, particularly in patients with heart failure where lowering blood pressure can be beneficial.
• The rate at which blood pressure is lowered should be appropriate for the patient's clinical condition.

Renal function deterioration:

• In some cases, using ACE inhibitors like enalapril can lead to a decline in kidney function or an increase in serum creatinine levels, especially in patients with conditions like renal artery stenosis or heart failure where kidney blood flow relies on angiotensin II for constriction of blood vessels.
• This deterioration in kidney function may lead to reduced urine output, acute kidney failure, and higher levels of waste products in the blood (azotemia).
• Small increases in serum creatinine may happen when starting the medication, but discontinuation is typically considered only if there is ongoing and significant worsening of kidney function.

Aortic stenosis

• In individuals with severe aortic stenosis, the use of ACE inhibitors like enalapril should be approached with caution.
• These medications can potentially reduce coronary perfusion, which means they might affect the blood supply to the heart muscle and lead to ischemia (inadequate blood flow).
• Therefore, it's important for healthcare providers to carefully consider the risks and benefits of using ACE inhibitors in patients with severe aortic stenosis and to closely monitor their condition during treatment.

Ascites:

• The use of ACE inhibitors like enalapril should generally be avoided in patients with ascites caused by cirrhosis or refractory ascites.
• If there is a compelling reason to use these medications in such patients, it's crucial to monitor their blood pressure and kidney function very closely.
• This close monitoring is necessary to prevent the rapid development of kidney failure, which can occur in these individuals.
• Healthcare providers should weigh the potential benefits and risks carefully before prescribing ACE inhibitors in patients with ascites due to cirrhosis and exercise caution in their management.

Cardiovascular disease

• When starting therapy with ACE inhibitors like enalapril in patients with ischemic heart disease or cerebrovascular disease, it's essential to closely monitor these individuals.
• A potential side effect of ACE inhibitors is low blood pressure, which can have serious consequences such as heart attacks (MI) or strokes.
• If a patient experiences a drop in blood pressure, fluid replacement may be necessary to restore it to a safer level, and then therapy can be resumed.
• However, if hypotension (low blood pressure) recurs or becomes problematic, it may be necessary to discontinue ACE inhibitor therapy.
• Careful observation and management are crucial to balance the potential benefits of the medication against the risk of low blood pressure in these patients.

Collagen vascular disease:

• In patients with collagen vascular diseases, especially when there is also kidney impairment, the use of ACE inhibitors like enalapril should be approached with caution.
• These individuals may have an increased risk of experiencing hematologic toxicity (problems with blood cells).

Hypertrophic cardiomyopathy with outflow tract obstruction (HCM)

• In patients with hypertrophic cardiomyopathy (HCM) who also have outflow tract obstruction, the use of ACE inhibitors like enalapril should be approached with caution.
• These medications can reduce the heart's afterload, which may worsen symptoms associated with HCM in these patients.

Renal artery stenosis

• In patients with unstented unilateral (one-sided) or bilateral (both sides) renal artery stenosis (narrowing of the arteries that supply the kidneys with blood), the use of ACE inhibitors like enalapril should be approached with caution.
• In cases of unstented bilateral renal artery stenosis, it's typically avoided unless the potential benefits significantly outweigh the risks.
• This is because using ACE inhibitors in such patients can increase the risk of kidney function deterioration.

Renal impairment

• In individuals with preexisting kidney problems, ACE inhibitors like enalapril should be used cautiously.
• It may be necessary to adjust the dosage of the medication based on the degree of renal insufficiency.
• It's important to avoid rapid increases in dosage, as this could potentially worsen renal function.

Enalapril: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Risk Factor C (Monitor therapy)
Alfuzosin	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Amphetamines	May lessen the effectiveness of antihypertensive agents.
Angiotensin II	The therapeutic efficacy of angiotensin II may be enhanced by angiotensin-converting enzyme inhibitors.
Antipsychotic Agents (Second Generation [Atypical])	Antipsychotic drugs' hypotensive effects may be enhanced by blood pressure-lowering medications (Second Generation [Atypical]).
Aprotinin	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
AzaTHIOprine	AzaTHIOprine's myelosuppressive effects may be enhanced by angiotensin-converting enzyme inhibitors.
Barbiturates	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Benperidol	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Brigatinib	May lessen the effectiveness of antihypertensive agents. Antihypertensive Agents' bradycardic action may be strengthened by brutinib.
Brimonidine (Topical)	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Dapoxetine	The impact of angiotensin-converting enzyme inhibitors on hyperkalemia may be enhanced.
Dexmethylphenidate	Can lessen an antihypertensive drug's therapeutic impact.
Diazoxide	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Dipeptidyl Peptidase-IV Inhibitors	May worsen angiotensin-converting enzyme inhibitors' toxic or severe effects. Particularly, there may be a higher incidence of angioedema.
Drospirenone	Drospirenone's hyperkalemic impact may be enhanced by angiotensin-converting enzyme inhibitors.
DULoxetine	The hypotensive impact of DULoxetine may be enhanced by blood pressure lowering medications.
Eplerenone	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Everolimus	May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. Particularly, there may be a higher incidence of angioedema.
Ferric Gluconate	Angiotensin-Converting Enzyme Inhibitors might make ferric gluconate more harmful or poisonous.
Ferric Hydroxide Polymaltose Complex	Ferric Hydroxide Polymaltose Complex may have a more negative or toxic effect when taken with angiotensin-converting enzyme inhibitors. In particular, there may be an elevated risk for angioedema or allergic responses.
Gelatin (Succinylated)	Ferric Hydroxide Polymaltose Complex may have a more negative or toxic effect when taken with angiotensin-converting enzyme inhibitors. In particular, there may be an elevated risk for angioedema or allergic responses.
Gold Sodium Thiomalate	Gold Sodium Thiomalate may have a more negative or toxic effect when used with angiotensin-converting enzyme inhibitors. Nitritoid responses are more likely now, it has been noted.
Heparin	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Heparins (Low Molecular Weight)	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Herbs (Hypertensive Properties)	May lessen the effectiveness of antihypertensive agents.
Herbs (Hypotensive Properties)	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Hypotension-Associated Agents	The hypotensive action of hypotension-associated agents may be strengthened by blood pressure lowering medications.
Icatibant	May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.
Levodopa-Containing Products	Levodopa-Containing Products' hypotensive effects may be strengthened by blood pressure-lowering medications.
Loop Diuretics	May strengthen angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by loop diuretics.
Lormetazepam	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Methylphenidate	May lessen the effectiveness of antihypertensive agents.
Molsidomine	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Naftopidil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nicergoline	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nicorandil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nicorandil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nitroprusside	Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside.
Nonsteroidal Anti-Inflammatory Agents	Nonsteroidal Anti-Inflammatory Agents' negative/toxic effects may be increased by angiotensin-converting enzyme inhibitors. In particular, the combination may cause a marked decline in renal function. Angiotensin-Converting Enzyme Inhibitors' antihypertensive effects may be lessened by nonsteroidal anti-inflammatory drugs.
Pentoxifylline	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Pholcodine	Pholcodine's hypotensive impact may be strengthened by blood pressure lowering medications.
Phosphodiesterase 5 Inhibitors	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Potassium Salts	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Potassium-Sparing Diuretics	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Pregabalin	Angiotensin-Converting Enzyme Inhibitors may intensify Pregabalin's negative/toxic effects. Particularly, there may be a higher incidence of angioedema.
Prostacyclin Analogues	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Quinagolide	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Racecadotril	May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. In particular, this combination may make angioedema more likely.
Ranolazine	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Salicylates	May intensify angiotensin-converting enzyme inhibitors' nephrotoxic effects. The therapeutic benefit of angiotensin-converting enzyme inhibitors may be reduced by salicylates.
Sirolimus	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger..
Tacrolimus (Systemic)	Angiotensin-Converting Enzyme Inhibitors may enhance the hyperkalemic effect of Tacrolimus (Systemic).
Temsirolimus	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Thiazide and Thiazide-Like Diuretics	May increase the angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by thiazide and thiazide-like diuretics.
TiZANidine	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Tolvaptan	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Trimethoprim	Angiotensin-Converting Enzyme Inhibitors might make their effect on hyperkalemia stronger.
Yohimbine	May lessen the effectiveness of antihypertensive agents.
Risk Factor D (Consider therapy modification)
Aliskiren	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects. Angiotensin-Converting Enzyme Inhibitors' hypotensive effects may be strengthened by aliskiren. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be made worse by aliskiren. Treatment: It is not advised for diabetic patients to take aliskiren along with ACEIs or ARBs. Combination therapy should be avoided in other patients, especially when CrCl is less than 60 mL/min. If combined, keep a close eye on your blood pressure, potassium, and creatinine levels.
Allopurinol	Angiotensin-Converting Enzyme Inhibitors might make Allopurinol more likely to cause allergic or hypersensitive reactions.
Amifostine	Amifostine's hypotensive impact may be strengthened by blood pressure lowering medications. Treatment: Blood pressure-lowering drugs need to be avoided for 24 hours before amifostine is administered when used at chemotherapeutic doses. Amifostine should not be given if blood pressure lowering treatment cannot be stopped.
Angiotensin II Receptor Blockers	May worsen angiotensin-converting enzyme inhibitors' toxic or severe effects. Angiotensin-Converting Enzyme Inhibitors' serum levels may rise in response to angiotensin II receptor blockers. Management: According to US labelling, it is not advisable to take telmisartan and ramipril. It is unclear whether another ACE inhibitor and ARB combo would be any safer. When possible, take into account alternatives to the mix.
Grass Pollen Allergen Extract (5 Grass Extract)	Grass pollen allergen extract may have a more negative or toxic effect if angiotensin-converting enzyme inhibitors are used (5 Grass Extract). With regard to grass pollen allergen extract, ACE inhibitors may specifically enhance the likelihood of a severe allergic reaction (5 Grass Extract).
Iron Dextran Complex	Angiotensin-Converting Enzyme Inhibitors might make Iron Dextran Complex more harmful or poisonous. Patients taking an ACE inhibitor may be more susceptible to events of the anaphylactic variety. Management: Adhere strictly to the instructions for iron dextran administration, including the use of a test dose before the initial therapeutic dose and the availability of resuscitation tools and qualified people.
Lanthanum	May lower angiotensin-converting enzyme inhibitors' serum concentration. Angiotensin-converting enzyme inhibitors should be given at least two hours before or after lanthanum.
Lithium	The serum concentration of lithium may rise in response to angiotensin-converting enzyme inhibitors. Management: After adding an ACE inhibitor, lithium dosage decreases will probably be required. Following the addition or discontinuation of concurrent ACE inhibitor therapy, carefully monitor the patient's response to lithium.
Obinutuzumab	The hypotensive effects of blood pressure-lowering medications may be strengthened. Management: Take into account temporarily stopping blood pressure-lowering drugs 12 hours before the start of the obinutuzumab infusion and keeping them off until 1 hour after the infusion is finished.
Sodium Phosphates	The nephrotoxic impact of sodium phosphates may be enhanced by angiotensin-converting enzyme inhibitors. In particular, there may be an increased risk of acute phosphate nephropathy. Treatment: You might want to temporarily stop taking ACEIs or look into alternatives to the oral sodium phosphate bowel preparation in order to prevent this combo. Maintaining appropriate hydration and properly monitoring renal function should be done if the combination cannot be avoided.
Urapidil	Angiotensin-Converting Enzyme Inhibitors may interact with them through an unidentified method. Avoid taking urapidil and ACE inhibitors simultaneously as a management strategy.
Risk Factor X (Avoid combination)
Bromperidol	May lessen blood pressure lowering agents' hypotensive effects. The hypotensive impact of bromperidol may be enhanced by blood pressure lowering medications.
Sacubitril	The negative or hazardous effects of sacubitril may be increased by angiotensin-converting enzyme inhibitors. In particular, this combination may raise the risk of angioedema.

Monitoring parameters:

• Blood Pressure: Regularly check blood pressure to ensure it's within the desired range for your specific condition.
• Serum Creatinine and Potassium: Monitor levels of serum creatinine and potassium in your blood. Changes in these levels may require adjustments to your treatment.
• Collagen Vascular Disease and Renal Impairment: If you have collagen vascular disease (a group of autoimmune diseases) and/or kidney problems, periodic monitoring of your complete blood count (CBC) with differential (looking at different types of blood cells) may be necessary.

Heart Failure:

• Renal Function and Serum Potassium: Within 1 to 2 weeks after starting enalapril for heart failure, and regularly afterward, your healthcare provider will assess your renal (kidney) function and serum potassium levels. This is especially important if you have preexisting issues like low blood pressure, low sodium levels, diabetes, kidney problems, or if you take potassium supplements.

Hypertension:

• Blood Pressure Targets (ACC/AHA 2017):
  • If you have confirmed hypertension and known cardiovascular disease (CVD) or a high risk of CVD (greater than 10% 10-year risk), your target blood pressure is recommended to be below 130/80 mm Hg.
  • If you have confirmed hypertension without markers of increased CVD risk, a target blood pressure below 130/80 mm Hg may be reasonable.
• Diabetes and Hypertension (ADA 2019):
  • For patients aged 18 to 65 without CVD and a 10-year CVD risk of less than 15%, the recommended target blood pressure is below 140/90 mm Hg.
  • If you are aged 18 to 65 with known CVD or a 10-year CVD risk greater than 15%, a target blood pressure below 130/80 mm Hg may be appropriate if it's safe for you.
  • For patients over 65, the target blood pressure is typically below 140/90 mm Hg, but in very complex or poor health, it may be below 150/90 mm Hg.

These monitoring guidelines help ensure that your treatment with enalapril is safe and effective for your specific medical condition.

How to administer Enalapril (Epaned, Renitec)?

• You can take enalapril by mouth without needing to consider whether you've eaten or not.
• It can be taken with or without food.

Mechanism of action of Enalapril (Epaned, Renitec):

• Enalapril is a medication that competes with angiotensin-converting enzyme (ACE) in the body.
• It works by blocking ACE's action, which normally converts angiotensin I into angiotensin II.
• Angiotensin II is a powerful substance that constricts blood vessels.
• When you take enalapril, it lowers the levels of angiotensin II in your body.
• This, in turn, leads to an increase in plasma renin activity (an enzyme related to blood pressure regulation) and a decrease in the secretion of aldosterone (a hormone that affects salt and water balance).
• The overall effect is a reduction in blood pressure and less strain on the heart.

Onset of Action:

• It starts to work in approximately 1 hour after taking the medication.

Peak Effect:

• The maximum effect is usually reached at 4 to 6 hours after taking it.

Duration:

• Its effects typically last for 12 to 24 hours.

Absorption:

• Enalapril is absorbed by the body in the range of 55% to 75%.

Protein Binding:

• About 50% of enalapril binds to proteins in the blood.

Metabolism:

• Enalapril is a prodrug, which means it needs to be transformed in the liver to become active.
• It is converted into its active form, enalaprilat, through hepatic biotransformation.

Half-life Elimination:

• Enalapril has a half-life of about 2 hours in healthy adults, but it can be longer in individuals with congestive heart failure (CHF), ranging from 3.4 to 5.8 hours.
• Enalaprilat, the active metabolite, has a half-life of approximately 35 hours in adults and can vary in neonates and children.

Time to Peak, Serum:

• After taking enalapril orally, it reaches peak serum levels within 0.5 to 1.5 hours.
• Enalaprilat, the active form, reaches its peak serum levels at 3 to 4.5 hours.

Excretion:

• The drug is primarily excreted in the urine (about 61%), with a smaller portion excreted in the feces (approximately 33%).

International Brand Names of Enalapril:

• Epaned
• Vasotec
• ACT Enalapril
• APO-Enalapril
• JAMP Enalapril
• MAR-Enalapril
• MYLAN-Enalapril
• NOVO-Enalapril
• PMS-Enalapril
• PRO-Enalapril-10
• PRO-Enalapril-2.5
• PRO-Enalapril-20
• PRO-Enalapril-5
• RAN-Enalapril
• RIVA-Enalapril
• SANDOZ Enalapril
• SIG-Enalapril
• TARO-Enalapril
• TEVA-Enalapril
• Acapril
• Acebitor
• Acetec
• Acetensil
• Alapren
• Amprace
• Analept
• Anapril
• Anapril S Minitab
• Angiotec
• Angonic
• Antens
• Apridal
• Auspril
• Bajaten
• Baripril
• Bealipril
• Beartec
• Benalipril
• Berlipril
• Biocronil
• Bonapress
• BQL
• Converten
• Corodil
• Crinoren
• Dabonal
• Danssan
• Dynapril
• Ednyt
• Elfonal
• Enace
• Enahexal
• Enalagamma
• Enalap
• Enalapril
• Enaloc
• Enam
• Enap
• Enap i.v.
• Enap [inj.]
• Enaprel
• Enapren
• Enapril
• Enaprin
• Enaril
• Enatec
• Enazil
• Enbid-20
• Enetil
• Enpril
• Entab
• Envas
• Eril
• Ezapril
• Glioten
• Grifopil
• Herten
• Hypace
• Hyperil
• Hypril
• Hytrol
• Iecatec
• Ileveran
• Innovace
• Invoril
• Istopril
• Kalpiren
• KaparlonS
• Korandil
• Lapril
• Lenipril
• Lotrial
• Macpril
• Meipril
• Naprilate
• Naprilene
• Narapril
• Neopril
• Nuril
• Olivin
• Perisafe
• Pres
• Presil
• Prilace
• Rapril
• Renacardon
• Renallapin
• Renite
• Renite XL
• Renitec
• Renitek
• Reniten
• Renivace
• Sintec
• Tenace
• Tenaten
• Unipril
• Vasonorm
• Vasopress
• Vasopril
• Xanef

Enalapril Brand Names in Pakistan:

Enalapril Maleate Tablets 5 Mg in Pakistan
Acelar	Pharmevo (Pvt) Ltd.
Cardace	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Cardil	Himont Pharmaceuticals (Pvt) Ltd.
Cardiotec	Wilsons Pharmaceuticals
Coniuren	Gray`S Pharmaceuticals
Cortec	Nabiqasim Industries (Pvt) Ltd.
Enace	Atco Laboratories Limited
Enetec	Alliance Pharmaceuticals (Pvt) Ltd.
Enpril	Bryon Pharmaceuticals (Pvt) Ltd.
Hipril	Raazee Theraputics (Pvt) Ltd.
Japril	Jawa Pharmaceuticals(Pvt) Ltd.
Lopritol	Unipharma (Pvt) Ltd.
Medipril	Medicaids Pakistan (Pvt) Ltd.
Napril	Caylex Pharmaceuticals (Pvt) Ltd.
Renitec	Obs
Stadelant	Meezab International
Zepres	Continental Chemical Company (Pvt) Ltd.

Enalapril Maleate Tablets 10 Mg in Pakistan
Acelar	Pharmevo (Pvt) Ltd.
Alphrin	Qureshi Pharma (Pvt) Ltd.
Amotac	Mass Pharma (Private) Limited
Cardace	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Cardil	Himont Pharmaceuticals (Pvt) Ltd.
Cardiotec	Wilsons Pharmaceuticals
Coniuren	Gray`S Pharmaceuticals
Cortec	Nabiqasim Industries (Pvt) Ltd.
Cortec Plus	Nabiqasim Industries (Pvt) Ltd.
Enace	Atco Laboratories Limited
Enetec	Alliance Pharmaceuticals (Pvt) Ltd.
Enpril	Bryon Pharmaceuticals (Pvt) Ltd.
Hipril	Raazee Theraputics (Pvt) Ltd.
Japril	Jawa Pharmaceuticals(Pvt) Ltd.
Laporide	Usawa Pharmaceuticals
Maxpril	Makson Pharmaceuticals
Napril	Caylex Pharmaceuticals (Pvt) Ltd.
Redopril	Novartis Pharma (Pak) Ltd
Renitec	Obs
Shozupril	W & Ali Sons Pharmaceuticals
Zepres	Continental Chemical Company (Pvt) Ltd.

Enalapril Maleate Tablets 20 Mg in Pakistan
Maxpril	Makson Pharmaceuticals
Renitec	Obs
Stadelant	Meezab International
Zepres	Continental Chemical Company (Pvt) Ltd.