Enalapril

Enalapril is a second-generation ACE inhibitor and has been used since the 1980s to treat high blood pressure and heart failure. As a prodrug, it is converted in the body into active enalaprilat.

It is available as a single-ingredient product and in combination with hydrochlorothiazide (Enalapril-ratiopharm® comp.) or lercanidipine (Enalapril/Lercanidipin-ratiopharm). For high blood pressure, enalapril is taken once daily. For heart failure, it is taken as a single dose or divided into two doses.

Like all ACE inhibitors, enalapril works by inhibiting the angiotensin-converting enzyme:

Mechanism of action:

• Is converted in the body into enalaprilat (the active form)
• Inhibits the conversion of angiotensin I to angiotensin II
• Angiotensin II is a potent vasoconstrictor
• The blood vessels widen, and blood pressure falls

Special features:

• Prodrug that is activated by metabolism in the liver
• Onset of action after 1 hour
• Duration of action 12-24 hours
• Protects the heart and kidneys from remodeling

Additional effects:

• Reduction of afterload on the heart
• Improvement of cardiac performance in heart failure
• Reduction of protein excretion via the kidneys

Enalapril is suitable for:

• Adults with high blood pressure
• Patients with heart failure
• Prevention of symptomatic heart failure

Advantages:

• Many years of experience and a strong body of study data
• Also approved for heart failure
• Available as a generic

Not suitable:

• Pregnancy and breastfeeding
• History of angioedema
• Bilateral renal artery stenosis
• Children (except for a specific indication)

High blood pressure:

• Starting dose: 5 mg once daily
• Usual maintenance dose: 20 mg once daily
• Maximum dose: 40 mg daily

Heart failure:

• Starting dose: 2.5 mg once daily
• Gradual increase
• Target dose: 20 mg daily (as a single dose or divided into two doses)

Available strengths:

• 2.5 mg, 5 mg, 10 mg, 20 mg tablets

Combination products:

• Enalapril + hydrochlorothiazide (Enalapril comp.)
• Enalapril + lercanidipine

How to take:

• Once or twice daily, always at the same time
• With or without food
• With sufficient water

Notes:

• Take the first dose in the evening if possible (drop in blood pressure)
• Gradual dose increase over weeks
• Regular blood pressure and laboratory checks
• Do not stop abruptly

If you miss a dose:

• Take it within a few hours
• Otherwise, take the next dose at the usual time
• Never take a double dose

Enalapril must not be taken in cases of:

• Hypersensitivity to enalapril or other ACE inhibitors
• History of angioedema
• Bilateral renal artery stenosis
• Pregnancy in the 2nd and 3rd trimester

Caution in cases of:

• Impaired kidney function
• Liver function disorders
• Elevated potassium levels
• Concomitant diuretic therapy
• Aortic stenosis

Pregnancy and breastfeeding: Enalapril is not recommended in the 1st trimester of pregnancy and is contraindicated in the 2nd and 3rd trimesters. Can cause serious harm to the unborn child. Treatment should not be started during pregnancy. If pregnancy is detected, treatment must be stopped immediately and, if necessary, another therapy started. If you wish to have children, switch to a safe medication in good time. Enalapril is not recommended when breastfeeding premature infants or in the first weeks after delivery. For older infants, use during breastfeeding may be considered if the treatment is necessary for the mother and the infant is carefully monitored.

Very common (10% or more):

• Dry, irritating cough
• Dizziness
• Feeling of weakness
• Blurred vision
• Nausea

Common (1-10%):

• Headache
• Drop in blood pressure (including orthostatic)
• Diarrhea
• Skin rash
• Elevated potassium levels
• Angioedema (call emergency services immediately!)

Uncommon (0.1-1%):

• Muscle cramps
• Severe kidney dysfunction

Rare:

• Liver function disorders
• Changes in blood count

Note: The cough is typically dry and persistent and subsides after treatment is stopped.

Increased blood pressure lowering:

• Other antihypertensives
• Diuretics
• Nitrates

Increase in potassium:

• Potassium-sparing diuretics
• Potassium supplements
• Trimethoprim

Reduced effect:

• NSAIDs (ibuprofen, diclofenac)
• High salt intake

Other interactions:

• Lithium (increased levels)
• Antidiabetic drugs (increased blood sugar lowering)
• Allopurinol (increased risk of allergy)