Clinical beta

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Drug Monograph

Enalapril

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Enalapril

ACE inhibitor (prodrug to enalaprilat)

AdultACEiHFHTNCKD

Indication

HFrEF β€’ Post-MI LV dysfunction risk reduction β€’ CKD proteinuria β€’ HTN

At a glance

INDICATIONS (CORE USE)

HFrEF, post-MI remodeling risk reduction, CKD with proteinuria, hypertension.

ADULT DOSE (STANDARD)

PO START at 2.5–5 mg daily (or BID in HF) and titrate with BP/renal labs.

MAX DOSE

Typical max 40 mg/day (indication-specific).

Route

PO (prodrug); formulation-specific titration

PEDIATRIC DOSE

Specialist pediatric HTN protocols only.

Do not miss

Must-not-miss safety points

Major warning

- Angioedema can be delayed and fatal β†’ DO NOT re-challenge any ACE inhibitor - Pregnancy is contraindicated β†’ DO NOT use

Indications

USE IF: HFrEF, post-MI, CKD proteinuria, HTN. AVOID IF: pregnancy, prior ACEi angioedema, bilateral renal artery stenosis, hyperkalemia, or active hypoperfusion.

Primary

  • Hypertension
  • HFrEF
  • CKD with albuminuria/proteinuria

Secondary

  • Post-MI LV dysfunction/remodeling risk reduction

Dosing

STANDARD (ADULT PO)

START low, titrate by BP + creatinine + potassium.

ADULT DOSE

HTN: START 5 mg daily, titrate to response. HFrEF/post-MI: START lower (e.g. 2.5 mg BID), up-titrate cautiously. DO NOT up-titrate without interval lab check.

PEDIATRIC DOSE

Specialist only.

MAX DOSE

Typically up to 40 mg/day.

Practical Note

Volume depletion before initiation increases first-dose hypotension risk β€” correct volume first.

Warnings

Clinical warnings

  • Angioedema can be delayed and fatal β€” DO NOT re-challenge. First-dose hypotension risk is higher with volume depletion / HF / high-renin states; correct volume before starting.

Adverse effects

  • Cough
  • hyperkalemia
  • hypotension
  • AKI trend
  • angioedema (rare, severe)

Contraindications

  • Pregnancy
  • Prior ACE inhibitor-induced angioedema
  • Bilateral renal artery stenosis (known/suspected)
  • Baseline K+ β‰₯5.5 mmol/L

Drug interactions

  • ARB / aliskiren combination: avoid routine dual RAAS blockade (AKI, hyperkalemia, hypotension risk)
  • Potassium-sparing agents / supplements: hyperkalemia risk
  • NSAIDs β†’ ↑ AKI risk + ↓ ACEi effect β€” avoid or monitor closely
  • Loop/thiazide preload depletion can amplify first-dose hypotension.

Special populations

Pediatrics

Specialist pediatric HTN protocols only.

Pregnancy

Pregnancy: DO NOT use (teratogenic).

Lactation

specialist risk/benefit decision.

Renal impairment

START lower in CKD; monitor creatinine/potassium closely after each change.

Hepatic impairment

No major hepatic activation concern beyond prodrug conversion context; dose to BP + lab response.

Elderly

START low and titrate slower due to hypotension/renal sensitivity.

Administration

PO at consistent timing; titrate with lab safety checks.

Monitoring

  • Recheck: - Check creatinine + potassium within 1–2 weeks after initiation - Recheck creatinine + potassium within 1–2 weeks after dose increase - Check earlier if CKD, elderly, volume depletion, or interacting drugs
  • Hold if:
    - HOLD if:
    - SBP <90–100
    - K+ β‰₯5.5 mmol/L
    - creatinine rise >30% from baseline
    - symptomatic hypotension
    - STOP permanently if angioedema
  • If targets not met after reassessment of dose, organ function, and interactions β†’ escalate per protocol (DO NOT continue blindly)

Overdose / toxicity

Clinical Picture

A) Mild β†’ dizziness, hypotension, fatigue B) Moderate β†’ persistent hypotension, AKI trend, hyperkalemia C) Severe β†’ refractory shock, severe hyperkalemia, respiratory compromise (e.g. angioedema context)

Immediate Actions

β€’ Airway + continuous monitoring (ABC, BP, telemetry) β€’ Hypotension β†’ IV fluids first-line β€’ Refractory hypotension β†’ early vasopressors (norepinephrine) β€’ Check potassium immediately β†’ treat per hyperkalemia protocol if elevated β€’ Stop ACE inhibitor

Antidote

- No specific antidote - Supportive care + hemodynamic stabilization - Hyperkalemia treatment β†’ calcium + insulin/dextrose + potassium-shifting protocol - Airway intervention β†’ if angioedema compromises respiration

Decontamination

β€’ Recent oral ingestion β†’ activated charcoal if protected airway and early presentation (toxicology-guided)

Escalation

- Refractory hypotension or airway compromise β†’ ICU + early vasopressors / airway team - Severe hyperkalemia / AKI β†’ nephrology + renal replacement planning if indicated

Clinical pearls

Common mistakes, resistance logic, and bedside traps

High-Yield Summary

Lab-driven titration drug: creatinine/potassium checks are mandatory after start and dose changes.

Clinical pearls

Do not confuse transient creatinine rise tolerance with unchecked AKI progression.

ACE inhibitor safety

  • Check labs 1–2 weeks after initiation
  • Stop permanently if ACEi angioedema occurs

Pharmacy Tool

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Enalapril 0.1 mg/mL oral suspension

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Pharmacokinetics

Prodrug to enalaprilat; HF regimens often split BID for stability.

Mechanism of action

RAAS blockade via ACE inhibition β†’ afterload reduction + renal efferent vasodilation effect.

Common brand names

Saudi Arabia

Renitec, Vasotec, Enap

Global

(placeholder β€” verify local formulation)

Common trade names are curated examples only β€” formulations and availability vary. Verify the exact product name with your local pharmacy and national regulator before prescribing or dispensing.

Country practice notes

Global data (no country-specific data available)

  • Follow local antimicrobial stewardship policy, hospital formulary, and national resistance guidance.
  • Confirm dosing, stock, and restrictions with institutional pharmacy and current product labeling.

References

Saudi Arabia

  • SFDA (Saudi Food & Drug Authority)
  • Saudi National Formulary / MOH (where available)

International

  • WHO Model List of Essential Medicines (verify current edition)
  • US FDA or EU EMA product information (when national SmPC is unavailable)
  • ACC / AHA HF, post-MI, and HTN guidance
  • KDIGO CKD and proteinuria guidance
  • FDA / SFDA product labeling

Do not miss

  • Angioedema can be delayed and fatal β†’ DO NOT re-challenge
  • Pregnancy contraindicated β†’ DO NOT use
  • First-dose hypotension risk (especially HF / volume depletion) β†’ correct volume before starting
  • Hyperkalemia risk β†’ monitor potassium early
  • Check labs 1–2 weeks after initiation
  • Stop permanently if ACEi angioedema occurs