Enalapril
ACE inhibitor for high blood pressure and heart failure
Enalapril is a widely prescribed ACE inhibitor (angiotensin-converting enzyme inhibitor) used to treat high blood pressure (hypertension), heart failure, and left ventricular dysfunction. It works by relaxing blood vessels, thereby lowering blood pressure and reducing the heart's workload. Enalapril is listed on the WHO Model List of Essential Medicines and has been in clinical use since the 1980s, supported by extensive evidence from landmark trials including CONSENSUS and SOLVD.
Quick Facts: Enalapril
Key Takeaways
- Enalapril is an ACE inhibitor that lowers blood pressure by preventing the formation of angiotensin II, a hormone that constricts blood vessels.
- It is used to treat hypertension, heart failure, and left ventricular dysfunction, and has been shown to reduce hospitalization and improve survival in heart failure patients.
- The most common side effect is a persistent dry cough, which affects more than 1 in 10 users. Other common effects include dizziness and fatigue.
- Enalapril must never be used during pregnancy (especially the second and third trimesters) due to the risk of serious fetal harm.
- The medication typically begins working within 1 hour, with effects lasting approximately 24 hours, but optimal blood pressure control may take several weeks to achieve.
What Is Enalapril and What Is It Used For?
Quick Answer: Enalapril is an ACE inhibitor medication used to treat high blood pressure (hypertension), heart failure, and left ventricular dysfunction. It works by blocking the angiotensin-converting enzyme, causing blood vessels to relax and widen, which lowers blood pressure and reduces strain on the heart.
Enalapril belongs to a class of medications known as ACE inhibitors (angiotensin-converting enzyme inhibitors). The active substance, enalapril maleate, is a prodrug that is converted in the liver to its active form, enalaprilat. This active metabolite blocks the ACE enzyme, which normally converts angiotensin I to angiotensin II — a potent vasoconstrictor. By preventing this conversion, enalapril causes blood vessels to dilate, reduces the secretion of the hormone aldosterone, and ultimately lowers blood pressure.
The medication was first approved by the FDA in 1985 and has since become one of the most widely prescribed antihypertensive drugs worldwide. It is included on the WHO Model List of Essential Medicines, reflecting its proven efficacy, safety profile, and cost-effectiveness. Enalapril is available as a generic medication from multiple manufacturers, making it accessible in healthcare systems around the world.
Approved Indications
Enalapril is approved for the following indications:
- Hypertension (high blood pressure): Enalapril is used as first-line or second-line therapy for the management of essential hypertension. According to ESC/ESH guidelines, ACE inhibitors are one of the five main drug classes recommended for the initial treatment of hypertension, particularly in patients under 55 years of age, those with diabetes, or those with chronic kidney disease with proteinuria.
- Heart failure: Enalapril is used in the treatment of symptomatic heart failure (reduced ejection fraction). The landmark CONSENSUS trial (1987) demonstrated that enalapril reduced mortality by 40% at six months in patients with severe heart failure. The SOLVD trial further confirmed significant reductions in mortality and hospitalization. ACE inhibitors remain a cornerstone of heart failure management in all international guidelines.
- Asymptomatic left ventricular dysfunction: In patients with reduced ejection fraction but without symptoms, enalapril has been shown to delay the progression to symptomatic heart failure and reduce the risk of hospitalization.
How Enalapril Works
The renin-angiotensin-aldosterone system (RAAS) is one of the body's key mechanisms for regulating blood pressure and fluid balance. When blood pressure drops, the kidneys release an enzyme called renin, which converts angiotensinogen to angiotensin I. The angiotensin-converting enzyme (ACE) then converts angiotensin I to angiotensin II, a powerful vasoconstrictor that also stimulates the release of aldosterone, leading to sodium and water retention.
Enalapril interrupts this cascade by inhibiting ACE. This has several beneficial effects: blood vessels relax and widen (vasodilation), aldosterone secretion decreases (reducing fluid retention), and the breakdown of bradykinin (a vasodilator) is reduced. The net result is lower blood pressure and decreased cardiac workload. The effect typically begins within 1 hour of taking the medication and lasts for at least 24 hours, allowing for once-daily dosing in most patients.
Some individuals may require several weeks of treatment before the optimal blood pressure reduction is achieved. This is because the full hemodynamic and hormonal effects of ACE inhibition take time to manifest, including the reversal of vascular remodeling and reductions in left ventricular hypertrophy that occur over months of treatment.
What Should You Know Before Taking Enalapril?
Quick Answer: Do not take enalapril if you are pregnant, have a history of angioedema, or are taking sacubitril/valsartan or aliskiren (in patients with diabetes or kidney impairment). Tell your doctor about all medical conditions, especially kidney disease, diabetes, or heart problems, and all medications you are taking.
Contraindications
You must not take enalapril in the following situations:
- You are allergic to enalapril maleate or any other ingredient in the formulation.
- You have ever had angioedema (swelling of the face, lips, tongue, or throat causing breathing or swallowing difficulties) related to previous ACE inhibitor use, or a hereditary or idiopathic angioedema.
- You are in the second or third trimester of pregnancy. Use during the first trimester is also not recommended.
- You have diabetes or impaired kidney function and are being treated with aliskiren (a direct renin inhibitor).
- You are taking or have recently taken sacubitril/valsartan (used for chronic heart failure), as this increases the risk of angioedema. Enalapril must not be started until at least 36 hours after the last dose of sacubitril/valsartan.
Warnings and Precautions
Before starting enalapril, inform your doctor if any of the following conditions apply to you, as special monitoring or dose adjustments may be necessary:
- Heart disease: Including coronary artery disease, aortic stenosis, or hypertrophic cardiomyopathy. Excessive blood pressure reduction may impair coronary perfusion.
- Cerebrovascular disease: Patients with conditions affecting blood vessels in the brain are at increased risk of complications from low blood pressure.
- Kidney disease or kidney transplant: Enalapril is primarily excreted by the kidneys and may elevate potassium levels. Dose adjustments are required, and your doctor will monitor kidney function and electrolytes regularly.
- Dialysis: Anaphylactoid reactions have been reported in patients on dialysis with high-flux membranes (e.g., AN69) who are also taking ACE inhibitors.
- Diabetes: Blood glucose levels should be monitored closely, especially during the first month of treatment, as ACE inhibitors may enhance insulin sensitivity. Potassium levels may also increase.
- Liver disease: Rarely, ACE inhibitors have been associated with a syndrome beginning with cholestatic jaundice and progressing to fulminant hepatic necrosis. If you develop jaundice or significant elevations in liver enzymes, stop enalapril and seek medical attention.
- Blood disorders: Including low white blood cell count (neutropenia), low platelet count (thrombocytopenia), or anemia. Regular blood tests may be needed.
- Collagen vascular disease: Including systemic lupus erythematosus (SLE), rheumatoid arthritis, or scleroderma. These conditions, especially when combined with immunosuppressive therapy or allopurinol, increase the risk of neutropenia and agranulocytosis.
- Low blood pressure: Particularly common at the start of treatment, especially in patients who are volume-depleted (e.g., from diuretic therapy, dietary salt restriction, diarrhea, or vomiting). You may experience weakness or dizziness, especially when standing up.
The risk of angioedema is higher if you are also taking racekadotril (for diarrhea), mTOR inhibitors such as temsirolimus, sirolimus, or everolimus (for organ transplant rejection or cancer), or vildagliptin (for diabetes). Black patients may have a higher incidence of angioedema with ACE inhibitors. If you develop swelling of the face, lips, tongue, or throat, stop the medication immediately and seek emergency medical attention.
Before Medical Procedures
Tell your doctor or dentist that you are taking enalapril if you are scheduled for any of the following:
- Surgery or anesthesia (including dental procedures)
- LDL apheresis (a procedure to remove cholesterol from the blood)
- Desensitization therapy (e.g., for bee or wasp sting allergy)
Pregnancy and Breastfeeding
Enalapril must not be used during pregnancy. If you become pregnant while taking enalapril, contact your doctor immediately to switch to an alternative medication. Enalapril can cause serious harm to the developing fetus, including:
- Fetal kidney dysfunction and failure
- Oligohydramnios (reduced amniotic fluid)
- Skull ossification defects
- Hypotension and renal failure in the newborn
- Fetal death (in severe cases)
The risk is particularly high during the second and third trimesters, but first-trimester use should also be avoided. Your doctor will typically recommend switching to an alternative antihypertensive before conception if pregnancy is planned.
Breastfeeding: Enalapril and its active metabolite enalaprilat are excreted in breast milk in small amounts. Breastfeeding of newborns (especially premature infants) during enalapril treatment is not recommended due to the potential for cardiovascular and renal effects. For older infants, your doctor will weigh the benefits of treatment against the potential risks to the nursing child.
Driving and Operating Machinery
Enalapril may cause dizziness and fatigue, particularly at the start of treatment or when the dose is increased. If you experience these effects, do not drive or operate machinery until you know how the medication affects you. These effects are most likely to occur in the first few days after starting treatment or after a dose increase.
Excipients
Some enalapril formulations contain lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency, or glucose-galactose malabsorption should not take these formulations. The tablets contain less than 1 mmol (23 mg) sodium per dose, i.e., essentially sodium-free.
How Does Enalapril Interact with Other Drugs?
Quick Answer: Enalapril can interact with many medications. The most clinically significant interactions include potassium supplements and potassium-sparing diuretics (risk of hyperkalemia), NSAIDs (reduced antihypertensive effect and kidney damage), lithium (increased lithium toxicity), and dual RAAS blockade with ARBs or aliskiren (increased risk of hypotension, kidney impairment, and hyperkalemia).
Always inform your doctor or pharmacist about all medications you are taking, including over-the-counter medicines, herbal supplements, and vitamins. Some medications can significantly alter the effectiveness or safety of enalapril, and dose adjustments or additional monitoring may be required.
Major Interactions
| Drug / Class | Interaction | Clinical Significance |
|---|---|---|
| Aliskiren | Dual RAAS blockade increases risk of hypotension, hyperkalemia, and renal impairment | Contraindicated in patients with diabetes or renal impairment; avoid combination in others |
| ARBs (e.g., valsartan, telmisartan) | Dual RAAS blockade with similar risks as aliskiren combination | Generally avoid combination; increased risk of hypotension, renal failure, hyperkalemia |
| Sacubitril/Valsartan | Markedly increased risk of angioedema due to combined inhibition of neprilysin and ACE | Contraindicated; allow at least 36-hour washout before switching |
| Potassium supplements / K-sparing diuretics | ACE inhibitors reduce aldosterone secretion, increasing potassium retention | Risk of life-threatening hyperkalemia; monitor potassium levels closely |
| Lithium | ACE inhibitors reduce renal lithium clearance, increasing serum lithium levels | Risk of lithium toxicity; monitor lithium levels frequently if combination is necessary |
| NSAIDs (including COX-2 inhibitors) | Reduced antihypertensive effect; increased risk of renal impairment and hyperkalemia | Monitor blood pressure and renal function; avoid long-term combination if possible |
Other Interactions to Be Aware Of
| Drug / Class | Effect | Advice |
|---|---|---|
| Diuretics (thiazide, loop) | Enhanced blood pressure reduction; risk of first-dose hypotension | Consider reducing or stopping diuretic before starting enalapril; monitor blood pressure |
| Beta-blockers | Additive blood-pressure-lowering effect | Common and often beneficial combination; monitor for excessive hypotension |
| Antidiabetic agents (insulin, sulfonylureas) | Enhanced hypoglycemic effect | Monitor blood glucose closely, especially in the first month of enalapril therapy |
| Trimethoprim / Co-trimoxazole | Increased risk of hyperkalemia | Monitor potassium levels; use with caution |
| Gold injections (sodium aurothiomalate) | Nitritoid reactions (flushing, nausea, hypotension) reported rarely | Be aware of this rare but documented interaction |
| mTOR inhibitors (temsirolimus, sirolimus, everolimus) | Increased risk of angioedema | Monitor for signs of angioedema; use with caution |
| Racekadotril | Increased risk of angioedema (inhibition of neprilysin-mediated bradykinin degradation) | Use with caution; monitor for angioedema symptoms |
| Vildagliptin | Increased risk of angioedema | Monitor for swelling of face, lips, tongue, or throat |
Food and Alcohol Interactions
Food: Enalapril can be taken with or without food. Absorption is not significantly affected by meals. Take the tablet with an adequate amount of fluid (approximately 150 ml / half a glass of water).
Alcohol: Alcohol enhances the blood-pressure-lowering effect of enalapril and may cause excessive drops in blood pressure, leading to dizziness, lightheadedness, or fainting. Patients should be cautious with alcohol consumption, especially during the first weeks of treatment or after dose adjustments.
Potassium-rich foods and salt substitutes: Since enalapril can increase potassium levels, patients should avoid excessive consumption of potassium-rich foods (bananas, oranges, potatoes, spinach) and potassium-containing salt substitutes without medical advice.
What Is the Correct Dosage of Enalapril?
Quick Answer: For hypertension, the usual starting dose is 5–20 mg once daily, with a maintenance dose of 20 mg/day and a maximum of 40 mg/day. For heart failure, the starting dose is 2.5 mg once daily, gradually increased to a target of 20 mg/day (in one or two doses), with a maximum of 40 mg/day. Dose adjustments are required for kidney impairment and elderly patients.
Always take enalapril exactly as prescribed by your doctor. The dose will be individualized based on your condition, response to treatment, kidney function, and other factors. Do not change your dose without medical advice. The tablet should be taken with an adequate amount of fluid at approximately the same time each day.
Adults
| Indication | Starting Dose | Maintenance Dose | Maximum Dose |
|---|---|---|---|
| Hypertension | 5–20 mg once daily | 20 mg once daily | 40 mg once daily |
| Heart failure | 2.5 mg once daily | 20 mg once daily (or in 2 divided doses) | 40 mg daily (in 2 divided doses) |
| LV dysfunction (asymptomatic) | 2.5 mg twice daily | 10 mg twice daily | 20 mg twice daily |
For hypertension, some patients may require a lower starting dose, particularly those who are volume-depleted (from diuretic therapy), on a strict low-salt diet, or who have severe hypertension. If you are already taking a diuretic, your doctor may consider stopping it 2–3 days before starting enalapril or starting with a lower dose of 2.5 mg.
For heart failure, the dose should be increased gradually over 2–4 weeks or as tolerated. Blood pressure, kidney function, and potassium levels should be monitored during dose titration. The goal is to reach the target dose shown to provide maximum benefit in clinical trials (typically 10–20 mg twice daily), but many patients benefit even if the maximum dose is not reached.
Patients with Kidney Impairment
Dose Adjustments for Renal Impairment
- Moderate impairment (CrCl 30–80 mL/min): Starting dose 5–10 mg daily
- Severe impairment (CrCl <30 mL/min): Starting dose 2.5 mg daily
- Dialysis patients: 2.5 mg on dialysis days. Dose may be adjusted on non-dialysis days based on blood pressure response
Your doctor will monitor your kidney function and potassium levels regularly and adjust the dose accordingly.
Children
Experience with enalapril in children with hypertension is limited. If a child can swallow tablets, the dose is based on body weight and blood pressure response:
- Children 20–50 kg: Starting dose 2.5 mg daily; maximum 20 mg daily
- Children ≥50 kg: Starting dose 5 mg daily; maximum 40 mg daily
Enalapril is not recommended for neonates (first weeks of life) or children with significant kidney impairment. The orodispersible formulation (AQUMELDI) is available for pediatric patients who cannot swallow tablets, particularly for the treatment of heart failure in children from birth.
Elderly Patients
In elderly patients, the dose should be based on kidney function and blood pressure response. Particular caution is needed when initiating treatment, as elderly patients may be more susceptible to first-dose hypotension, particularly if they have impaired renal function or are taking diuretics. It is important to start with a low dose and titrate gradually under close monitoring.
Missed Dose
If you forget to take a dose, skip the missed dose and take your next dose at the usual time. Do not take a double dose to make up for a missed one. If you regularly forget doses, consider setting a daily reminder or using a pill organizer.
Overdose
If you take more enalapril than prescribed, seek medical attention immediately or call your local poison control center. Bring the medication packaging with you. The most likely symptoms of overdose include:
- Severe dizziness or lightheadedness
- Fainting or loss of consciousness
- Markedly low blood pressure (hypotension)
- Abnormally slow heart rate (bradycardia)
- Kidney failure
- Electrolyte disturbances
Treatment of overdose is primarily supportive, including intravenous saline infusion and monitoring of blood pressure, kidney function, and electrolytes.
Stopping Treatment
Do not stop taking enalapril without consulting your doctor, even if you feel well. High blood pressure often has no symptoms, and stopping treatment abruptly may cause your blood pressure to rise, increasing the risk of cardiovascular events. If your doctor decides to discontinue enalapril, they will advise you on how to do so safely.
What Are the Side Effects of Enalapril?
Quick Answer: The most common side effects include dry cough (affecting >10% of patients), dizziness, blurred vision, and fatigue. Serious but less common side effects include angioedema (swelling of the face, lips, or throat), severe hypotension, hyperkalemia (high potassium), and kidney impairment. If you experience swelling of the face or difficulty breathing, seek emergency medical attention immediately.
Like all medications, enalapril can cause side effects, although not everyone will experience them. Most side effects are mild and may improve as your body adjusts to the medication. However, some side effects can be serious and require immediate medical attention.
- Swelling of the face, lips, tongue, or throat (angioedema) — which may cause difficulty breathing or swallowing
- Difficulty swallowing
- Swelling of the hands, feet, or ankles
- Raised red skin rash (hives/urticaria)
Stop taking enalapril immediately and contact your doctor or go to the emergency department. Black patients have a higher incidence of angioedema with ACE inhibitors.
Very Common
Affects more than 1 in 10 patients
- Blurred vision
- Dizziness, weakness, or feeling unwell
- Dry cough (persistent, non-productive)
Common
Affects up to 1 in 10 patients
- Headache, depression
- Low blood pressure (may cause dizziness when standing up), fainting
- Chest pain, angina pectoris, irregular heartbeat, rapid pulse
- Shortness of breath
- Diarrhea, abdominal pain
- Skin rash, hypersensitivity reactions (swelling)
- Fatigue
- Elevated potassium levels, elevated blood creatinine
Uncommon
Affects up to 1 in 100 patients
- Flushing, sudden blood pressure drop
- Rapid or irregular heartbeat (palpitations)
- Heart attack, stroke (possibly due to excessive blood pressure reduction in high-risk patients)
- Anemia (including aplastic and hemolytic)
- Confusion, insomnia or drowsiness, nervousness
- Tingling or numbness, vertigo, tinnitus
- Runny nose, sore throat, hoarseness, asthma-like chest tightness
- Nausea, vomiting, constipation, loss of appetite, stomach irritation, dry mouth, peptic ulcer
- Intestinal obstruction (ileus), pancreatitis
- Muscle cramps, impaired kidney function, kidney failure
- Increased sweating, itching, hives, hair loss
- Impotence, general malaise, fever
- Elevated protein in urine, low blood sugar, low sodium, elevated blood urea
Rare
Affects up to 1 in 1,000 patients
- Raynaud's phenomenon (cold, white fingers and toes due to reduced blood flow)
- Changes in blood values: low white or red blood cells, low hemoglobin, low platelets
- Bone marrow depression
- Swollen lymph nodes
- Autoimmune diseases
- Abnormal dreams, sleep disturbances
- Pulmonary infiltrates, pneumonitis (lung inflammation causing breathing difficulties)
- Inflammation of the nose, mouth, gums, tongue, lips, or throat (stomatitis, glossitis)
- Reduced urine output
- Erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, exfoliative dermatitis, pemphigus
- Liver problems: reduced liver function, hepatitis, jaundice, elevated liver enzymes and bilirubin
- Gynecomastia (breast enlargement in males)
Very Rare
Affects up to 1 in 10,000 patients
- Intestinal angioedema (swelling in the bowel wall, causing abdominal pain)
Additional Reported Effects
Syndrome of inappropriate antidiuretic hormone secretion (SIADH): This rare effect causes fluid retention, leading to weakness, fatigue, or confusion due to low sodium levels.
Symptom complex: A combination of symptoms has been reported, which may include fever, inflammation of blood vessels (serositis/vasculitis), muscle pain (myalgia/myositis), joint pain (arthralgia/arthritis), rash, photosensitivity, or other skin changes.
The persistent dry cough is the most commonly reported side effect of all ACE inhibitors. It occurs because ACE is also responsible for breaking down bradykinin, a substance that can irritate the airways. When ACE is inhibited, bradykinin levels rise, potentially triggering a cough reflex. The cough typically begins within the first few months of treatment and resolves within 1–4 weeks of stopping the medication. If the cough is bothersome, your doctor may consider switching to an ARB (angiotensin receptor blocker) such as losartan or valsartan, which work by a different mechanism and do not affect bradykinin levels.
How Should You Store Enalapril?
Quick Answer: Store enalapril at or below 30°C (86°F) in the original packaging to protect from moisture. Keep out of reach and sight of children. Do not use after the expiry date printed on the packaging.
- Temperature: Store at or below 30°C (86°F). Do not freeze.
- Packaging: Keep in the original packaging to protect from moisture.
- Expiry: Do not use after the expiry date (EXP) printed on the carton. The expiry date refers to the last day of the stated month.
- Children: Keep out of the sight and reach of children.
- Disposal: Do not dispose of medications down the drain or in household waste. Ask your pharmacist for information on how to properly dispose of unused medications. These measures help protect the environment.
What Does Enalapril Contain?
Quick Answer: The active ingredient is enalapril maleate. Tablets are available in strengths of 2.5 mg, 5 mg, 10 mg, and 20 mg. Inactive ingredients typically include lactose monohydrate, maize starch, sodium hydrogen carbonate, talc, hydroxypropyl cellulose, and magnesium stearate.
Active Ingredient
Enalapril maleate is the active pharmaceutical ingredient. It is a prodrug that is rapidly absorbed from the gastrointestinal tract and hydrolyzed in the liver to enalaprilat, the pharmacologically active diacid form. The bioavailability of oral enalapril is approximately 60%.
Inactive Ingredients (Excipients)
Typical excipients in enalapril tablet formulations include:
- Sodium hydrogen carbonate
- Lactose monohydrate
- Maize starch (corn starch)
- Talc
- Hydroxypropyl cellulose
- Magnesium stearate
The exact excipients may vary depending on the manufacturer and formulation. Always refer to the patient information leaflet supplied with your specific product.
Available Strengths and Presentations
Enalapril is available in multiple strengths, including 2.5 mg, 5 mg, 10 mg, and 20 mg tablets. Combination products containing enalapril with hydrochlorothiazide (a diuretic) are also available in some markets (e.g., 20 mg/12.5 mg). The orodispersible formulation (AQUMELDI) is available in 0.25 mg and 0.5 mg strengths for pediatric use. Packaging varies by manufacturer and typically includes blister packs of 28, 30, 50, 60, 98, or 100 tablets.
Frequently Asked Questions About Enalapril
Enalapril is primarily used to treat high blood pressure (hypertension), heart failure with reduced ejection fraction, and asymptomatic left ventricular dysfunction. It works by blocking the angiotensin-converting enzyme (ACE), causing blood vessels to relax and reducing the workload on the heart. It is one of the most widely prescribed ACE inhibitors worldwide and is included on the WHO Model List of Essential Medicines. In heart failure patients, enalapril has been proven to reduce mortality, improve symptoms, and decrease hospitalization rates.
Enalapril typically begins to lower blood pressure within 1 hour of taking a dose. Peak blood pressure reduction occurs at 4 to 6 hours, and the effect lasts approximately 24 hours, allowing for once-daily dosing. However, it may take 2 to 4 weeks of consistent use before you achieve the maximum blood pressure-lowering effect. For heart failure, clinical benefits (reduced symptoms, improved exercise tolerance) may continue to develop over several months of treatment. Your doctor will monitor your response and adjust the dose as needed.
No. Enalapril is strictly contraindicated during pregnancy, particularly during the second and third trimesters. ACE inhibitors can cause serious fetal harm including kidney dysfunction, reduced amniotic fluid (oligohydramnios), skull bone defects, neonatal hypotension, and in severe cases, fetal death. If you discover that you are pregnant while taking enalapril, contact your doctor immediately to switch to a pregnancy-safe alternative. Women planning pregnancy should discuss switching to a different antihypertensive medication in advance. The use of enalapril during breastfeeding of newborns and premature infants is also not recommended.
The most common side effects of enalapril include a persistent dry cough (affecting more than 1 in 10 patients), dizziness, blurred vision, and general weakness or feeling unwell. The dry cough is a characteristic class effect of all ACE inhibitors caused by elevated bradykinin levels in the lungs. If the cough becomes bothersome, speak with your doctor about potentially switching to an ARB (angiotensin receptor blocker), which works through a different mechanism and typically does not cause cough. Other common side effects include headache, fatigue, low blood pressure (especially when standing up), and mild digestive symptoms.
Alcohol can enhance the blood-pressure-lowering effect of enalapril, potentially causing excessive drops in blood pressure that lead to dizziness, lightheadedness, or even fainting. While moderate alcohol consumption may be acceptable for some individuals, you should discuss your alcohol habits with your doctor. It is particularly important to be cautious with alcohol during the initial phase of treatment or after a dose increase, as the blood-pressure-lowering effect may be more pronounced during these periods.
If you miss a dose of enalapril, skip the missed dose entirely and take your next dose at the usual scheduled time. Do not take a double dose to compensate for the one you missed. Taking two doses at once could cause your blood pressure to drop too low, leading to dizziness or fainting. If you frequently forget doses, consider using strategies such as setting a daily alarm on your phone, placing your medication next to something you use every day (like your toothbrush), or using a weekly pill organizer.
References
- The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med. 1987;316(23):1429-1435. doi:10.1056/NEJM198706043162301
- The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med. 1991;325(5):293-302. doi:10.1056/NEJM199108013250501
- European Medicines Agency (EMA). Enalapril — Summary of Product Characteristics. www.ema.europa.eu
- World Health Organization (WHO). WHO Model List of Essential Medicines — 23rd list, 2023. www.who.int
- Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021-3104. doi:10.1093/eurheartj/ehy339
- McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-3726. doi:10.1093/eurheartj/ehab368
- Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation. 2022;145(18):e895-e1032. doi:10.1161/CIR.0000000000001063
- British National Formulary (BNF). Enalapril maleate. bnf.nice.org.uk
- U.S. Food and Drug Administration (FDA). Vasotec (enalapril maleate) — Prescribing Information. www.fda.gov
- National Institute for Health and Care Excellence (NICE). Hypertension in adults: diagnosis and management. NICE guideline [NG136]. www.nice.org.uk
Medical Editorial Team
This article was written by the iMedic Medical Editorial Team, a group of licensed specialist physicians with expertise in clinical pharmacology, cardiology, and internal medicine. All content is reviewed according to international guidelines from the WHO, EMA, FDA, BNF, ESC, and ACC/AHA.
Our editorial process follows the GRADE evidence framework, and all medical claims are supported by Level 1A evidence (systematic reviews and meta-analyses of randomized controlled trials) wherever possible. We maintain strict independence with no pharmaceutical company funding, sponsorship, or advertising.
Reviewed by: iMedic Medical Review Board
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