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Enalapril: Drug information

Enalapril: Drug information
(For additional information see "Enalapril: Patient drug information" and see "Enalapril: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Fetal toxicity:

When pregnancy is detected, discontinue enalapril as soon as possible. Drugs that act directly on the renin-angiotensin system can cause injury and death to the developing fetus.

Brand Names: US
  • Epaned;
  • Vasotec
Brand Names: Canada
  • ACT Enalapril;
  • APO-Enalapril;
  • JAMP Enalapril;
  • MAR-Enalapril;
  • MYLAN-Enalapril [DSC];
  • NOVO-Enalapril;
  • PRO-Enalapril-10;
  • PRO-Enalapril-2.5;
  • PRO-Enalapril-20;
  • PRO-Enalapril-5;
  • RIVA-Enalapril [DSC];
  • SANDOZ Enalapril;
  • TARO-Enalapril;
  • TEVA-Enalapril [DSC];
  • Vasotec
Pharmacologic Category
  • Angiotensin-Converting Enzyme (ACE) Inhibitor;
  • Antihypertensive
Dosing: Adult
Acute coronary syndrome

Acute coronary syndrome:

Non-ST elevation acute coronary syndrome (off-label use): Note: Patients should be hemodynamically stable before initiation. Use as a component of an appropriate medical regimen, which may also include antiplatelet agent(s), a beta-blocker, and a statin. Continue angiotensin-converting enzyme inhibitor therapy indefinitely for patients with concurrent diabetes, left ventricular ejection fraction ≤40%, hypertension, or stable chronic kidney disease (AHA/ACC [Amsterdam 2014]). Dosing is based on expert opinion and general dosing range in manufacturer's labeling.

Oral: Initial: 2.5 to 5 mg in 1 or 2 divided doses (depending on initial blood pressure); titrate slowly based on tolerability and response up to 40 mg/day in 1 or 2 divided doses (Reeder 2019a; Reeder 2022b).

ST-elevation myocardial infarction (off-label use): Note: Patients should be hemodynamically stable before initiation. Use as a component of an appropriate medical regimen, which may also include antiplatelet agent(s), a beta-blocker, and a statin (ACCF/AHA [O'Gara 2013]). Dosing is based on expert opinion and general dosing range in manufacturer's labeling.

Oral: Initial: 2.5 to 5 mg in 1 or 2 divided doses (depending on initial blood pressure); titrate slowly based on tolerability and response up to 40 mg/day in 1 or 2 divided doses (Reeder 2019a; Reeder 2022b).

Heart failure with reduced ejection fraction

Heart failure with reduced ejection fraction:

Note: If tolerated, an angiotensin II receptor-neprilysin inhibitor is generally preferred over an angiotensin-converting enzyme inhibitor (AHA/ACC/HFSA [Heidenreich 2022]).

Oral: Initial: 2.5 mg twice daily; increase dose (eg, double) as tolerated every ≥1 to 2 weeks to a target dose of 10 to 20 mg twice daily (AHA/ACC/HFSA [Heidenreich 2022]). In hospitalized patients, may titrate more rapidly as tolerated (Meyer 2021).

Hypertension, chronic

Hypertension, chronic:

Note: For patients who warrant combination therapy (BP >20/10 mm Hg above goal or suboptimal response to initial monotherapy), may use with another appropriate agent (eg, long-acting dihydropyridine calcium channel blocker or thiazide diuretic) (ACC/AHA [Whelton 2018]).

Oral: Initial: 5 to 10 mg once daily; evaluate response after ~2 to 4 weeks and titrate dose (eg, increase the daily dose by doubling), as needed, up to 40 mg/day in 1 or 2 divided doses; if additional blood pressure control is needed, consider combination therapy. Patients with severe asymptomatic hypertension and no signs of acute end organ damage should be evaluated for medication titration within 1 week (ACC/AHA [Whelton 2018]; Mann 2021).

Posttransplant erythrocytosis, kidney transplant recipients

Posttransplant erythrocytosis, kidney transplant recipients (off-label use): Note: For patients with a hemoglobin concentration >17 g/dL (Vlahakos 2021).

Oral: Initial: 2.5 or 5 mg daily; if inadequate response seen within 4 weeks, may titrate up to 40 mg/day based on hemoglobin and blood pressure response; if hemoglobin remains >17 g/dL after an additional 4 weeks, consider additional therapy (eg, phlebotomy) (MacGregor 1996; Ok 1995; Perazella 1995; Rell 1994; Vlahakos 2021; Yildiz 2001).

Proteinuric chronic kidney disease, diabetic or nondiabetic

Proteinuric chronic kidney disease, diabetic or nondiabetic (off-label use): Dosing recommendations based on expert opinion and general dosing range in manufacturer's labeling:

Oral: Initial: 2.5 to 5 mg in 1 or 2 divided doses depending on blood pressure; titrate slowly based on tolerability and response up to 40 mg/day in 1 or 2 divided doses. Target to an appropriate blood pressure goal and a proteinuria goal of <1 g/day (KDIGO 2013; Mann 2019; Praga 2003).

IgA nephropathy: In addition to an appropriate blood pressure goal, a proteinuria goal of <1 g/day is also generally recommended (KDIGO 2012). Some experts treat to a proteinuria goal of <500 mg/day. If proteinuria goal is not met with monotherapy at the maximum dose, consider adding other modalities and/or agents (Cattran 2022).

Conversion from IV enalaprilat to oral enalapril therapy: If not concurrently receiving diuretics, initiate enalapril 5 mg once daily; if concurrently receiving diuretics and responding to enalaprilat 0.625 mg IV every 6 hours, initiate with enalapril 2.5 mg once daily; subsequent titration as needed.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Altered kidney function: (expert opinion derived from Elung-Jensen 2003; Hoyer 1993; Kelly 1986; MacFadyen 1993; Sica 1991; manufacturer’s labeling)

CrCl >30 mL/minute: No dosage adjustment necessary.

CrCl 10 to 30 mL/minute: Initial: 2.5 mg daily in 1 or 2 divided doses; titrate slowly based on tolerability and response. Maximum recommended dose: 20 mg/day.

CrCl <10 mL/minute: Consider alternative therapy; risk of adverse effects or complications (eg, hyperkalemia, kidney failure) are increased (expert opinion). Initial: 1.25 mg once daily (or 2.5 mg every other day); titrate slowly based on tolerability and response. Maximum recommended dose: 10 mg/day.

Hemodialysis, intermittent (thrice weekly): Dialyzable (~45% [enalaprilat]) (Kelly 1988): Note: Avoid use if an AN69 hemofilter is used (associated with anaphylactoid reaction) (Kammerl 2000).

Initial: 2.5 mg 3 times weekly administered post dialysis on dialysis days; titrate slowly based on tolerability and response (manufacturer’s labeling). Maximum recommended dose: 10 mg once daily (expert opinion).

Peritoneal dialysis: Dialyzable (manufacturer’s labeling): Dose as in CrCl <10 mL/minute (expert opinion).

CRRT: Dose as in CrCl 10 to 30 mL/minute (expert opinion). Avoid use if an AN69 hemofilter is used (associated with anaphylactoid reaction) (Kammerl 2000).

PIRRT (eg, sustained, low-efficiency diafiltration): Dose as in CrCl 10 to 30 mL/minute (expert opinion). Avoid use if an AN69 hemofilter is used (associated with anaphylactoid reaction) (Kammerl 2000).

Conversion from IV enalaprilat to oral enalapril therapy:

CrCl >30 mL/minute: May initiate enalapril 5 mg once daily.

CrCl 10 to 30 mL/minute: May initiate enalapril 2.5 mg once daily.

CrCl <10 mL/minute: May initiate enalapril 1.25 mg once daily.

Dosing: Hepatic Impairment: Adult

No dosage adjustment necessary. Hydrolysis of enalapril to enalaprilat may be delayed and/or impaired in patients with severe hepatic impairment, but the pharmacodynamic effects of the drug do not appear to be significantly altered. Use with caution, particularly in patients with ascites due to cirrhosis (AASLD [Biggins 2021]; AASLD [Runyon 2013]).

Dosing: Pediatric

(For additional information see "Enalapril: Pediatric drug information")

Note: Use lower listed initial dose in patients with hyponatremia, hypovolemia, severe CHF, decreased renal function, or in those receiving diuretics.

Heart failure

Heart failure: Limited data available: Infants, Children and Adolescents: Oral: Initial: 0.1 mg/kg/day in 1 to 2 divided doses; increase as required over 2 weeks to maximum of 0.5 mg/kg/day; mean dose required for CHF improvement in 39 children (age range: 9 days to 17 years) was 0.36 mg/kg/day; select individuals have been treated with doses up to 0.94 mg/kg/day (Leversha 1994; Momma 2006).

Hypertension

Hypertension: Infants, Children and Adolescents: Oral: Initial: 0.08 mg/kg/dose once daily (maximum dose: 5 mg); adjust dose according to blood pressure readings; doses >0.58 mg/kg (or >40 mg) have not been studied.

Proteinuria, nephrotic syndrome

Proteinuria, nephrotic syndrome: Limited data available: Oral:

Fixed dosing: Children ≥7 years and Adolescents: 2.5 to 5 mg/day was reported in a retrospective study in normotensive pediatric patients as either monotherapy (n=17; mean age: 13.7 years; range: 8 to 17 years) or with prednisone (n=11; mean age: 12.6 years; range: 7 to 16 years); significant decrease in proteinuria (with or without nephrotic syndrome) occurred; no significant change in blood pressure was observed (Sasinka 1999); a case series of three adolescents with sickle anemia nephropathy reported an initial dose of 5 mg/day; one patient required an increase to 7.5 mg/day (Fitzhugh 2005).

Weight-directed dosing: Children and Adolescents: Initial: 0.2 mg/kg/day; titrate to response at 4- to 12-week intervals; range: 0.2 to 0.6 mg/kg/day; maximum daily dose: 20 mg/day; a crossover dose comparison trial showed effects on proteinuria were dose-dependent (Bagga 2004; Chandar 2007; Delucchi 2000; Lama 2000; White 2003); if combined with other angiotensin blockade (ARB), lower doses have been reported (0.1 to 0.16 mg/kg/day) (Chandar 2007).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

Infants, Children, and Adolescents:

Manufacturer’s labeling: Use in infants, children, and adolescents ≤16 years of age with GFR <30 mL/minute/1.73 m2 is not recommended; no dosing data available in this population

Alternate recommendations (Aronoff 2007):

GFR >50 mL/minute/1.73 m2: No dosage adjustment necessary

GFR 10 to 50 mL/minute/1.73 m2: Administer 75% of usual dose

GFR <10 mL/minute/1.73 m2: Administer 50% of usual dose

Dosing: Hepatic Impairment: Pediatric

No dosage adjustment necessary. Hydrolysis of enalapril to enalaprilat may be delayed and/or impaired in patients with severe hepatic impairment, but the pharmacodynamic effects of the drug do not appear to be significantly altered.

Dosing: Older Adult

Refer to adult dosing.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Oral, as maleate:

Epaned: 1 mg/mL (150 mL) [contains sodium benzoate]

Generic: 1 mg/mL (150 mL)

Tablet, Oral, as maleate:

Vasotec: 2.5 mg, 5 mg, 10 mg, 20 mg [scored]

Generic: 2.5 mg, 5 mg, 10 mg, 20 mg

Generic Equivalent Available: US

Yes

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral, as maleate:

Vasotec: 5 mg, 10 mg, 20 mg [contains corn starch]

Generic: 2.5 mg, 5 mg, 10 mg, 20 mg

Administration: Adult

Oral: Administer without regard to meals.

Administration: Pediatric

Oral: May administer without regard to food

Use: Labeled Indications

Heart failure with reduced ejection fraction: Treatment of symptomatic heart failure with reduced ejection fraction (HFrEF) to improve symptoms, increase survival, and decrease hospitalizations. In patients with stable asymptomatic HFrEF, enalapril decreases the risk of developing overt heart failure and the incidence of heart failure hospitalizations.

Hypertension, chronic: Management of hypertension, alone or in combination with other antihypertensive agents.

Use: Off-Label: Adult

Non-ST-elevation acute coronary syndrome; Posttransplant erythrocytosis, kidney transplant recipients; Proteinuric chronic kidney disease, diabetic or nondiabetic; Stable coronary artery disease; ST-elevation myocardial infarction

Medication Safety Issues
Sound-alike/look-alike issues:

Enalapril may be confused with Anafranil, Elavil, Eldepryl, ramipril

Administration issues:

Significant differences exist between oral and IV dosing. Use caution when converting from one route of administration to another.

International issues:

Acepril [Hungary, Switzerland] may be confused with Accupril which is a brand name for quinapril [US, Canada, multiple international markets]

Acepril: Brand name for enalapril [Hungary, Switzerland], but also brand name for captopril [Great Britain]; lisinopril [Malaysia]

Adverse Reactions (Significant): Considerations
Acute kidney injury

Use may be associated with increased blood urea nitrogen and increased serum creatinine, resulting in oliguria and acute kidney injury (AKI) in all ages. Increases in serum creatinine are expected and usually stabilize within 20% to 30% of baseline; higher increases may indicate high efferent tone (such as with hypovolemia, congestive heart failure, or renal artery stenosis) (Ref).

Mechanism: Related to pharmacologic action; inhibits efferent arteriolar vasoconstriction, lowering glomerular filtration pressure (and inhibiting renal autoregulation), which can lead to a reduction in the glomerular filtration rate (GFR). Kidney hypoperfusion from systemic hypotension may also occur (Ref).

Onset: Intermediate; increases in serum creatinine generally occur within 2 weeks of initiation and stabilize within 2 to 4 weeks (Ref). However, more immediate increases may occur in patients with other risk factors for AKI (Ref).

Risk factors:

• Patients with low renal blood flow whose GFR is dependent on efferent arteriolar vasoconstriction by angiotensin II, including (Ref):

- Low effective circulating volume (sodium or volume depletion)

- Congestive heart failure

- Hypotension or shock

- Renal artery stenosis

• High dose at initiation (Ref)

• Age:

- Neonates; risk may be higher in preterm neonates (Ref)

- Older adults (Ref)

• Preexisting kidney impairment (Ref)

• Concurrent diuretic and/or nonsteroidal anti-inflammatory drug use (Ref)

Angioedema

Angioedema may occur rarely; edema may manifest in the head and neck (potentially compromising the airway) or the intestine (presenting as abdominal pain). Use is contraindicated in patients with idiopathic or hereditary angioedema or previous angioedema associated with any angiotensin-converting enzyme inhibitors or neprilysin inhibitors (Ref).

Mechanism: Related to pharmacologic action (ie, increased bradykinin and substance P, vascular permeability, vasodilation) (Ref).

Onset: Varied; may occur at any time during treatment. Most cases occur within the first week of therapy but may also occur years after therapy (Ref).

Risk factors:

• Black patients (estimated 4- to 5-fold higher risk); the mechanism for this is not completely understood but may be related to genetic variants (Ref)

• Females (Ref)

• Smoking history (Ref)

• Previous history of angioedema (Ref)

• Age >65 years (Ref)

• Seasonal allergies (Ref)

• Concurrent use of mechanistic target of rapamycin (mTOR) inhibitors (eg, everolimus) (Ref)

• Concurrent use of neprilysin inhibitor (contraindicated)

Cough

A dry, hacking, nonproductive cough that is typically associated with tickling or scratching in the throat may occur with angiotensin converting enzyme inhibitors (ACEI) in adult and pediatric patients (Ref). Recurrence is likely with rechallenge (Ref). Resolution of cough typically occurs 1 to 4 weeks after ACEI discontinuation but may persist for up to 3 months (Ref).

Mechanism: Various proposed mechanisms. May be related to pharmacologic action (ie, increased bradykinin and substance P, resulting in accumulation in the lungs and bronchoconstriction) (Ref).

Onset: Varied; within hours to 4 weeks after initiation but can be delayed for up to 6 months (Ref).

Risk factors:

• Females (Ref)

• Possibly certain genetic variants (some of which may be independent of the bradykinin pathway) (Ref).

Hyperkalemia

Hyperkalemia (elevated serum potassium) may occur with angiotensin-converting enzyme inhibitors (ACEI), including enalapril (Ref).

Mechanism: Related to pharmacologic action; inhibits formation of circulating angiotensin II, which leads to efferent arteriole vasodilation and subsequent lowering of glomerular filtration rate, which lowers potassium elimination. Additionally, ACEI interfere with the generation and release of aldosterone from the adrenal cortex, leading to an impairment of potassium excretion from the kidney (Ref).

Risk factors:

• Disease states associated with hyperkalemia (congestive heart failure, diabetes mellitus, chronic kidney disease) (Ref)

• Concurrent use of medications which cause hyperkalemia (ACEI, angiotensin receptor blockers, spironolactone, nonsteroidal anti-inflammatory drugs, beta blockers, heparin, tacrolimus, cyclosporine) (Ref)

• Acute kidney injury (elevated BUN and/or serum creatinine) (Ref)

• High dietary intake of potassium or concomitant use of potassium supplements (including potassium-containing salt substitutes) (Ref)

• Baseline elevated potassium level (≥5 mmol/L) (Ref)

• Age >70 years (Ref)

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency ranges include data from hypertension and heart failure trials. Higher rates of adverse reactions have generally been noted in patients with heart failure. However, the frequency of adverse effects associated with placebo is also increased in this population.

1% to 10%:

Cardiovascular: Hypotension (≤7%), orthostatic hypotension (2%), syncope (≤2%)

Dermatologic: Skin rash (1%)

Gastrointestinal: Diarrhea (2%), nausea (1%), vomiting (1%)

Nervous system: Dizziness (8%), headache (2%), orthostatic dizziness (1% to 2%), vertigo (2%)

Neuromuscular & skeletal: Asthenia (1% to 2%)

Respiratory: Bronchitis (1%), cough (1% to 2%) (table 1), dyspnea (1%)

Enalapril: Adverse Reaction: Cough

Drug (Enalapril)

Placebo

Indication

Number of Patients (Enalapril)

Number of Patients (Placebo)

2%

0.6%

Cardiac failure

673

339

1%

0.9%

Hypertension

2,314

230

<1%: Renal: Increased blood urea nitrogen, increased serum creatinine

Frequency not defined:

Cardiovascular: Acute myocardial infarction, atrial fibrillation, atrial tachycardia, bradycardia, cardiac arrhythmia, cerebrovascular accident, flushing, palpitations, pulmonary embolism, Raynaud's disease

Dermatologic: Alopecia, diaphoresis, erythema multiforme, exfoliative dermatitis, pemphigus, pruritus, skin photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria

Gastrointestinal: Anorexia, constipation, dysgeusia, dyspepsia, glossitis, intestinal obstruction, melena, sore throat, stomatitis, xerostomia

Genitourinary: Impotence, oliguria

Hematologic & oncologic: Bone marrow depression, neutropenia

Infection: Herpes zoster infection

Nervous system: Abnormal dreams, anosmia, ataxia, confusion, depression, drowsiness, dysesthesia, flank pain, insomnia, nervousness, paresthesia

Neuromuscular & skeletal: Muscle cramps

Ophthalmic: Blurred vision, conjunctivitis, dry eye syndrome, lacrimation

Otic: Tinnitus

Respiratory: Asthma, bronchospasm, eosinophilic pneumonitis, hoarseness, pulmonary edema, pulmonary infarct, pulmonary infiltrates, rhinorrhea, upper respiratory tract infection

Postmarketing:

Cardiovascular: Vasculitis

Dermatologic: Psoriasis (Song 2021)

Endocrine & metabolic: Gynecomastia (Llop 1994), hyperkalemia (Albareda 1998), hyponatremia (Gonzalez-Martinez 1993)

Gastrointestinal: Pancreatitis (Carnovale 2003, Maringhini 1997)

Hematologic: Agranulocytosis (Elis 1991), decreased hematocrit (Graafland 1992, Ozbek 1997), decreased hemoglobin (Graafland 1992, Ozbek 1997), eosinophilia (Barnes 1983), hemolysis (with G6PD), hemolytic anemia, increased erythrocyte sedimentation rate, leukocytosis, positive ANA titer, thrombocytopenia (Ackroyd 1989)

Hepatic: Cholestatic jaundice (Todd 1990), hepatic failure (Jeserich 2000), hepatitis (Macias 2003), increased liver enzymes (Macias 2003), increased serum bilirubin (Macias 2003)

Hypersensitivity: Angioedema (Sato 2021), nonimmune anaphylaxis (Tunon-de-Lara 1992)

Nervous system: Peripheral neuropathy (Hormigo 1992), visual hallucination (Doane 2013)

Neuromuscular & skeletal: Arthralgia (Peppers 1995), arthritis, myalgia (Peppers 1995), myositis, serositis

Renal: Acute kidney injury (Hennesy 1992), renal insufficiency (Albareda 1998)

Miscellaneous: Fever

Contraindications

Hypersensitivity to enalapril or any component of the formulation; angioedema related to previous treatment with an ACE inhibitor; idiopathic or hereditary angioedema; concomitant use with aliskiren in patients with diabetes mellitus; coadministration with or within 36 hours of switching to or from a neprilysin inhibitor (eg, sacubitril).

Documentation of allergenic cross-reactivity for ACE inhibitors is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Canadian labeling: Additional contraindications (not in US labeling): Concomitant use with aliskiren-containing drugs in patients with moderate to severe kidney impairment (GFR <60 mL/minute/1.73 m2).

Warnings/Precautions

Concerns related to adverse effects:

• Hypersensitivity reactions: Anaphylactic reactions/nonimmune anaphylaxis can occur with ACE inhibitors. Severe nonimmune anaphylaxis may be seen during hemodialysis (eg, CVVHD) with high-flux dialysis membranes (eg, AN69), and rarely, during low density lipoprotein apheresis with dextran sulfate cellulose. Rare cases of nonimmune anaphylaxis have been reported in patients undergoing sensitization treatment with hymenoptera (bee, wasp) venom while receiving ACE inhibitors.

• Hypotension/Syncope: Symptomatic hypotension with or without syncope can occur with ACE inhibitors (usually with the first several doses). Effects are most often observed in volume-depleted patients; correct volume depletion prior to initiation. Close monitoring of patient is required, especially with initial dosing and dosing increases; blood pressure must be lowered at a rate appropriate for the patient's clinical condition. Although dose reduction may be necessary, hypotension is not a reason for discontinuation of future ACE inhibitor use, especially in patients with HF where a reduction in systolic blood pressure is a desirable observation.

Disease-related concerns:

• Aortic stenosis: Use with caution in patients with severe aortic stenosis; may reduce coronary perfusion resulting in ischemia.

• Ascites: Generally, avoid use in patients with ascites due to cirrhosis or refractory ascites; if use cannot be avoided in patients with ascites due to cirrhosis, monitor BP and kidney function carefully to avoid rapid development of kidney failure (AASLD [Runyon 2013]).

• Cardiovascular disease: Initiation of therapy in patients with ischemic heart disease or cerebrovascular disease warrants close observation due to the potential consequences posed by falling blood pressure (eg, MI, stroke). Fluid replacement, if needed, may restore blood pressure; therapy may then be resumed. Discontinue therapy in patients whose hypotension recurs. In a retrospective cohort study of elderly patients (≥65 years of age) with myocardial infarction and impaired left ventricular function, administration of an ACE inhibitor was associated with a survival benefit, including patients with serum creatinine concentrations >3 mg/dL (265 micromol/L) (Frances 2000).

• Collagen vascular disease: Use with caution in patients with collagen vascular disease especially with concomitant kidney impairment; may be at increased risk for hematologic toxicity.

• Hypertrophic cardiomyopathy with left ventricular outflow tract obstruction: Use with caution in patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction since reduction in afterload may worsen symptoms associated with this condition (AHA/ACC [Ommen 2020]).

• Kidney impairment: Use with caution in preexisting kidney insufficiency; dosage adjustment may be needed. Avoid rapid dosage escalation which may lead to further kidney impairment.

Special populations:

• Race/Ethnicity: In Black patients, the BP-lowering effects of ACE inhibitors may be less pronounced. The exact mechanism is not known; differences in the renin-angiotensin-aldosterone system, low renin levels, and salt sensitivity more commonly found in Black patients may contribute (Brewster 2013; Helmer 2018).

• Surgical patients: In patients on chronic ACE inhibitor therapy, intraoperative hypotension may occur with induction and maintenance of general anesthesia; use with caution before, during, or immediately after major surgery. Cardiopulmonary bypass, intraoperative blood loss, or vasodilating anesthesia increases endogenous renin release. Use of ACE inhibitors perioperatively will blunt angiotensin II formation and may result in hypotension. However, discontinuation of therapy prior to surgery is controversial. If continued preoperatively, avoidance of hypotensive agents during surgery is prudent (Hillis 2011). Based on current research and clinical guidelines in patients undergoing non-cardiac surgery, continuing ACE inhibitors is reasonable in the perioperative period. If ACE inhibitors are held before surgery, it is reasonable to restart postoperatively as soon as clinically feasible (ACC/AHA [Fleisher 2014]).

Dosage forms specific issues:

• Benzyl alcohol and derivatives: Oral solution: May contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol. Large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity ("gasping syndrome") in neonates; the "gasping syndrome" consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP 1997; CDC 1982). Some data suggest that benzoate displaces bilirubin from protein-binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer's labeling.

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Aliskiren: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Aliskiren may enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Aliskiren may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Management: Aliskiren use with ACEIs or ARBs in patients with diabetes is contraindicated. Combined use in other patients should be avoided, particularly when CrCl is less than 60 mL/min. If combined, monitor potassium, creatinine, and blood pressure closely. Risk D: Consider therapy modification

Allopurinol: Angiotensin-Converting Enzyme Inhibitors may enhance the potential for allergic or hypersensitivity reactions to Allopurinol. Risk C: Monitor therapy

Alteplase: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Alteplase. Specifically, the risk for angioedema may be increased. Risk C: Monitor therapy

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When used at chemotherapy doses, hold blood pressure lowering medications for 24 hours before amifostine administration. If blood pressure lowering therapy cannot be held, do not administer amifostine. Use caution with radiotherapy doses of amifostine. Risk D: Consider therapy modification

Amphetamines: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Angiotensin II: Angiotensin-Converting Enzyme Inhibitors may enhance the therapeutic effect of Angiotensin II. Risk C: Monitor therapy

Angiotensin II Receptor Blockers: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Angiotensin II Receptor Blockers may increase the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Management: Use of telmisartan and ramipril is not recommended. It is not clear if any other combination of an ACE inhibitor and an ARB would be any safer. Consider alternatives when possible. Monitor blood pressure, renal function, and potassium if combined. Risk D: Consider therapy modification

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor therapy

Aprotinin: May diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

AzaTHIOprine: Angiotensin-Converting Enzyme Inhibitors may enhance the myelosuppressive effect of AzaTHIOprine. Risk C: Monitor therapy

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Brigatinib: May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Bromperidol: May diminish the hypotensive effect of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Risk X: Avoid combination

Dapoxetine: May enhance the orthostatic hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Dexmethylphenidate: May diminish the therapeutic effect of Antihypertensive Agents. Risk C: Monitor therapy

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Dipeptidyl Peptidase-IV Inhibitors: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Drospirenone-Containing Products: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Risk C: Monitor therapy

Eplerenone: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Everolimus: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Ferric Gluconate: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Ferric Gluconate. Risk C: Monitor therapy

Ferric Hydroxide Polymaltose Complex: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Ferric Hydroxide Polymaltose Complex. Specifically, the risk for angioedema or allergic reactions may be increased. Risk C: Monitor therapy

Finerenone: Angiotensin-Converting Enzyme Inhibitors may enhance the hyperkalemic effect of Finerenone. Risk C: Monitor therapy

Flunarizine: May enhance the therapeutic effect of Antihypertensive Agents. Risk C: Monitor therapy

Gelatin (Succinylated): Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Gelatin (Succinylated). Specifically, the risk of a paradoxical hypotensive reaction may be increased. Risk C: Monitor therapy

Gold Sodium Thiomalate: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Gold Sodium Thiomalate. This combination may increase the risk of developing a nitritoid reaction. Risk C: Monitor therapy

Grass Pollen Allergen Extract (5 Grass Extract): Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Grass Pollen Allergen Extract (5 Grass Extract). Specifically, ACE inhibitors may increase the risk of severe allergic reaction to Grass Pollen Allergen Extract (5 Grass Extract). Risk X: Avoid combination

Heparin: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Heparins (Low Molecular Weight): May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Herbal Products with Blood Pressure Increasing Effects: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Herbal Products with Blood Pressure Lowering Effects: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Icatibant: May diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Iron Dextran Complex: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Iron Dextran Complex. Specifically, patients receiving an ACE inhibitor may be at an increased risk for anaphylactic-type reactions. Risk C: Monitor therapy

Lanthanum: May decrease the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Management: Administer angiotensin-converting enzyme inhibitors at least two hours before or after lanthanum. Risk D: Consider therapy modification

Levodopa-Containing Products: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Containing Products. Risk C: Monitor therapy

Lithium: Angiotensin-Converting Enzyme Inhibitors may increase the serum concentration of Lithium. Management: Lithium dosage reductions will likely be needed following the addition of an ACE inhibitor. Monitor for increased concentrations/toxic effects of lithium if an ACE inhibitor is initiated/dose increased, or if switching between ACE inhibitors. Risk D: Consider therapy modification

Loop Diuretics: May enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Loop Diuretics may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Methylphenidate: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicorandil: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Nonsteroidal Anti-Inflammatory Agents may diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents (Topical): May diminish the therapeutic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Risk D: Consider therapy modification

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Risk C: Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Potassium Salts: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Potassium-Sparing Diuretics: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Pregabalin: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Pregabalin. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Racecadotril: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk for angioedema may be increased with this combination. Risk C: Monitor therapy

Ranolazine: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Sacubitril: Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Sacubitril. Specifically, the risk of angioedema may be increased with this combination. Risk X: Avoid combination

Salicylates: May enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Salicylates may diminish the therapeutic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Sirolimus Products: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk for angioedema may be increased. Risk C: Monitor therapy

Sodium Phosphates: Angiotensin-Converting Enzyme Inhibitors may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Risk C: Monitor therapy

Tacrolimus (Systemic): Angiotensin-Converting Enzyme Inhibitors may enhance the hyperkalemic effect of Tacrolimus (Systemic). Risk C: Monitor therapy

Temsirolimus: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Tenapanor: May decrease serum concentrations of the active metabolite(s) of Enalapril. Tenapanor may decrease the serum concentration of Enalapril. Risk C: Monitor therapy

Thiazide and Thiazide-Like Diuretics: May enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Thiazide and Thiazide-Like Diuretics may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Tolvaptan: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Trimethoprim: May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy

Urapidil: May interact via an unknown mechanism with Angiotensin-Converting Enzyme Inhibitors. Management: Avoid concomitant use of urapidil and angiotensin-converting enzyme (ACE) inhibitors. Risk D: Consider therapy modification

Urokinase: May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased. Risk C: Monitor therapy

Vasopressin: Drugs Suspected of Causing SIADH may enhance the therapeutic effect of Vasopressin. Specifically, the pressor and antidiuretic effects of vasopressin may be increased. Risk C: Monitor therapy

Reproductive Considerations

Avoid use of angiotensin-converting enzyme (ACE) inhibitor therapy in patients who may become pregnant and who are not using effective contraception (ADA 2021).

ACE inhibitors should generally be avoided for the treatment of hypertension in patients planning to become pregnant; use should only be considered for cases of hypertension refractory to other medications (ACOG 203 2019).

Pregnancy Considerations

Enalapril crosses the placenta; the active metabolite enalaprilat can be detected in the newborn (Schubiger 1988).

Exposure to an angiotensin-converting enzyme (ACE) inhibitor during the first trimester of pregnancy may be associated with an increased risk of fetal malformations (ACOG 203 2019; ESC [Regitz-Zagrosek 2018]); however, outcomes observed may also be influenced by maternal disease (ACC/AHA [Whelton 2017]).

[US Boxed Warning]: Drugs that act on the renin-angiotensin system can cause injury and death to the developing fetus. Discontinue as soon as possible once pregnancy is detected.

Drugs that act on the renin-angiotensin system are associated with oligohydramnios. Oligohydramnios, due to decreased fetal kidney function, may lead to fetal lung hypoplasia and skeletal malformations. The use of these drugs in pregnancy is also associated with anuria, hypotension, kidney failure, skull hypoplasia, and death in the fetus/neonate. Infants exposed to an ACE inhibitor in utero should be monitored for hyperkalemia, hypotension, and oliguria. Oligohydramnios may not appear until after irreversible fetal injury has occurred. Exchange transfusions or dialysis may be required to reverse hypotension or improve kidney function, although data related to the effectiveness in neonates is limited.

Chronic maternal hypertension is also associated with adverse events in the fetus/infant. Chronic maternal hypertension may increase the risk of birth defects, low birth weight, premature delivery, stillbirth, and neonatal death. Actual fetal/neonatal risks may be related to duration and severity of maternal hypertension. Untreated chronic hypertension may also increase the risks of adverse maternal outcomes, including gestational diabetes, preeclampsia, delivery complications, stroke, and myocardial infarction (ACOG 203 2019).

When treatment of hypertension in pregnancy is indicated, ACE inhibitors should generally be avoided due to their adverse fetal events; use in pregnant women should only be considered for cases of hypertension refractory to other medications (ACOG 203 2019). ACE inhibitors are not recommended for the treatment of heart failure in pregnancy (Regitz-Zagrosek [ESC 2018]).

When treatment is needed in females of reproductive potential with diabetic nephropathy, the ACE inhibitor should be discontinued at the first positive pregnancy test (Cabiddu 2016; Spotti 2018).

Breastfeeding Considerations

Enalapril and enalaprilat are present in breast milk.

The relative infant dose (RID) of enalapril is 1.1% when calculated using the highest breast milk concentration located and compared to an infant therapeutic dose of 0.08 mg/kg/day.

In general, breastfeeding is considered acceptable when the RID of a medication is <10% (Anderson 2016; Ito 2000).

The RID of enalapril was calculated using a milk concentration of 5.9 ng/mL, providing an estimated daily infant dose via breast milk of 0.00089 mg/kg/day. This milk concentration was obtained following maternal administration enalapril 20 mg. Enalaprilat was also present (Redman 1990).

Due to the potential for serious adverse reactions in the breastfed infant, the manufacturer recommends a decision be made whether to discontinue breastfeeding or to discontinue the drug, taking into account the importance of treatment to the mother. Available guidelines consider enalapril to be acceptable for use in breastfeeding women (ESC [Bauersachs 2016]; ESC [Regitz-Zagrosek 2018]) unless high doses are required (ACOG 203 2019).

Dietary Considerations

Limit salt substitutes or potassium-rich diet.

Monitoring Parameters

BP; serum creatinine and potassium (especially in patients on concomitant potassium-sparing diuretics, potassium supplements and/or potassium containing salts); if patient has collagen vascular disease and/or kidney impairment, periodically monitor CBC with differential. If angioedema is suspected, assess risk of airway obstruction (eg, involvement of tongue, glottis, larynx, and/or history of airway surgery).

Reference Range

BP goals: May vary depending on clinical condition, different clinical practice guidelines, and expert opinion. Refer to clinical practice guidelines for specific treatment goals.

Mechanism of Action

Competitive inhibitor of angiotensin-converting enzyme (ACE); prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; results in lower levels of angiotensin II which causes an increase in plasma renin activity and a reduction in aldosterone secretion

Pharmacokinetics

Onset of action: ~1 hour

Peak effect: 4 to 6 hours

Duration: 12 to 24 hours

Absorption: 55% to 75%

Protein binding: ~50% (Davies 1984)

Metabolism: Prodrug, undergoes hepatic biotransformation to enalaprilat

Half-life elimination:

Enalapril: CHF: Neonates (n=3, PNA: 10 to 19 days): 10.3 hours (range: 4.2 to 13.4 hours) (Nakamura 1994); CHF: Infants and Children ≤6.5 years of age (n=11): 2.7 hours (range: 1.3 to 6.3 hours) (Nakamura 1994); Adults: Healthy: 2 hours; CHF: 3.4 to 5.8 hours

Enalaprilat: CHF: Neonates (n=3, PNA: 10 to 19 days): 11.9 hours (range: 5.9 to 15.6 hours) (Nakamura 1994); CHF: Infants and Children ≤6.5 years of age (n=11): 11.1 hours (range: 5.1 to 20.8 hours) (Nakamura 1994); Infants 6 weeks to 8 months of age: 6 to 10 hours (Lloyd 1989); Adults: ~35 hours (Till 1984; Ulm 1982)

Time to peak, serum: Oral: Enalapril: 0.5 to 1.5 hours; Enalaprilat (active metabolite): 3 to 4.5 hours

Excretion: Urine (61%; 18% of which was enalapril, 43% was enalaprilat); feces (33%; 6% of which was enalapril, 27% was enalaprilat) (Ulm 1982)

Pharmacokinetics: Additional Considerations

Kidney function impairment: In those with glomerular filtration rate (GFR) 30 mL/minute or less, the peak and trough enalaprilat levels increase, Tmax increases, and time to steady state may be delayed.

Pricing: US

Solution (Enalapril Maleate Oral)

1 mg/mL (per mL): $4.08

Solution (Epaned Oral)

1 mg/mL (per mL): $4.30

Tablets (Enalapril Maleate Oral)

2.5 mg (per each): $0.52 - $1.46

5 mg (per each): $0.67 - $1.85

10 mg (per each): $0.70 - $1.94

20 mg (per each): $1.00 - $2.77

Tablets (Vasotec Oral)

2.5 mg (per each): $19.36

5 mg (per each): $22.45

10 mg (per each): $24.69

20 mg (per each): $35.13

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Brand Names: International
  • Acapril (EG);
  • Acebitor (PH);
  • Acepril (HU);
  • Acetec (MY);
  • Acetensil (ES);
  • Alapren (ZA);
  • Amprace (NZ);
  • Anapril (BD, SG, TH);
  • Anapril S Minitab (TH);
  • Angiotec (JO, QA, SA);
  • Angonic (VN);
  • Antens (ET, KR);
  • Apridal (PY);
  • Auspril (AU);
  • Bagopril (RU);
  • Bajaten (CL);
  • Baripril (ES);
  • Bealipril (LV);
  • Beartec (KR);
  • Benalipril (DE);
  • Berlipril (BG, HR, UA);
  • Biocronil (CO);
  • Blocatril (CR, DO, GT, HN, NI, PA, SV);
  • BQL (BF, BJ, CI, ET, GH, GM, GN, IN, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, TZ, UG, ZM);
  • Converten (IN);
  • Corodil (DK);
  • Crinoren (ES);
  • Dabonal (ES);
  • Danssan (MY);
  • Dynapril (PH);
  • Ednyt (BB, BM, BS, BZ, GY, HU, JM, LV, SR, TT);
  • Ekaril (CR, DO, GT, HN, NI, PA, SV);
  • Elfonal (KR);
  • Enac (AT);
  • Enace (TH);
  • Enahexal (UA);
  • Enalagamma (DE);
  • Enalap (EG);
  • Enalapril (ES);
  • Enam (LK, UA);
  • Enap (HK, HR, HU, IE, LV, RO, SG, SI, SK, UA, ZA);
  • Enap i.v. (HR);
  • Enap [inj.] (HU);
  • Enaprel (ET);
  • Enapren (IT);
  • Enapril (ZW);
  • Enaprin (KR);
  • Enaril (BD, KR, TH);
  • Enatec (BB, BM, BS, BZ, GY, JM, SR, TT);
  • Enazil (PL);
  • Enbid-20 (PH);
  • Enetil (CO);
  • Enpril (KR);
  • Entab (LK);
  • Envas (BF, BJ, CI, ET, GH, GM, GN, IN, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, TZ, UG, ZM);
  • Eril (BD);
  • Ezapril (EG);
  • Glioten (BR, CR, DO, EC, GT, HN, NI, PA, PE, PY, SG, SV);
  • Grifopil (CL);
  • Herten (ES);
  • Hypace (PH, ZA);
  • Hyperil (KR);
  • Hypril (PH);
  • Hytrol (IN);
  • Iecatec (QA);
  • Ileveran (MX);
  • Innovace (GB, IE);
  • Invoril (AE, BF, BJ, CI, ET, GH, GM, GN, IN, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SG, SL, SN, TH, TN, TZ, UG, ZM);
  • Istopril (TR);
  • Kalpiren (MT);
  • Kaparlon-S (MT);
  • Korandil (BH, ET, MT, TR, ZW);
  • Lapril (JO, QA, SA, TH);
  • Lenipril (KR);
  • Lotrial (AR, PE, UY);
  • Macpril (LK);
  • Malean (AU);
  • Meipril (ID);
  • Naprilate (PH);
  • Naprilene (IT);
  • Narapril (AE, BH, KR);
  • Neopril (KR);
  • Nuril (IN);
  • Olivin (HR);
  • Perisafe (TW);
  • Pres (DE);
  • Presil (CO);
  • Prilace (EC);
  • Rapril (KR);
  • Renacardon (ID);
  • Renallapin (KR);
  • Renistad (AT);
  • Renite (PH);
  • Renite XL (PH);
  • Renitec (AE, AR, AT, AU, BE, BF, BG, BH, BJ, BR, CI, CN, CO, CY, CZ, EC, EE, EG, ES, ET, FI, FR, GH, GM, GN, GR, HU, JO, KE, KW, LB, LR, LU, MA, ML, MR, MU, MW, MY, NE, NG, NL, NO, NZ, PE, PH, PK, PT, QA, SA, SC, SD, SE, SL, SN, TN, TR, TZ, UA, UG, VE, VN, ZM);
  • Renitek (RU);
  • Reniten (CH);
  • Renivace (JP);
  • Sintec (TW);
  • Tenace (ID);
  • Tenaten (ID);
  • Unipril (CO);
  • Vasonorm (LK);
  • Vasopress (PH);
  • Vasopril (AE, BD, JO);
  • Xanef (DE)


For country code abbreviations (show table)
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