Sacubitril Valsartan
Contraindicated
Textbook
Increased risk of angioedema.
Do not use in conjunction with ACEIs.
Source: G&G 14e · p602
Drug reference
Enalapril
ACE Inhibitor · Antihypertensive
Also known as Enalapril maleate, Vasotec, Renitec
START
5 mg PO once daily (2.5 mg BID for HF)
TYPICAL MAX
40 mg/day
STOP IF
Pregnancy · bilateral RAS · angioedema · hyperkalemia
WATCH
K⁺ · creatinine (1-2 wks) · cough · angioedema (rare)
CDSCO approvedSchedule HJan AushadhiATC C09AA02
KDIGO 2024 + manufacturer label
- ONSET
- 1h · BP effect onset
- PEAK
- 4h · enalaprilat (active) Cmax
- t½
- 11h · enalaprilat effective t½
- DURATION
- 12h · BID dosing window (q24 for many HTN)
EXCRETION
Hepatic prodrug → enalaprilat · renal excretion
route + CYP
INTERACTIONS
12 major
incl. contraindicated
PREGNANCY
Category D — fetal renal injury, oligohydramnios
FDA category + note
Top interactionssee all 12 →
- Sacubitril ValsartanContraindicatedTextbookG&G 14e · p602
- SacubitrilContraindicatedDatabase
- AminoglycosidesSevereTextbookG&G 14e
- Angiotensin Receptor BlockersSevereTextbookHarrison 22e · p2396
Available in India
140 branded formulations and 18 fixed-dose combinations. Look up specific brands in the Drugs workspace.
Jan Aushadhi — generic available at GoI pharmacies
Mechanism
Enalapril is a prodrug that is hydrolyzed to enalaprilat, which inhibits angiotensin-converting enzyme (ACE). This prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor and stimulator of aldosterone secretion. The resulting effects include reduced systemic vascular resistance, decreased aldosterone-mediated sodium and water retention, and inhibition of bradykinin breakdown, leading to vasodilation and blood pressure reduction.
Indications
HypertensionSymptomatic Heart FailureAsymptomatic Left Ventricular DysfunctionDiabetic Nephropathy (off-label)high blood pressurecardiovascular diseaseheart failurediabetic nephropathyacute myocardial infarctionhigh risk of cardiovascular eventscoronary artery disease (without heart failure)Congestive heart failure (CHF)Myocardial infarction (MI)Prophylaxis in high cardiovascular risk subjectsNondiabetic nephropathyScleroderma crisis
Dosing
- Adult
- Hypertension: Initial 5 mg orally once daily. Doses typically range from 10-40 mg daily, given as a single dose or two divided doses, titrated based on blood pressure response. Heart Failure: Initial 2.5 mg orally once or twice daily. Titrate gradually over 2-4 weeks to a target dose of 10-20 mg twice daily, as tolerated.
- Pediatric
- For children >1 month old with hypertension: Initial 0.08 mg/kg orally once daily (maximum 5 mg). Titrate based on response up to 0.6 mg/kg/day (maximum 40 mg/day). Not first-line for hypertension in children.
- Renal adjustment
- CrCl >30 mL/min: No dose adjustment needed for hypertension; for heart failure, start with 2.5 mg daily. CrCl 10-30 mL/min: Start with 2.5 mg once daily. CrCl <10 mL/min (including dialysis patients): Start with 2.5 mg on dialysis days.
- Hepatic adjustment
- No specific dose adjustment recommended for mild-moderate hepatic impairment, but use with caution as enalapril is a prodrug requiring hepatic activation.
- Geriatric
- Start with a lower initial dose (e.g., 2.5 mg once daily) and titrate carefully due to potential for greater sensitivity and increased risk of renal impairment in elderly patients.
- Max dose
- 40 mg daily
Pharmacokinetics
Onset
1 hour
Peak effect
4-6 hours (for blood pressure reduction)
Duration
24 hours
Half-life
Enalaprilat (active metabolite) effective half-life is approximately 11 hours
Bioavailability
Approximately 60% after oral administration
Protein binding
Approximately 50-60%
Metabolism
Enalapril is a prodrug, extensively hydrolyzed to its active metabolite enalaprilat in the liver by esterases
Excretion
Primarily renal; enalaprilat and unchanged enalapril are excreted in urine
Contraindications
- History of angioedema related to previous ACE inhibitor treatment
- Hereditary or idiopathic angioedema
- Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment (eGFR < 60 mL/min/1.73m^2)
- Pregnancy (especially 2nd and 3rd trimesters)
- Bilateral renal artery stenosis (relative contraindication)
- Hypersensitivity to enalapril or any other ACE inhibitor
- bilateral renal artery stenosis
- therapy with neprilysin inhibitor (sacubitril)
- Do not use in combination with ARB
- Contraindicated in pregnancy
Side effects
Common
DizzinessCough (dry, persistent)FatigueHeadacheNauseaDiarrheaHypotension (especially with first dose)Rashcoughhypotensionhyperkalemiaskin rashcough (5%-10%)increase in serum creatinine (<25% normal)Rashes (less frequent than captopril)Loss of taste (less frequent than captopril)Hyperkalemia in CKDAcute kidney failure in severe bilateral renal artery stenosisAngioedema
Serious
- Angioedema (of face, lips, tongue, glottis/larynx)
- Hyperkalemia
- Renal impairment or acute renal failure (especially in bilateral renal artery stenosis or severe heart failure)
- Agranulocytosis
- Hepatotoxicity
- Anaphylactic reactions
- angioedema
- acute renal failure
- fetopathic syndrome
- neutropenia
- glycosuria
- anemia
- dysgeusia
- hepatic failure (rare)
- agranulocytosis (rare)
Pregnancy & lactation
Pregnancy
Category D — fetal renal injury, oligohydramnios
Lactation
Enalapril and enalaprilat are excreted in human milk in small amounts. Generally considered low risk for healthy, full-term infants, but caution is advised, especially in preterm infants or those with renal impairment. Consult a pediatrician.
Drug interactions
Sacubitril
Contraindicated
Database
Increased rate of angioedema, a rare but life-threatening condition.
The combination is contraindicated. Discontinue ACEI or ARB, and then add ARNI.
Aminoglycosides
Severe
Textbook
Increased risk and severity of renal impairment and nephrotoxicity.
Not explicitly stated, but implies careful monitoring of renal function and cautious co-administration.
Source: G&G 14e
Angiotensin Receptor Blockers
Severe
Textbook
Greater incidence of acute kidney injury (AKI) and adverse cardiac events.
The combination of these two classes should be avoided.
Source: Harrison 22e · p2396
Azilsartan
Severe
Textbook
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: G&G 14e
Candesartan
Severe
Textbook
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: G&G 14e
Dipeptidyl Peptidase Iv Inhibitor
Severe
Textbook
Increased risk of angioedema.
Avoid combination.
Source: G&G 14e · p600
Losartan + Hydrochlorothiazide
Severe
Textbook
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: G&G 14e
Olmesartan + Amlodipine
Severe
Textbook
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: G&G 14e
Olmesartan + Hydrochlorothiazide
Severe
Textbook
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: G&G 14e
Olmesartan Medoxomil
Severe
Textbook
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: G&G 14e
Sacubitril With Valsartan
Severe
Textbook
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: G&G 14e
Related guidelines
Other ACE Inhibitor drugs
Ask House about Enalapril
Continue into a citation-backed clinical answer with the drug context already attached.
Sources: KD Tripathi 7e, Goodman & Gilman 14e, Harrison 22e, Katzung·Verified: 2026-05-17 · House clinical team·Cockpit curated: 2026-05-16