Enalapril (Vasotec, Enalaprilat)
Indications
Rationale
Clinical Efficacy
Pharmacology
Administration
Dose Adjustment
Combination ACE Inhibitor and ARB Therapy Increases the Risk of Adverse Effects (Arch Int Med, 2007) [MEDLINE ]: including hyperkalemia, medication discontinuation due to adverse effects, worsened renal function, and symptomatic hypotensionCombination ACE Inhibitor and ARB Therapy Does Not Increase the Rate of Malignancy (J Hypertens, 2011) [MEDLINE ]Recommendation : it is recommended to not use combination ACE inhibitor and ARB therapy
Adverse Effects
Allergic/Immunologic Adverse Effects
Epidemiology : occurs in 0.1-0.2% of ACE-Inhibitor treated patientsPhysiology Class Effect (Common to All ACE Inhibitors) Mediated by Bradykinins (and Possibly by Autoantibodies and Complement Activation) Clinical Time of Onset : onset can occur from hours-months after starting ACE-InhibitorHowever, most cases within hrs-1 week after starting ACE-Inhibitor Lingual Edema (see Lingual Edema )Facial Edema (see Facial Edema )Treatment
Cardiovascular Adverse Effects
Physiology Class Effect (Common to All ACE Inhibitors)
Endocrinologic Manifestations
Physiology Class Effect (Common to All ACE Inhibitors)
Gastrointestinal Adverse Effects
Elevation of Hepatic Transaminases with Hepatocellular Injury (see Drug-Induced Hepatotoxicity )
Pulmonary Adverse Effects
Cough (see Cough )
Epidemiology : occurs in 5-20% of treated patientsPhysiology Class Effect (Common to All ACE Inhibitors) Likely related to accumulation of kinins and substance P (which are usually degraded by ACE and other endopeptidases) Clinical : dry cough with onset typically wihtin the first few weeks of therapy (although some cases do not present with cough until months later)Treatment : 50% of cases with cough ultimately need to have ACE-I discontinued -> cough usually stops within 4 days of discontinuation of ACE-IRechallenge with ACE-I is not recommended, as cough will usually recur However, since ARB’s have much lower incidence of cough, one of these may be substituted
Physiology Class Effect (Common to All ACE Inhibitors) Associated Agents
Epidemiology : very rarePhysiology Class Effect (Common to All ACE Inhibitors)
Renal Adverse Effects
Physiology Class Effect (Common to All ACE Inhibitors) Due to Drug-Induced Hypoaldosteronism (See Above)
Rheumatologic Adverse Effects
Epidemiology Low-Moderate Risk of Developing Drug-Induced SLE Physiology Class Effect (Common to All ACE Inhibitors)
References
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