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Enalapril


Pronunciation

 (e NAL a pril)


U.S. Brand Names

 Vasotec®


Synonyms

 Enalaprilat; Enalapril Maleate


Generic Available

 Yes


Canadian Brand Names

 Vasotec®


Use

 Management of mild to severe hypertension; treatment of congestive heart failure, left ventricular dysfunction after myocardial infarction


Use - Unlabeled/Investigational

Unlabeled: Hypertensive crisis, diabetic nephropathy, rheumatoid arthritis, diagnosis of anatomic renal artery stenosis, hypertension secondary to scleroderma renal crisis, diagnosis of aldosteronism, idiopathic edema, Bartter's syndrome, postmyocardial infarction for prevention of ventricular failure

Investigational: Severe congestive heart failure in infants, neonatal hypertension, acute pulmonary edema


Pregnancy Risk Factor

 C/D (2nd and 3rd trimesters)


Pregnancy Implications

 Cranial defects, hypocalvaria/acalvaria, oligohydramnios, persistent anuria following delivery, hypotension, renal defects, renal dysgenesis/dysplasia, renal failure, pulmonary hypoplasia, limb contractures secondary to oligohydramnios, and stillbirth reported. ACE inhibitors should be avoided during pregnancy, particularly in the 2nd and 3rd trimesters.


Lactation

 Enters breast milk/compatible


Contraindications

 Hypersensitivity to enalapril or enalaprilat; angioedema related to previous treatment with an ACE inhibitor; patients with idiopathic or hereditary angioedema; bilateral renal artery stenosis; pregnancy (2nd and 3rd trimesters)


Warnings/Precautions

 Anaphylactic reactions can occur. Angioedema can occur at any time during treatment (especially following first dose). Angioedema may involve head and neck (potentially affecting the airway) or the intestine (presenting with abdominal pain). Careful blood pressure monitoring with first dose (hypotension can occur especially in volume depleted patients). Dosage adjustment needed in renal impairment. Use with caution in hypovolemia; collagen vascular diseases; valvular stenosis (particularly aortic stenosis); hyperkalemia; or before, during, or immediately after anesthesia. Avoid rapid dosage escalation which may lead to renal insufficiency.

Rare toxicities associated with ACE inhibitors include cholestatic jaundice (which may progress to hepatic necrosis) and neutropenia/agranulocytosis with myeloid hyperplasia. Hypersensitivity reactions may be seen during hemodialysis with high-flux dialysis membranes (eg, AN69). Hyperkalemia may rarely occur. If patient has renal impairment then a baseline WBC with differential and serum creatinine should be evaluated and monitored closely during the first 3 months of therapy. Use with caution in unilateral renal artery stenosis and pre-existing renal insufficiency.


Adverse Reactions

 Note: Frequency ranges include data from hypertension and heart failure trials. Higher rates of adverse reactions have generally been noted in patients with CHF. However, the frequency of adverse effects associated with placebo is also increased in this population.

1% to 10%:

Cardiovascular: Hypotension (0.9% to 7%), chest pain (2%), syncope (0.5% to 2%), orthostasis (2%), orthostatic hypotension (2%)

Central nervous system: Headache (2% to 5%), dizziness (4% to 8%), fatigue (2% to 3%)

Dermatologic: Rash (2%)

Gastrointestinal: Abnormal taste, abdominal pain, vomiting, nausea, diarrhea, anorexia, constipation

Neuromuscular & skeletal: Weakness

Renal: Increased serum creatinine (0.2% to 20%), worsening of renal function (in patients with bilateral renal artery stenosis or hypovolemia)

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

<1% (Limited to important or life-threatening): Agranulocytosis, alopecia, anemia, angina pectoris, angioedema, cardiac arrest, asthma, ataxia, blurred vision, bronchospasm, confusion, conjunctivitis, CVA, depression, diaphoresis, drowsiness, dysrhythmias, dyspepsia, erythema multiforme, glossitis, gynecomastia, hemolysis with G6PD, hepatitis, hyperkalemia, hypoglycemia, ileus, impotence, insomnia, jaundice, MI, nervousness, neutropenia, oliguria, palpitation, pancreatitis, paresthesia, pemphigus, pruritus, pulmonary edema, renal dysfunction, Stevens-Johnson syndrome, stomatitis, tinnitus, upper respiratory infection, urinary tract infection, urticaria, vertigo, xerostomia. Worsening of renal function may occur in patients with bilateral renal artery stenosis or in hypovolemic patients.

Postmarketing and/or case reports: Depression, exfoliative dermatitis, giant cell arteritis, hallucinations, Henoch-Sch&ouml;nlein purpura, lichen-form reaction, ototoxicity, pemphigus foliaceus, photosensitivity, psychosis, sicca syndrome, systemic lupus erythematosus, toxic epidermal necrolysis, toxic pustuloderma. A syndrome which may include arthralgia, elevated ESR, eosinophilia and positive ANA, fever, interstitial nephritis, myalgia, rash, and vasculitis has been reported for enalapril and other ACE inhibitors.


Overdosage/Toxicology

 Mild hypotension has been the primary toxic effect seen with acute overdose. Bradycardia may also occur. Hyperkalemia occurs even with therapeutic doses, especially in patients with renal insufficiency and those taking NSAIDs. Following initiation of essential overdose management, toxic symptom treatment and supportive treatment should be initiated.


Drug Interactions

 Substrate of CYP3A4 (major)

Alpha1 blockers: Hypotensive effect increased.

Aspirin: The effects of ACE inhibitors may be blunted by aspirin administration, particularly at higher dosages (see Cardiovascular Considerations) and/or increase adverse renal effects.

CYP3A4 inducers: CYP3A4 inducers may decrease the levels/effects of enalapril. Example inducers include aminoglutethimide, carbamazepine, nafcillin, nevirapine, phenobarbital, phenytoin, and rifamycins.

Diuretics: Hypovolemia due to diuretics may precipitate acute hypotensive events or acute renal failure.

Insulin: Risk of hypoglycemia may be increased.

Lithium: Risk of lithium toxicity may be increased; monitor lithium levels, especially in the first 4 weeks of therapy.

Mercaptopurine: Risk of neutropenia may be increased.

NSAIDs: May attenuate hypertensive efficacy; effect has been seen with captopril and may occur with other ACE inhibitors; monitor blood pressure. May increase risk of renal adverse effects.

Potassium-sparing diuretics (amiloride, spironolactone, triamterene): Increased risk of hyperkalemia.

Potassium supplements may increase the risk of hyperkalemia.

Trimethoprim (high dose) may increase the risk of hyperkalemia.


Ethanol/Nutrition/Herb Interactions

 Herb/Nutraceutical: St John's wort may decrease enalapril levels. Avoid dong quai if using for hypertension (has estrogenic activity). Avoid ephedra, yohimbe, ginseng (may worsen hypertension). Avoid natural licorice (causes sodium and water retention and increases potassium loss). Avoid garlic (may have increased antihypertensive effect).


Stability

 Enalaprilat: Clear, colorless solution which should be stored at <30°C; I.V. is 24 hours at room temperature in D5W or NS


Compatibility

 Stable in dextran 40 10% in dextrose, D5LR, D5NS, D5W, hetastarch 6%, NS

Y-site administration: Compatible: Allopurinol, amifostine, amikacin, aminophylline, ampicillin, ampicillin/sulbactam, aztreonam, butorphanol, calcium gluconate, cefazolin, cefoperazone, ceftazidime, ceftizoxime, chloramphenicol, cimetidine, cisatracurium, cladribine, clindamycin, dextran 40, dobutamine, docetaxel, dopamine, doxorubicin liposome, erythromycin lactobionate, esmolol, etoposide, famotidine, fentanyl, filgrastim, ganciclovir, gatifloxacin, gemcitabine, gentamicin, granisetron, heparin, hetastarch, hydrocortisone sodium succinate, labetalol, lidocaine, linezolid, magnesium sulfate, melphalan, meropenem, methylprednisolone sodium succinate, metronidazole, morphine, nafcillin, nicardipine, penicillin G potassium, phenobarbital, piperacillin, piperacillin/tazobactam, potassium chloride, potassium phosphates, propofol, ranitidine, remifentanil, sodium acetate, sodium nitroprusside, teniposide, thiotepa, tobramycin, trimethoprim/sulfamethoxazole, vancomycin, vinorelbine. Incompatible: Amphotericin B, amphotericin B cholesteryl sulfate complex, cefepime, phenytoin

Compatibility when admixed: Compatible: Dobutamine, dopamine, heparin, meropenem, nitroglycerin, potassium chloride, sodium nitroprusside


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


Pharmacodynamics/Kinetics

Onset of action: Oral: ~1 hour

Duration: Oral: 12-24 hours

Absorption: Oral: 55% to 75%

Protein binding: 50% to 60%

Metabolism: Prodrug, undergoes hepatic biotransformation to enalaprilat

Half-life elimination:

Enalapril: Adults: Healthy: 2 hours; Congestive heart failure: 3.4-5.8 hours

Enalaprilat: Infants 6 weeks to 8 months old: 6-10 hours; Adults: 35-38 hours

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

Excretion: Urine (60% to 80%); some feces


Dosage

 Use lower listed initial dose in patients with hyponatremia, hypovolemia, severe congestive heart failure, decreased renal function, or in those receiving diuretics.

Oral: Enalapril : Children 1 month to 16 years: Hypertension: Initial: 0.08 mg/kg (up to 5 mg) once daily; adjust dosage based on patient response; doses >0.58 mg/kg (40 mg) have not been evaluated in pediatric patients

Investigational: Congestive heart failure: Initial oral doses of enalapril : 0.1 mg/kg/day increasing as needed over 2 weeks to 0.5 mg/kg/day have been used in infants

Investigational: Neonatal hypertension: I.V. doses of enalaprilat : 5-10 mcg/kg/dose administered every 8-24 hours have been used; monitor patients carefully; select patients may require higher doses

Adults:

Oral: Enalapril:

Hypertension: 2.5-5 mg/day then increase as required, usually at 1- to 2-week intervals; usual dose range (JNC 7): 2.5-40 mg/day in 1-2 divided doses. Note: Initiate with 2.5 mg if patient is taking a diuretic which cannot be discontinued. May add a diuretic if blood pressure cannot be controlled with enalapril alone.

Heart failure: As standard therapy alone or with diuretics, beta-blockers, and digoxin, initiate with 2.5 mg once or twice daily (usual range: 5-20 mg/day in 2 divided doses; target: 40 mg). Titrate slowly at 1- to 2-week intervals.

Asymptomatic left ventricular dysfunction: 2.5 mg twice daily, titrated as tolerated to 20 mg/day

I.V.: Enalaprilat:

Hypertension: 1.25 mg/dose, given over 5 minutes every 6 hours; doses as high as 5 mg/dose every 6 hours have been tolerated for up to 36 hours. Note: If patients are concomitantly receiving diuretic therapy, begin with 0.625 mg I.V. over 5 minutes; if the effect is not adequate after 1 hour, repeat the dose and administer 1.25 mg at 6-hour intervals thereafter; if adequate, administer 0.625 mg I.V. every 6 hours.

Heart failure: Avoid I.V. administration in patients with unstable heart failure or those suffering acute myocardial infarction.

Conversion from I.V. to oral therapy if not concurrently on diuretics: 5 mg once daily; subsequent titration as needed; if concurrently receiving diuretics and responding to 0.625 mg I.V. every 6 hours, initiate with 2.5 mg/day.

Dosing adjustment in renal impairment:

Oral: Enalapril:

Clcr 30-80 mL/minute: Administer 5 mg/day titrated upwards to maximum of 40 mg.

Clcr<30 mL/minute: Administer 2.5 mg day; titrated upward until blood pressure is controlled.

For heart failure patients with sodium <130 mEq/L or serum creatinine >1.6 mg/dL, initiate dosage with 2.5 mg/day, increasing to twice daily as needed. Increase further in increments of 2.5 mg/dose at >4-day intervals to a maximum daily dose of 40 mg.

I.V.: Enalaprilat:

Clcr >30 mL/minute: Initiate with 1.25 mg every 6 hours and increase dose based on response.

Clcr<30 mL/minute: Initiate with 0.625 mg every 6 hours and increase dose based on response.

Hemodialysis: Moderately dialyzable (20% to 50%); administer dose postdialysis (eg, 0.625 mg I.V. every 6 hours) or administer 20% to 25% supplemental dose following dialysis; Clearance: 62 mL/minute.

Peritoneal dialysis: Supplemental dose is not necessary, although some removal of drug occurs.

Dosing adjustment in hepatic impairment: 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; no dosage adjustment.


Administration

 Administer direct IVP over at least 5 minutes or dilute up to 50 mL and infuse; discontinue diuretic, if possible, for 2-3 days before beginning enalapril therapy


Monitoring Parameters

 Blood pressure, renal function, WBC, serum potassium; blood pressure monitor required during intravenous administration


Test Interactions

 Positive Coombs' [direct]; may cause false-positive results in urine acetone determinations using sodium nitroprusside reagent


Dietary Considerations

 Limit salt substitutes or potassium-rich diet.


Patient Education

 Inform prescriber of all prescriptions, OTC medications, or herbal products you are taking, and any allergies you have. Do not take any new medication during therapy unless approved by prescriber. Do not use potassium supplement or salt substitutes without consulting prescriber. Take exactly as directed; do not discontinue without consulting prescriber. Take first dose at bedtime. Take all doses on an empty stomach, 1 hour before or 2 hours after meals. This drug does not eliminate need for diet or exercise regimen as recommended by prescriber. May cause dizziness, fainting, or lightheadedness (use caution when driving or engaging in tasks that require alertness until response to drug is known); postural hypotension (use caution when rising from lying or sitting position or climbing stairs); or nausea, vomiting, abdominal pain, dry mouth, or transient loss of appetite (small, frequent meals, frequent mouth care, sucking lozenges, or chewing gum may help). Report persistent nausea and vomiting; chest pain or palpitations; mouth sores; fever or chills; swelling of extremities, face, mouth, or tongue; skin rash; numbness, tingling, or pain in muscles; respiratory difficulty or unusual cough; or other persistent adverse reactions. Pregnancy precaution: Inform prescriber if you are or intend to become pregnant. This drug should not be used in the 2nd or 3rd trimester of pregnancy. Consult prescriber for appropriate contraceptive measures if necessary.


Anesthesia and Critical Care Concerns/Other Considerations

 Severe hypotension may occur in patients who are sodium and/or volume depleted, initiate lower doses and monitor closely when starting therapy in these patients

ACE inhibitors decrease morbidity and mortality in patients with asymptomatic and symptomatic left ventricular dysfunction. In this situation, they decrease hospitalizations for, and retard progression to, congestive heart failure. ACE inhibitors are also indicated in patients postmyocardial infarction in whom left ventricular ejection fraction is <40%. When used in patients with heart failure, the target dose of 10 mg twice daily should be achieved, if possible. Lower daily doses of ACE inhibitors have not demonstrated the same cardioprotective effects.

ACE inhibitor therapy may elicit rapid increases in potassium and creatinine, especially when used in patients with bilateral renal artery stenosis. When ACE inhibition is introduced in patients with pre-existing diuretic therapy who are hypovolemic, the ACE inhibitor may induce acute hypotension.


Cardiovascular Considerations

 Enalapril should be prescribed twice daily for congestive heart failure. Enalaprilat should be used with caution and avoided if possible in the acute treatment of myocardial infarction. In a study to evaluate enalaprilat therapy administered within the first 24 hours of the onset of acute myocardial infarction therapy worsened survival.

ACE inhibitors decrease morbidity and mortality in patients with asymptomatic and symptomatic left ventricular dysfunction. In this situation, they decrease hospitalizations for, and retard progression to, congestive heart failure. According to 2004 ACC/AHA STEMI guidelines, an ACE inhibitor should be administered orally within the first 24 hours of STEMI to patients with anterior infarction, pulmonary congestion or LVEF <0.4, in the absence of hypotension or known contraindications to that class of medicines. In the emergency management of complicated STEMI, a short-acting ACEI (eg, captopril 1-6.25 mg) may be added once the patient's systolic blood pressure is >100 mm Hg and not <30 mm Hg below baseline. When used in patients with heart failure, the target dose of 10 mg twice daily should be achieved, if possible. Lower daily doses of ACE inhibitors have not demonstrated the same cardioprotective effects. ACE inhibitors have renal protective effects in patients with proteinuria and possibly cardioprotective effects in high-risk patients.

ACE inhibitor therapy may elicit rapid increases in potassium and creatinine, especially when used in patients with bilateral renal artery stenosis. When ACE inhibition is introduced in patients with pre-existing diuretic therapy who are hypovolemic, the ACE inhibitor may induce acute hypotension. In those patients experiencing cough on an ACE inhibitor, the ACE inhibitor may be discontinued and, if necessary, angiotensin receptor blocker therapy instituted. Concomitant NSAID therapy may attenuate blood pressure control; use of NSAIDs should be avoided or limited, with monitoring of blood pressure control. In the setting of heart failure, NSAID use may be associated with an increased risk for fluid accumulation and edema. Because of the potent teratogenic effects of ACE inhibitors, these drugs should be avoided, if possible, when treating women of childbearing potential not on effective birth control measures.

In the treatment of unstable angina/non-ST-segment elevation MI, ACE inhibitors are recommended when hypertension persists despite treatment with nitroglycerin and a beta-blocker in patients with LV systolic dysfunction or CHF and in ischemic patients with diabetes (Class I). ACE inhibitors are also recommended for all post-ACS individuals (Class IIa).


Dental Health: Effects on Dental Treatment

 Key adverse event(s) related to dental treatment: Abnormal taste and orthostatic hypotension.


Dental Health: Vasoconstrictor/Local Anesthetic Precautions

 No information available to require special precautions


Mental Health: Effects on Mental Status

 May cause drowsiness and dizziness; rarely may cause insomnia, confusion, depression


Mental Health: Effects on Psychiatric Treatment

 May rarely cause agranulocytosis; use caution with clozapine and carbamazepine; may decrease lithium clearance resulting in an increase in serum lithium levels and potential lithium toxicity; monitor serum lithium levels


Dosage Forms

Injection, solution, as enalaprilat: 1.25 mg/mL (1 mL, 2 mL) [contains benzyl alcohol]

Tablet, as maleate (Vasotec®): 2.5 mg, 5 mg, 10 mg, 20 mg


Extemporaneously Prepared

An enalapril oral suspension (0.2 mg/mL) has been made using one 2.5 mg tablet and 12.5 mL sterile water; stability unknown; suspension should be used immediately and the remaining amount discarded

Young TE and Mangum OB, "Neofax®, '95: A Manual of Drugs Used in Neonatal Care," 8th ed, Columbus, OH: Ross Products Division, Abbott Laboratories, 1995, 85.

An enalapril oral suspension (1 mg/mL) has been made using 20 mg tablets and mL Bicitra®. Add 50 mL Bicitra® to a polyethylene terephthalate (PET) bottle containing ten 20 mg tablets and shake for at least 2 minutes. Let concentrate stand for 60 minutes. Following the 60-minute hold time, shake the concentration for an additional minute. Add 150 mL Bicitra® to the concentrate and shake the suspension to disperse the ingredients. The suspension should refrigerated at 2°C to 8°C (36°F to 46°F); it can be stored for up to 30 days. Shake suspension well before use.

Package labeling, Merck & Co, Inc, issued October 2000.


References

Antman EM, Anbe SC, Alpert JS, et al, "ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction - Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)," Circulation, 2004, 110:588-636. Available at: http://www.circulationaha.org/cgi/content/full/110/5/588. Last accessed October 26, 2004.

Braunwald E, Antman EM, Beasley JW, et al, "ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction - Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)," J Am Coll Cardiol , 2002, 40(7):1366-74. Available at: http://www.acc.org/clinical/guidelines/unstable/incorporated/index.htm. Accessed May 20, 2003.

Chase MP, Fiarman GS, Scholz FJ, et al, "Angioedema of the Small Bowel Due to an Angiotensin-Converting Enzyme Inhibitor," J Clin Gastroenterol , 2000, 31(3):254-7.

Chobanian AV, Bakris GL, Black HR, et al, "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report," JAMA , 2003, 289(19):2560-71.

Conlin P, Moore T, Swartz S, et al, "Effect of Indomethacin on Blood Pressure Lowering by Captopril and Losartan in Hypertensive Patients," Hypertension , 2000, 36(3):461-5.

"Consensus Recommendations for the Management of Chronic Heart Failure. On Behalf of the Membership of the Advisory Council to Improve Outcomes Nationwide in Heart Failure," Am J Cardiol , 1999, 83(2A):1A-38A.

Erstad BL and Barletta JF, "Treatment of Hypertension in the Perioperative Patient," Ann Pharmacother , 2000, 34(1):66-79.

Hunt SA, Baker DW, Chin MH, et al, "ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure)," J Am Coll Cardiol , 2001, 38(7):2101-13.

"K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Kidney Disease Outcome Quality Initiative," Am J Kidney Dis , 2002, 39(2 Suppl 2):1-246. Available at: http://www.kidney.org/professionals/doqi/kdoqi/toc.htm. Accessed August 1, 2003.

Packer M, Poole-Wilson PA, Armstrong PW, et al, "Comparative Effects of Low and High Doses of the Angiotensin-Converting Enzyme Inhibitor, Lisinopril, on Morbidity and Mortality in Chronic Heart Failure," Circulation , 1999, 100(23):2312-8.

Pfeffer MA, Greaves SC, Arnold JM, et al, "Early Versus Delayed Angiotensin-Converting Enzyme Inhibition Therapy in Acute Myocardial Infarction. The Healing and Early Afterload Reducing Therapy Trial," Circulation , 1997, 95(12):2643-51.

Smoger SH and Sayed MA, "Simultaneous Mucosal and Small Bowel Angioedema Due to Captopril," South Med J , 1998, 91(11):1060-3.


International Brand Names

 Acepril® (CH, HU); Aceren® (DK); Acetensil® (CZ, EC, ES); Adco-Enalapril® (ZA); Alacor® (DK); Alapren® (ZA); Alapril® (AT); Alphapril® (AU); Amprace® (AU); Anapril® (BD, SG, TH); Apo-Enalapril® (CZ); Atens® (BR); Bajaten® (CL); Balpril® (PT); Baripril® (ES); Benalapril® (DE, PL); Berlipril® (CZ, RU); Biocronil® (CO); Bitensil® (ES); Bonuten® (AR); BQL® (IN); Cardiol® (EC); Cardio-Pres® (DO); Cetampril® (PT); Ciplatec® (ZA); Clipto® (ES); Controlvas® (ES); Converten® (IT); Convertin® (IL); Co-Renitec® (AT, BR, CY, EG, HU, JO, KW, LB, RU); Corodil® (DK); Corprilor® (CR, DO, ES, PA, SG, SV); Corvo® (DE); Crinoren® (ES); Dabonal® (ES); Decliten® (EC); Defluin® (AR); Denapril® (PT); Ditensil® (DO); Ditensor® (ES); Ecaprilat® (AR); Ecaprinil® (DO); E-Cor® (CZ); Ednyt® (CZ, GB, HU, PL, RO, RU); Elpradil® (CH); Ena AbZ® (DE); Enabeta® (DE); Enacard® (GB); Enac® (AT); Enacodan® (DK); Enadil® (DK); enadura® (DE); Ena-Hennig® (DE); Enahexal® (DE); Enaladil® (MX); Enalafel® (AR); Enalagamma® (DE); Enalap® (DO, RO, TR); Enalapril 1A Farma® (DK); Enalapril 1A Pharma® (AT, DE); Enalapril AAA-Pharma® (DE); Enalapril Abello® (ES); Enalaprila® (CL); Enalapril-Akri® (RU); Enalapril AL® (DE); Enalapril Alpharma® (SE); Enalapril Alter® (ES); Enalapril AstraZeneca® (SE); Enalapril Atid® (DE); Enalapril AWD® (DE); Enalapril-axsan® (DE); Enalapril AZU® (DE); Enalapril Basics® (DE); Enalapril Bayvit® (ES); Enalapril Belmac® (ES); Enalapril Bexal® (ES); Enalapril Biochemie® (DE, DK, FI, SE); Enalapril-Chinoin® (HU); Enalapril Ciclum® (PT); Enalapril Cinfa® (ES); Enalapril® (CL, CZ, EC, IL, NO, PL, RO, RU, YU); Enalapril Copyfarm® (SE); Enalapril-corax® (DE); Enalapril Cuve® (ES); Enalapril Davur® (ES); Enalapril Durban® (ES); Enalapril Ecar® (CO); Enalapril Edigen® (ES); Enalapril Fada® (AR); Enalapril Farmalider® (ES); Enalapril findusFit® (DE); Enalapril Geminis® (ES); Enalapril Genericon® (AT); Enalapril Generics® (FI); Enalapril Genfar® (EC); Enalapril Grapa® (ES); Enalapril Helvepharm® (CH); Enalapril Heumann® (DE); Enalapril IVAX® (SE); Enalapril Klast® (DE); Enalapril KSK® (DE); Enalapril Kwizda® (AT); Enalapril Lachema® (RO); Enalapril Lareq® (ES); Enalapril Mabo® (ES); Enalaprilmaleat Arcana® (AT); Enalapril Maleate® (GB); Enalaprilmaleat Lindo® (DE); Enalapril Maleato® (CL); Enalapril Maleato L.CH.® (CL); Enalapril Merck® (ES, PT); Enalapril MK® (CO, CR, GT, HN, PA, SV); Enalapril NM® (DK); Enalapril NM Pharma® (SE); Enalapril Normon® (ES); Enalapril Pliva® (DK, SE); Enalapril Ranbaxy® (FI, SE); Enalapril Ratiopharm® (AT); Enalapril-ratiopharm® (DE); Enalapril Ratiopharm® (ES); Enalapril-ratiopharm® (FI); Enalapril Ratiopharm® (SE); Enalapril Richet® (AR); Enalapril Rowe® (CR, DO, HN, PA, SV); Enalapril-saar® (DE); Enalapril Sandoz® (CH, DE); Enalapril Stada® (DE); Enalapril Tamarang® (ES); Enalapril Tedec® (ES); Enalapril-TEVA® (DE); Enalapril Verla® (DE); Enalapril Vir® (ES); enalapril von ct® (DE); Enalapril Wolff® (DE); EnalaprilX® (DE); Enal® (DE); Enaldun® (AR); EnaLich® (DE); Enalind® (DE); Enaloc® (FI); Enalten® (CL, EC); Enam® (RU, TH); Enap® (CZ, HR, HU, IE, PL, RO, RU, SG, SI, ZA); Enap® [inj.] (HU, SI); Enapirex® (CZ); Enap i.v.® (HR); Enaplus® (EC); Enapren® (IT); Enapress® (FI, PL); Enapril® (AT, CZ, RO, TH, TR); Ena-Puren® (DE); Enaratio® (PL); Enarenal® (PL, RO); Enaril® (BD, SG, TH); Enasifar® (CH); Enatec® (CH, PL); Enatral® (AR); Enatrial® (AR); Enatyrol® (AT); Enazil® (HR, SI); Enetil® (CO); Envas® (IN, ZA); Ephicord® (RO); Epril® (CH, PL); Eritril® (AR); Esalfon® (CL); Eupressin® (BR); Fabotensil® (AR); Feliberal® (MX); Gadopril® (AR); Giloten® (BR); Glioten® (AR, CL, CO, CR, DO, GT, HN, MX, PA, SV); Grifopril® (CL); Herten® (ES); Hiperson® (CL); Hipertan® (AR); Hipoartel® (CL, ES); HR-Enalapril maleate® (ZA); Hypace® (ZA); Iecatec® (ES, TH); Innomel® (IE); Innovace® (GB, IE); Inoprilat® (ID); Insup® (ES); Invoril® (HU, IN, RO, RU, SG, TH); Istopril® (TH); Jutaxan® (DE); Kalipren® (CZ, RU, SK); Kalpiren® (RU); Kenopril® (MX); Kinfil® (AR); Konveril® (TR); Korandil® (CY, SG, TH); Lapril® (TH); Linatil® (FI, NO, SE); Lotrial® (AR, CL); Maleato de Enalapril® (BR); Maleato de Enalapril Merck® (PT); Malen® (PT); Mapryl® (PL); Megapress® (RO); Meipril® (ID); Mepril® (AT); Minipril® (BD); Nacor® (ES); Nalapril® (AR); Nalopril® (TH); Naprilene® (ES, IT); Naprilex® (DO); Naritec® (TH); Neolapril® (BR); Neotensin® (ES); Nor-Prilat® (GT, HN, SV); Norpril® (MX); Nuril® (IN); Olivin® (HR, SI); Omnipress® (EC); Palane® (MX); Pharmapress® (ZA); Pralenal® (GB); Pres® (DE); Presi Regul® (AR); Pres iv® (DE); Pressitan® (ES); Prevol® (CL); Prilace® (EC); Prilan® (PT); Prilenap® (YU); Priltenk® (AR); Pulsol® [tabs] (MX); Reca® (ES); Renacardon® (ID); Renapril® (YU); Renaton® (SG); Renipress® (SV); Renistad® (AT); Renitec® (AR, AT, AU, BE, BR, CO, CR, CZ, DK, EC, ES, FI, FR, GT, HK, HN, HU, LU, MX, NL, NO, NZ, PA, PT, RO, RU, SE, SG, SV, TH, TR, ZA); Renitec I.V.® (AT); Reniten® (CH); Reniten i.v.® (CH); Renivace® (CL, ID, JP); Sulapril® (DO); Sulocten® (AR); Tenace® (ID); Tenazide® (ID); Tensazol® (PT); Tesoren® (CO); Unipril® (CO); Vapresan® (AR); Vasocor® (CH); Vasolapril® (TR); Vasopril® (BD, BR); Vasotec® (CA); Vimapril® (RO); Virfen® (RO); Xanef® (DE)


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