What is the proper administration and dosing of Enalapril (Angiotensin-Converting Enzyme Inhibitor)?

Enalapril Administration Guidelines

For proper administration of enalapril, start with 2.5 mg twice daily for heart failure and 5 mg once daily for hypertension, then titrate upward as tolerated to target doses of 10-20 mg twice daily for heart failure and 10-40 mg daily for hypertension. 1

Dosing by Indication

Hypertension

• Initial dose: 5 mg once daily for patients with normal renal function 1
• Maintenance dose: 10-40 mg per day as a single dose or divided twice daily 1
• Dose adjustment: If blood pressure not controlled with once-daily dosing, consider twice-daily administration 1
• Maximum dose: 40 mg daily 1

Heart Failure

• Initial dose: 2.5 mg twice daily 1
• Target dose: 10-20 mg twice daily 1
• Titration: Increase gradually over days to weeks as tolerated 1
• Maximum dose: 40 mg daily in divided doses 1

Asymptomatic Left Ventricular Dysfunction

• Initial dose: 2.5 mg twice daily 1
• Target dose: 20 mg daily in divided doses 1

Hypertensive Emergency (IV Enalaprilat)

• Dose: Initial 1.25 mg over 5 minutes
• Frequency: Can be increased up to 5 mg every 6 hours as needed 2

Special Populations

Renal Impairment

Renal Status	Creatinine Clearance	Initial Dose
Normal	>80 mL/min	5 mg
Mild impairment	30-80 mL/min	5 mg
Moderate to severe	≤30 mL/min	2.5 mg
Dialysis patients	-	2.5 mg on dialysis days [1]

Heart Failure with Renal Impairment or Hyponatremia

• Initial dose: 2.5 mg once daily under close medical supervision
• Titration: May increase to 2.5 mg twice daily, then 5 mg twice daily at intervals of at least 4 days 1

Pediatric Patients

• Initial dose: 0.08 mg/kg (up to 5 mg) once daily
• Not recommended: In neonates or pediatric patients with GFR <30 mL/min/1.73 m² 1

Administration Guidelines

Oral Administration

1. Can be taken with or without food
2. For patients on diuretics:
   • Discontinue diuretic 2-3 days before starting enalapril if possible
   • If diuretic cannot be discontinued, start with 2.5 mg under medical supervision 1

First Dose Monitoring

• Monitor patient for at least 2 hours after initial dose
• Continue monitoring until blood pressure stabilizes for at least an additional hour 1
• Watch for first-dose hypotension, especially in patients:
  • On diuretics
  • With heart failure
  • With sodium/volume depletion 1

Preparation of Suspension (for pediatric use)

For 200 mL of a 1.0 mg/mL suspension:

1. Add 50 mL of Bicitra to a PET bottle containing ten 20 mg tablets
2. Shake for at least 2 minutes
3. Let stand for 60 minutes
4. Shake for an additional minute
5. Add 150 mL of Ora-Sweet SF
6. Refrigerate at 2-8°C and use within 30 days
7. Shake before each use 1

Monitoring Parameters

• Blood pressure: After initial dose and with each dose increase
• Renal function and electrolytes: Before starting, 1-2 weeks after initiation, and with each dose increase 1
• Potassium: Monitor regularly, especially if combined with potassium-sparing diuretics or supplements

Common Pitfalls and Precautions

• First-dose hypotension: Can be severe, especially in patients with heart failure, hyponatremia, or on diuretics
• Renal function deterioration: May occur in patients with bilateral renal artery stenosis
• Hyperkalemia: Monitor potassium levels, especially when combined with potassium-sparing diuretics
• Pregnancy: Contraindicated due to risk of fetal injury and death
• Angioedema: Discontinue immediately if facial, lip, tongue, glottis, or larynx swelling occurs

By following these guidelines, enalapril can be administered safely and effectively for the treatment of hypertension, heart failure, and asymptomatic left ventricular dysfunction.