Enalapril (Envas H) Dosing for Hypertension and Heart Failure
For hypertension, start enalapril at 5 mg once daily (or 2.5 mg if on diuretics) and titrate to a usual maintenance range of 10-40 mg daily in one or two divided doses; for heart failure, initiate at 2.5 mg twice daily and titrate up to the evidence-based target of 10 mg twice daily (20 mg total daily dose). 1
Hypertension Dosing
Initial Dosing
- Start with 5 mg once daily in patients not currently on diuretics 1
- Use 2.5 mg once daily if the patient is already taking a diuretic, with medical supervision for at least 2 hours after the first dose until blood pressure stabilizes 1
- If possible, discontinue the diuretic 2-3 days before starting enalapril to reduce hypotension risk 1
Maintenance Dosing
- Usual dosage range: 10-40 mg per day administered as a single dose or in two divided doses 1
- If once-daily dosing loses effectiveness toward the end of the dosing interval, consider increasing the dose or switching to twice-daily administration 1
- Add a diuretic if blood pressure remains uncontrolled on enalapril alone 1
Renal Impairment Adjustments
- Normal renal function (CrCl >80 mL/min): 5 mg initial dose 1
- Mild impairment (CrCl 30-80 mL/min): 5 mg initial dose 1
- Moderate to severe impairment (CrCl ≤30 mL/min): 2.5 mg initial dose, titrate to maximum 40 mg daily 1
- Dialysis patients: 2.5 mg on dialysis days, adjust on non-dialysis days based on blood pressure response 1
Heart Failure Dosing
Evidence-Based Target Doses
The mortality-reducing target dose is 10 mg twice daily (20 mg total daily), as demonstrated in landmark trials including CONSENSUS, V-HeFT II, and SOLVD 2. These trials showed that enalapril at this target dose achieved mean daily doses of 15.0-18.4 mg and significantly reduced mortality and hospitalizations 2.
Initiation Protocol
- Start with 2.5 mg once or twice daily 1
- Observe under medical supervision for at least 2 hours after the initial dose and until blood pressure stabilizes for an additional hour 1
- If possible, reduce concomitant diuretic dose before starting enalapril to minimize hypotension risk 2
Titration Strategy
- Titrate upward over a period of days to weeks as tolerated 1
- Target maintenance range: 2.5-20 mg twice daily 1
- Maximum dose tested in clinical trials: 40 mg daily in divided doses 1
- Check blood pressure, renal function, and electrolytes 5-7 days after each dose increment, then at 3 months, and subsequently every 6 months 2
Special Populations in Heart Failure
For patients with hyponatremia (serum sodium <130 mEq/L) or elevated creatinine (>1.6 mg/dL):
- Initiate at 2.5 mg daily under close medical supervision 1
- Increase to 2.5 mg twice daily, then 5 mg twice daily, and higher as needed at intervals of 4 days or more 1
- Monitor closely for hypotension and renal function deterioration 1
Critical Monitoring Parameters
Initial Monitoring
- Check serum potassium and creatinine after 5-7 days of starting therapy 2
- Recheck every 5-7 days during titration until potassium values are stable 2
Ongoing Monitoring
- Blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 2
- Reassess at 3 months, then every 6 months 2
Important Safety Considerations
Contraindications and Precautions
- Avoid potassium-sparing diuretics during initiation to prevent hyperkalemia 2
- Avoid NSAIDs and COX-2 inhibitors as they can reduce ACE inhibitor efficacy and worsen renal function 2
- Do not use with ARNIs (sacubitril/valsartan) concomitantly or within 36 hours due to angioedema risk 2
- Contraindicated in bilateral renal artery stenosis and history of angioedema with prior ACE inhibitor therapy 2
Common Pitfalls
- The appearance of hypotension after the initial dose does not preclude subsequent careful titration; manage the hypotension and continue titration 1
- If renal function deteriorates substantially during titration, stop treatment 2
- Many patients require twice-daily dosing for sustained 24-hour blood pressure control 1