Should Enalapril Dosage Be Increased?
Yes, increase enalapril from 10mg once daily to 10mg twice daily (20mg total daily dose) to achieve better blood pressure control, as the patient's BP of 130s/80s remains above target and the current dose is below the usual therapeutic range. 1
Rationale for Dose Escalation
The FDA-approved usual dosage range for enalapril in hypertension is 10-40mg per day, administered in a single dose or two divided doses, making the current 10mg daily dose at the lower end of the therapeutic spectrum 1
In some patients treated once daily, the antihypertensive effect may diminish toward the end of the dosing interval—in such patients, an increase in dosage or twice daily administration should be considered 1
The patient's persistent BP in the 130s/80s indicates inadequate 24-hour blood pressure control, suggesting end-of-dose waning of antihypertensive effect 1
Target Blood Pressure Considerations
Current guidelines recommend a target BP of <130/80 mmHg for most patients, which this patient is not achieving with systolic pressures in the 130s 2
The diastolic pressure of 80s mmHg is at the upper limit of acceptable control, warranting optimization of current therapy before adding additional agents 2
Dosing Strategy
Increase enalapril to 10mg twice daily (total 20mg/day) rather than simply doubling the once-daily dose, as twice-daily dosing provides more consistent 24-hour blood pressure control when once-daily dosing shows end-of-interval waning 1
This approach follows the guideline recommendation to optimize ACE inhibitor dosing before adding additional antihypertensive agents 2
If BP remains uncontrolled after 4 weeks on enalapril 10mg twice daily, further titration up to 40mg daily (20mg twice daily) is appropriate before considering combination therapy 1
Monitoring and Follow-up
Recheck blood pressure within 4 weeks of dose adjustment to assess response 2
Monitor for potential adverse effects including dizziness, cough, changes in renal function, and hyperkalemia 2, 3
Consider home blood pressure monitoring to guide therapy, with target home BP <135/85 mmHg 2
Alternative Consideration: Adding vs. Increasing
While adding a thiazide diuretic is a valid alternative strategy, optimizing the ACE inhibitor dose first is preferred in non-Black patients per guideline recommendations 2
The evidence shows that 70% of patients respond to enalapril monotherapy with adequate dose titration, and over 90% respond when a thiazide is added if needed 4
Enalapril 10-40mg/day has demonstrated efficacy comparable to thiazides and beta-blockers in controlling blood pressure across all grades of hypertension 5, 3
Critical Pitfall to Avoid
Do not prematurely add a second agent before optimizing the current ACE inhibitor dose, as this exposes the patient to unnecessary polypharmacy and increased risk of adverse effects 2
Ensure medication adherence is confirmed before escalating therapy, as non-adherence is a common cause of apparent treatment resistance 6