Instructions for Enalapril
Composition Enalapril:
Each 5 mg tablet contains the active ingredient: enalapril maleate - 5.0 mg. Excipients: lactose monohydrate (milk sugar) - 73.0 mg, potato starch - 17.0 mg, povidone-C17 - 4.0 mg, calcium stearate - 1.0 mg.
Pharmacokinetics Enalapril:
After ingestion, Enalapril is rapidly absorbed in the gastrointestinal tract. The degree of absorption of Enalapril when administered orally is approximately 60%. Simultaneous food intake does not affect the absorption of Enalapril. The maximum concentration in serum is reached within 1 hour after ingestion. After absorption, enalapril is rapidly hydrolyzed to form the active metabolite of enalaprilat, a powerful ACE inhibitor. Bioavailability when administered orally about 40% in the form of enaprilat.
Indications Enalapril:
• Essential hypertension of any severity;
• Renovascular hypertension
• Heart failure of any severity.
In patients with the presence of manifestations of CH, Enalapril is also indicated for:
- increase patient survival;
- slowing the progression of HF;
- reduce the frequency of hospitalizations for heart failure.
• Prevention of the development of clinically severe heart failure.
In patients without clinical symptoms of HF with left ventricular dysfunction, Enalapril is indicated for:
- slowing down the development of clinical manifestations of HF;
- reduce the frequency of hospitalizations for heart failure.
- Prevention of coronary ischemia in patients with left ventricular dysfunction.
The drug is indicated for:
- reduce the incidence of myocardial infarction;
- reduce the frequency of hospitalizations for unstable angina. Enalapril
Pharmacodynamics Enalapril:
Enalapril is a hypotensive agent whose mechanism of action is associated with the inhibition of the activity of angiotensin-converting enzyme (ACE), leading to a decrease in the formation of angiotensin II. As a result of hydrolysis of enalapril enalaprilat is formed, which inhibits ACE.
It is used to treat essential hypertension (primary arterial hypertension (AH) of any severity) and renovascular hypertension both in monotherapy and in combination with other antihypertensive drugs, in particular with diuretics. Enalapril is also used to treat or prevent the development of heart failure (HF).
Enalapril is a derivative of two amino acids, L-alanine and L-proline. Enalapril is a prodrug: as a result of its hydrolysis, enalaprilat is formed, which is a highly specific and long-acting ACE inhibitor that does not contain a sulfhydryl group. ACE (peptidyl dipeptidase A) catalyzes the conversion of angiotensin I into the pressor peptide of angiotensin II. Its mechanism of action is associated with a decrease in the formation of angiotensin II from angiotensin I, which leads to an increase in plasma renin activity (due to the elimination of negative feedback in response to renin release) and a decrease in aldosterone secretion.
At the same time, general peripheral vascular resistance, systolic and diastolic blood pressure (BP), post- and preload on the myocardium decrease. Enalapril expands the arteries to a greater extent than the veins, while there is no reflex increase in heart rate. ACE is identical to the enzyme kininase II, so Enalapril can also block the destruction of bradykinin - a peptide with a pronounced vasodilating action. Enalapril
Pharmacokinetics Enalapril:
Distribution In the range of therapeutic doses, the binding of enalaprilat to plasma proteins does not exceed 60%. Enalapril easily penetrates histohematogenous barriers, excluding the blood-brain barrier, a small amount penetrates through the placenta and into breast milk.
The maximum concentration of enalaprilat in the serum is observed after 3-4 hours, Enalapril - after 1 hour. Stable serum concentrations after 4 days. Metabolism There are no data on other significant metabolic pathways for Enalapril, other than hydrolysis by liver enzymes before enalaprilat. Approximately 60% of the absorbed enalapril is hydrolyzed. Enalapril
The rate of hydrolysis may decrease in patients with impaired liver function without reducing the therapeutic effect. The degree of absorption and hydrolysis of Enalapril is the same for different doses within the recommended therapeutic range. Withdrawal Withdrawal of enalaprilat is carried out mainly through the kidneys. The main metabolites detected in the urine are enalaprilat, which constitutes approximately 40% of the dose, and unchanged enalapril (approximately 20%).
Data on other metabolites of Enalapril no. The plasma concentration curve of enalaprilat has a long end phase, apparently due to its binding to ACE. The half-life (T1 / 2) of enalaprilat for oral administration of enalapril is 11 hours. It is removed during hemodialysis (speed 62 ml / min) and peritoneal dialysis.
Enalaprilat can be removed from the general bloodstream by hemodialysis. Enalapril
Side effects Enalapril:
The incidence of adverse events is classified according to the recommendations of the World Health Organization: very often (> 1/10), often (> 1/100 and <1/10), infrequently (> 1/1000 and <1/100), rarely ( > 1/10000 and <1/1000), very rarely (<1/10000), including individual messages, frequency unknown (cannot be estimated based on available data)
Disorders of the blood and lymphatic system: infrequently - anemia (including aplastic and hemolytic); rarely - neutropenia, decrease in hemoglobin and hematocrit, thrombocytopenia, agranulocytosis, inhibition of bone marrow hematopoiesis, pancytopenia, lymphadenopathy, autoimmune diseases.
Endocrine disruption: unknown frequency - syndrome of inadequate secretion of antidiuretic hormone.
Metabolic and nutritional disorders: infrequently - hypoglycemia (see section "Special Instructions"). Disturbances of the nervous system and mental disorders: very often, headache; often - headache, depression; infrequently - confusion, insomnia, irritability, paresthesia, vertigo; rarely - unusual dreams, sleep disorders. Enalapril
Special conditions Enalapril:
Symptomatic arterial hypotension The use of double blockade of RAAS (for example, by simultaneous use of an ACE inhibitor with ARA II) must be addressed in each case individually with careful monitoring of renal function.
Care must be taken in patients with reduced BCC (including when used concurrently with diuretics, under conditions of limiting salt intake, with hemodialysis, vomiting, diarrhea), in which a sudden and pronounced decrease in blood pressure may develop in response to the use of an ACE inhibitor.
In patients with CHF I, II functional class according to the NYHA classification, with or without chronic renal failure, symptomatic hypotension is usually not observed.
The development of arterial hypotension is most likely in patients with more severe CHF due to the use of high doses of diuretics, hyponatremia or functional renal failure. In these patients, therapy should begin under the supervision of a physician until the optimum dose adjustment of the drug Enalapril and / or diuretic.
A similar tactic can be applied to patients with coronary artery disease or cerebrovascular diseases in whom a pronounced decrease in blood pressure can lead to myocardial infarction or impaired cerebral circulation.
In such cases, a dose reduction and / or withdrawal of Enalapril and / or diuretic may be required. In patients with bilateral renal artery stenosis or arterial stenosis of a single kidney, taking ACE inhibitors, there is an increased risk of arterial hypotension and renal failure.
Only moderate changes in plasma creatinine concentration may indicate a decrease in kidney function. In such patients, treatment should begin with small doses under the supervision of a physician, gradually adjusting the individual dose and controlling the serum creatinine concentration.
Kidney transplantation
There is no experience with Enalapril in patients after kidney transplantation. Treatment with Enalapril patients after kidney transplantation is not recommended.
Liver failure
The use ofEnalapril in patients with hepatic insufficiency usually does not require dose adjustment. Rarely, when treating with ACE inhibitors, there is a syndrome that begins with cholestatic jaundice or hepatitis, which progresses to fulminant necrosis of the liver, sometimes fatal. The mechanism of this syndrome has not been studied.
Patients who develop jaundice or a pronounced increase in the activity of liver transaminases during the treatment with ACE inhibitors should discontinue the ACE inhibitors and prescribe appropriate supportive therapy. The patient must be under medical supervision.
Neutropenia / Agranulocytosis Enalapril
There are reports of the development of neutropenia / agranulocytosis, thrombocytopenia and anemia in patients treated with ACE inhibitors. The risk of neutropenia is likely to depend on the dose and the clinical condition of the patient. Neutropenia is more likely to occur in patients with reduced kidney function, especially if there is a concomitant connective tissue disease (systemic lupus erythematosus, scleroderma) or when treated with immunosuppressants, allopurinol or procainamide, as well as a combination of these complicating risk factors.
Some of these patients developed severe infectious diseases, in which in some cases there was no response to intensive antibiotic therapy. When enalapril is used in such patients, it is advisable before treatment, every 2 weeks during the first three months of treatment, and then to regularly monitor blood leukocytes and a complete blood count. Enalapril
The patient should be urged to inform the doctor about any symptom of an infectious disease (for example, sore throat, fever); in this case, the blood leukocyte count should be monitored.
If neutropenia is suspected or detected (less than 1000 / mm3), which is reversible, Enalapril and other concomitant medications should be discontinued (see the section "Interaction with Other Medicines").
Hypersensitivity Reactions / Angioedema
When using ACE inhibitors, including Enalapril, in rare cases and in any period of therapy, angioedema of the face, upper and lower extremities, lips, mucous membranes, tongue, vocal folds and / or larynx may develop (see act").
When symptoms appear, the drug should be immediately discontinued, and the patient should be observed until the signs of edema disappear completely. If the edema affects only the face and lips, then its manifestations usually disappear on their own, although antihistamines may be used to treat symptoms.
Angioedema, accompanied by swelling of the larynx, can be fatal. Swelling of the tongue, vocal folds or larynx can lead to airway obstruction, especially in patients with a history of surgical interventions on the respiratory organs.
In case of airway obstruction, emergency treatment is required as soon as possible, including subcutaneous administration of 0.3-0.5 ml of a solution of epinephrine (adrenaline) in a ratio of 1: 1000 and / or ensuring the airway patency (intubation or tracheostomy). Patients of the Negroid race, who took ACE inhibitors, developed angioedema more often than patients of other races.
Patients with a history of angioedema, not associated with taking ACE inhibitors, may be at greater risk of developing angioedema during therapy with ACE inhibitors (see the section "Contraindications"). In rare cases, on the background of therapy with ACE inhibitors, intestinal edema develops. At the same time, patients have abdominal pain as an isolated symptom or in combination with nausea and vomiting, in some cases without prior angioedema of the face and at a normal level of C1-esterase.
The diagnosis was established using computed tomography of the abdominal area, ultrasound, or during surgery.
Symptoms disappeared after discontinuation of ACE inhibitors. Therefore, in patients with abdominal pain, receiving ACE inhibitors, when conducting a differential diagnosis, it is necessary to take into account the possibility of developing angioedema of the intestine (see the “Side effect” section). In patients taking ACE inhibitors and rapamycin target inhibitors in mammalian cells (mTOR), estramustine, racecadotril, glyptines, there was an increase in the risk of developing angioedema (see "Interaction with other drugs")
Anaphylactoid reactions
during allergen desensitization from hymenoptera venom In rare cases, patients taking ACE inhibitors developed life-threatening anaphylactoid reactions during allergen desensitization from hymenoptera venom. To avoid appropriate reactions, prior to each session of desensitizing therapy, ACE inhibitor therapy should be temporarily discontinued.
The use of ACE inhibitors in patients receiving immunotherapy with bee venom should be avoided. Anaphylactoid reactions during low-density apheresis lipoproteins (LDL-apheresis) In rare cases, patients receiving ACE inhibitors may develop life-threatening anaphylactoid reactions during an LDL apheresis procedure. To prevent an anaphylactoid reaction, the ACE inhibitor therapy should be temporarily discontinued before each LDL apheresis procedure.
Hemodialysis patients
It should be borne in mind that the treatment with Enalapril in patients who have been shown to undergo hemodialysis may develop anaphylactoid reactions (swelling of the face, skin redness, marked reduction in blood pressure, shortness of breath) due to the use of high-capacity filter membranes consisting of polyacrylonitrile (eg AN69® high flow membranes). It is recommended to use other types of dialysis membranes for hemodialysis or antihypertensive drugs of other pharmacotherapeutic groups.
Race
Enalapril, like other ACE inhibitors, has a less pronounced antihypertensive effect in patients of the Negroid race, compared with other races, possibly due to the low renin activity in patients with arterial hypertension in this population. Sudden discontinuation of Enalapril does not lead to the development of "cancellation" syndrome. Impact on the ability to drive vehicles, mechanisms When using drugs Enalapril caution should be exercised when driving vehicles and occupations of potentially hazardous activities that require high concentration of attention and speed of psychomotor reactions (risk of dizziness, drowsiness).
Contraindications Enalapril:
Hypersensitivity to Enalapril, other components of the drug or other ACE inhibitors;
• lactose intolerance, lactase deficiency or glucose-galactose malabsorption syndrome;
• history of angioedema, associated with taking ACE inhibitors, and hereditary or idiopathic angioedema; • pregnancy;
• breastfeeding period;
• age up to 18 years (efficacy and safety of the drug have not been established);
• co-administration with aliskiren and aliskiren-containing drugs in patients with diabetes mellitus and / or moderate or severe renal impairment (glomerular filtration rate (GFR) less than 60 ml / min / 1.73 m2 of body surface area) (see section
"Interaction with other drugs");
• simultaneous use of angiotensin II receptor (APA II) with antagonists in patients with diabetic nephropathy. Carefully
• renovascular hypertension, bilateral renal artery stenosis, arterial stenosis of a single kidney (risk of developing renal failure);
• Ischemic heart disease (CHD) and cerebrovascular diseases (including cerebrovascular insufficiency), because excessive decrease in blood pressure can lead to the development of myocardial infarction and stroke;
• aortic and / or mitral stenosis (with impaired hemodynamic parameters), hypertrophic obstructive cardiomyopathy (GOKMP);
• systemic connective tissue diseases (including systemic lupus erythematosus, scleroderma);
• oppression of bone marrow hematopoiesis;
• immunosuppressive therapy, simultaneous use of allopurinol and procainamide, or a combination of these complicating factors;
• hyperkalemia; simultaneous use with potassium-sparing diuretics (for example, spironolactone, eplerenone, amiloride, triamterene), potassium preparations, potassium-containing substitutes for edible salt; simultaneous use with lithium preparations;
• diabetes;
• primary hyper aldosteronism;
• condition after kidney transplantation (no experience);
• abnormal liver function;
• renal dysfunction (CC less than 80 ml / min);
• conditions accompanied by a decrease in circulating blood volume (BCC) (as a result of diuretic therapy, while limiting salt intake, diarrhea, vomiting, dialysis);
• use in elderly patients;
• during desensitization with an allergen from hymenoptera venom;
• in patients after extensive surgery or with general anesthesia;
• in patients undergoing dialysis using high-flow membranes (such as AN 69®);
• carrying out the procedure of low density lipoprotein apheresis (LDL apheresis) using dextran sulfate;
• use of the Negroid race in patients;
• Burdened allergic history or angioedema in history. Use during pregnancy and during breastfeeding Pregnancy
The use of the drug Enalapril during pregnancy is not recommended. When confirming the fact of pregnancy during enalapril therapy, the drug should be immediately discontinued.
The published results of a retrospective epidemiological study of newborns whose mothers took ACE inhibitors in the first trimester of pregnancy noted an increased risk of developing serious congenital malformations compared to newborns whose mothers did not take ACE inhibitors during the first trimester of pregnancy.
The incidence of birth defects was low, and the results of this study were not confirmed again. ACE inhibitors can cause disease or death of the fetus or newborn when they are used by pregnant women during the second and third trimesters of pregnancy.
The use of ACE inhibitors in the second and third trimesters of pregnancy was accompanied by a negative effect on the fetus and newborn, which manifested itself as arterial hypotension, renal failure, hyperkalemia and / or hypoplasia of the cranial bones in the newborn.
Prematurity, intrauterine development of the fetus and non-closure of the arterial (Botallova) duct were also reported, but it is unclear whether these cases were associated with the action of ACE inhibitors. Oligohydramnion may develop due to impaired renal function of the fetus.
This complication can lead to contracture of the limbs, deformation of the bones of the skull, including its facial part, and hypoplasia of the fetal lungs. These adverse effects on the embryo and fetus do not appear to be the result of the intrauterine action of ACE inhibitors during the first trimester of pregnancy.
When using the drug Enalapril during pregnancy, it is necessary to inform the patient about the potential risk to the fetus.
In those rare cases where the use of the drug during pregnancy is vital for the mother, periodic ultrasound examinations should be conducted to evaluate the amniotic fluid index. In with
Drug Interactions Enalapril:
Potassium-sparing diuretics and potassium preparations Simultaneous use of Enalapril and quality-saving diuretics (spironolactone, eplerenone, triamterene, amiloride), potassium-containing salts, potassium supplements, as well as the use of other drugs that increase the serum level of potassium (eg, heparin). content of potassium in the blood plasma.
If, due to the diagnosed hypokalemia, simultaneous use of these drugs is shown, they should be used with caution, with regular monitoring of the content of potassium in the blood serum (see the section "Specific Instructions").
Diuretics (thiazide and "loop") The use of diuretics in high doses can lead to hypovolemia (by reducing the circulating blood volume (BCC)), and the addition of Enalapril to a pronounced decrease in blood pressure. The excessive antihypertensive effect of Enalapril can be reduced either by abolishing the diuretic, or by increasing the bcc or using salt, as well as by reducing the dose of Enalapril.
Other antihypertensive drugs An additive effect can be observed with simultaneous use of Enalapril and other antihypertensive therapy.
The simultaneous use of Enalapril with beta-blockers, methyldopa or blockers of "slow" calcium channels increases the severity of the antihypertensive effect.
The simultaneous use of Enalapril with alpha, beta-blockers and ganglioblokator should be carried out under strict medical supervision.
The simultaneous use of nitroglycerin in various dosage forms and other nitrates or other vasodilators enhances the antihypertensive effect.
Lithium preparations
ACE inhibitors, including Enalapril, reduce the excretion of lithium by the kidneys and increase the risk of developing lithium intoxication (increased cardiotoxic and neurotoxic effects of lithium).
If you need to use this combination, you should regularly monitor the concentration of lithium in the blood plasma. Tricyclic antidepressants / neuroleptics / general anesthetics
The simultaneous use of certain agents for general anesthesia, tricyclic antidepressants and antipsychotics with ACE inhibitors can lead to increased antihypertensive effect and increase the risk of orthostatic hypotension (additive effect). Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs, including selective cyclooxygenase-2 inhibitors (COX-2), can reduce the antihypertensive effect of antihypertensive drugs.
As a result, the antihypertensive effect of angiotensin II receptor antagonists (APA II) or ACE inhibitors can be weakened while being used with NSAIDs, including selective COX-2 inhibitors. NSAIDs and ACE inhibitors have an additive effect on the increase in serum potassium, which can lead to a deterioration in renal function, especially in patients with impaired renal function (for example, in elderly patients or patients with dehydration, including those taking diuretics), receiving NSAIDs,
including selective COX-2 inhibitors, the simultaneous use of ARA II or ACE inhibitors may cause further deterioration of renal function, including the development of acute renal failure. These effects are usually reversible, so the simultaneous use of these drugs should be carried out with caution in patients with impaired renal function.
Gold preparations
Symptom complex (nitrate-like reactions), including the sensation of "flushes" of blood to the skin of the face, nausea, vomiting and hypotension, was observed with simultaneous use of gold preparations for parenteral administration (sodium aurothiomalate) and ACE inhibitors, including Enalapril. Sympathomimetics
Sympathomimetics can weaken the antihypertensive effect of ACE inhibitors.
To confirm the antihypertensive effect of such patients should be under close medical supervision. Hypoglycemic agents Epidemiological studies have shown that the simultaneous use of ACE inhibitors and hypoglycemic agents (insulin, hypoglycemic agents for oral administration) can enhance the hypoglycemic effect of the latter with the risk of developing hypoglycemia.
This phenomenon, as a rule, was most often observed during the first weeks of combination therapy, as well as in patients with impaired renal function.
Patients with diabetes who are taking hypoglycemic agents for oral administration or insulin should regularly monitor their blood glucose concentration, especially during the first month of simultaneous use with ACE inhibitors. Ethanol Ethanol enhances the antihypertensive effect of ACE inhibitors. Acetylsalicylic acid, thrombolytics and beta-blockers Enalapril can be used with acetylsalicylic acid (as an antiplatelet agent), thrombolytics and beta-blockers. Allopurinol, cytostatics and immunosuppressants. Simultaneous use with ACE inhibitors may increase the risk of leukopenia. Cyclosporine Simultaneous use with ACE inhibitors may increase the risk of hyperkalemia.
Antacids May reduce the bioavailability of ACE inhibitors. Theophylline Enalapril reduces the effect of drugs containing theophylline. No clinically significant pharmacokinetic interaction was observed with hydrochlorothiazide, furosemide, digoxin, timolol, methyldopa, warfarin, indomethacin, sulindac and cimetidine.
Double blockade of RAAS Double blockade of RAAS using APA II and ACE inhibitors or aliskiren (renin inhibitor) is associated with an increased risk of arterial hypotension, fainting, hyperkalemia and renal impairment (including the development of acute renal failure) compared with monotherapy.
Dosage:
To accept inside, washing down with a small amount of liquid, irrespective of meal time and at the same time of day. To ensure the following dosage regimen of the drug, it is possible to use Enalapril at a dose of 2.5 mg with a risk from other manufacturers. If the drug is missed, you should take the missed dose. If there are several hours before the next dose is taken, the missed dose should not be taken. Dose should never be doubled. Essential hypertension The initial dose is 10-20 mg, depending on the severity of hypertension (AH) and is used 1 time per day. With mild severity of hypertension, the recommended initial dose is 10 mg 1 time per day. With other degrees of hypertension, the initial dose is 20 mg 1 time per day.
Maintenance dose - 20 mg 1 time per day. The dosage is selected individually for each patient. The maximum daily dose of the drug is 40 mg per day. Renovascular hypertension Since in this group of patients blood pressure and renal function may be particularly sensitive to ACE inhibition, therapy starts with a low initial dose of 2.5 mg (1/2 tablet 5 mg) - 5 mg. Then the dose is selected in accordance with the needs and condition of the patient. Usually, an effective dose of 20 mg of the drug Enalapril 1 time per day.
Caution should be exercised when using the drug Enalapril in patients who have recently taken diuretics (see below Concomitant treatment of hypertension with diuretics). Patients with hyponatremia (the content of sodium ions in the serum of less than 130 mmol / l) or serum creatinine concentration of more than 0.14 mmol / l, the initial dose is 2.5 mg (1/2 tablet 5 mg) 1 time per day. The maximum daily dose is 20 mg. Concomitant Treatment of AH with Diuretics
Regular monitoring of blood pressure, kidney function and electrolyte content in the blood plasma of patients taking Enalapril and other drugs that affect the RAAS are necessary.
Interaction with other drugs Enalapril should not be used simultaneously with aliskiren and aliskiren containing drugs in patients with diabetes mellitus and / or moderate or severe renal impairment (GFR less than 60 min / 1.73 m2 of body surface area) (see section "Contraindications").
The simultaneous use of Enalapril with ARA II is contraindicated in patients with diabetic nephropathy (see section "Contraindications"). Inhibitors of dipeptidyl peptidase type IV (DPP-IV) (gliptiny) (linagliptin, saxagliptin, sitagliptin, vildagliptin) The combined use of ACE inhibitors may increase the risk of angioedema due to suppression of the activity of dipeptidyl peptidase type IV (DPP-IV) gliptinom.
mTOR inhibitors (mammalian Target of Rapamycin - target of rapamycin in mammalian cells), e.g., temsirolimus, sirolimus, everolimus and racecadotril (enkephalinase inhibitor used to treat acute diarrhea), estramustine when used in conjunction with Enalapril - increased risk of angioedema. Co-trimoxazole preparations (trimethoprim + sulfamethoxazole), when used with Enalapril, increase the risk of hyperkalemia.
After the first dose of Enalapril, symptomatic hypotension may develop.
This effect is most likely in patients who take diuretics. The drug is recommended to be used with caution, since in these patients an imbalance of water and electrolyte balance may be observed. In the case of the appointment of patients receiving diuretics at the same time, diuretic treatment should be stopped 2-3 days before enalapril is started.
If this is not possible, then the initial dose of Enalapril should be 2.5 (1/2 tablets of 5 mg) per day to determine the primary effect of the drug on blood pressure.
Further, the dose must be selected based on the needs and condition of the patient. Heart Failure / Asymptomatic Left Ventricular Dysfunction
With clinically severe heart failure or asymptomatic left ventricular dysfunction, the initial dose is 2.5 mg (1/2 tablet 5 mg) 1 time per day. The use of the drug Enalapril should be carried out under the close supervision of a physician to determine the primary effect of the drug on blood pressure.
The drug Enalapril can be used for the treatment of heart failure with severe clinical manifestations in conjunction with diuretics and, when necessary, with cardiac glycosides.
In the absence of symptomatic hypotension (resulting from the use of the drug Enalapril) or after its correction, the dose should be gradually increased to the usual maintenance dose of 20 mg, which is used either once or divided into 2 doses depending on the patient's tolerance to the drug.
Selection of the dose should be carried out within 2-4 weeks or in a shorter time, if there are residual signs or symptoms of heart failure. Such a therapeutic regimen effectively reduces the mortality rate of patients with clinically severe heart failure. Both before and after the start of treatment with Enalapril, regular monitoring of blood pressure and kidney function should be carried out, since development of arterial hypotension as a result of taking the drug was reported followed by (more rarely) the occurrence of acute liver failure.
In patients taking diuretics, the dose of diuretics should, if possible, be reduced before initiating therapy with Enalapril.
The development of arterial hypotension after taking the first dose of Enalapril does not mean that arterial hypotension will develop again with prolonged treatment, and does not indicate the need to discontinue the drug. When treating with drug Enalapril, it is also necessary to control the content of potassium in the blood serum.
Special patient groups Older patients (over 65 years) Older patients are more likely to have a more pronounced hypotensive effect and prolonged drug action time, which is associated with a decrease in the rate of enalapril excretion, therefore the recommended initial dose for the elderly is 1.25 mg. Impaired renal function In chronic renal failure, cumulation occurs with a decrease in filtration of less than 10 ml / min. With creatinine clearance (CK) 80-30 ml / min, the dose is usually 5-10 mg / day, with CK up to 30-10 ml / min - 2.5 (1/2 tablets of 5 mg) - 5 mg / day, with CC less than 10 ml / min - 1.25 - 2.5 (1/2 tablets of 5 mg) per day only on dialysis days.
The duration of treatment depends on the effectiveness of the therapy. With too pronounced decrease in blood pressure, the dose of the drug is gradually reduced. The drug is used both in monotherapy and in combination with other antihypertensive drugs.
Overdose Enalapril:
Symptoms: pronounced decrease in blood pressure, up to the development of collapse, myocardial infarction, acute cerebral circulatory disorders or thromboembolic complications, impaired water and electrolyte balance, renal failure, increased breathing, tachycardia, palpitations, bradycardia, dizziness, anxiety, feeling, heartbeat, bradycardia, dizziness, anxiety, feeling, feeling, heartbeat, bradycardia, dizziness, anxiety, feeling, feeling, heartbeat, feeling, heartbeat, bradycardia, dizziness, anxiety, feeling, feeling, heartbeat, anxiety, feeling, heartbeat, bradycardia, dizziness, anxiety, feeling, feeling, heartbeat, anxiety, feeling, heartbeat, bradycardia, dizziness, anxiety, feeling, feeling, palpitations, tachycardia, palpitations, bradycardia, dizziness, anxiety, feeling, feeling, cough, stupor.
Serum enalaprilat concentrations exceeding 100 and 200 times the concentrations observed with the use of therapeutic doses occurred after taking respectively 300 and 440 mg of Enalapril
.
