What to Know About Vasotec (Enalapril)

Vasotec (enalapril) is an angiotensin-converting enzyme (ACE) inhibitor that is most commonly used to treat people with hypertension and/or heart failure.

ACE inhibitors block a key enzyme in the renin-angiotensin-aldosterone system (RAAS). This system is a cascade of enzymes that work together to regulate blood pressure and the concentration of sodium in the blood.

Angiotensin II constricts blood vessels and increases blood pressure. Vasotec inhibits ACE. Inhibition of ACE decreases levels of angiotensin II, leading to less vasoconstriction and decreased blood pressure.

Uses

There are three main indications for use of Vasotec in patients. These include:

• Hypertension
• Heart failure
• Asymptomatic left ventricular dysfunction (ejection fraction less than or equal to 35%)

Vasotec is effective alone or can be used in combination with other antihypertensive medications, including thiazide type diuretics.

Off-Label Uses

In addition to the aforementioned uses, ACE inhibitors may be used to help control abnormal heart rhythms, particularly after a heart attack.

ACE inhibitors are also used off-label in the treatment of such diseases as rheumatoid arthritis, migraines, Raynaud’s phenomenon, and Bartter syndrome.

Before Taking

Talk to It’s important to discuss with your medical provider all allergies to medications prior to taking a enalapril including other ACE inhibitors. Do not use this medicine if you are allergic to enalapril or to other ACE inhibitors. Other precautions and contraindications include:

• Discuss with a medical provider if you are having surgery, including dental surgery.
• Tell your healthcare provider if you have or have ever had heart or kidney disease, lupus, scleroderma, and/or angioedema.
• If you are diagnosed with bilateral renal artery stenosis, you will need closer monitoring on this medication.
• Talk to your healthcare provider before using salt substitutes containing potassium as this may cause potential interactions.
• Discuss with your healthcare provider if you are pregnant, planning on becoming pregnant, or breastfeeding.
• If you are currently taking lithium you may need dosage adjustment and careful monitoring on this medication.
• Be prepared to start the medication under medical supervision which may require inpatient hospitalization.

Talk to your healthcare provider about all medications, supplements, and vitamins that you currently take. While some drugs pose minor interaction risks, others may outright contraindicate use or prompt careful consideration as to whether the pros of treatment outweigh the cons in your case.

Other ACE Inhibitors

Vasotec is an ACE inhibitor. Other ACE inhibitors include:

• Capoten (captopril)
• Prinivil and Zestril (lisinopril)
• Lotensin (benazepril)
• Altace (ramipril)
• Accupril (quinapril)
• Monopril (fosinopril)
• Mavik (trandolapril)
• Aceon (perindopril)
• Univasc (moexipril)

Dosage

All listed dosages are according to the drug manufacturer. Check your prescription and talk to your healthcare provider to make sure you are taking the right dose for you. 

Hypertension:

• Stop diuretic use two to three days before the initiation of Vasotec as these medications could cause severe hypotension.
• If your blood pressure is not controlled with Vasotec alone, diuretic therapy may be resumed. 
• If diuretics are not discontinued, start an initial dose of 2.5 milligrams (mg) under medical supervision for at least two hours and until blood pressure has stabilized for at least an additional hour.
• Without diuretics, the initial dosage is 5 mg.
• The dosage range is 10 to 40 mg per day administered in a single dose or two divided doses.

Heart failure:

• Initial dose: 2.5 mg
• Dosage range: 2.5 to 20 mg given twice a day
• Doses should be titrated upward, as tolerated, over a period of a few days or weeks.
• Maximum daily dose: 40 mg in divided doses

Asymptomatic left ventricular dysfunction:

• Initial dose: 2.5 mg twice daily
• Target daily dose: 20 mg

Dosage adjustment in patients with heart failure and renal impairment or hyponatremia:

• Patients with serum sodium less than 130 mEq/L or with serum creatinine greater than 1.6 mg/dL
• Initial dose: 2.5 mg daily started under direct medical supervision
• Increase to 2.5 mg twice daily, then 5 mg twice daily
• Increase at intervals of four days or more
• Maximum daily dose: 40 mg in divided doses

Pediatric hypertensive patients:

• Initial dose: 0.08 mg/kg (up to 5 mg) once daily
• Doses above 0.58 mg/kg (or in excess of 40 mg) have not been approved for pediatric patients.

Modifications

Vasotec is not recommended for people who are pregnant or lactating. It is also not recommended in neonates or pediatric patients with a glomerular filtration rate less than 30 mL/min/1.73 m2.

This medication generally comes in tablets but also can be mixed into a suspension for patients unable to swallow pills. Follow exact mixing instructions from the pharmacist to prepare the suspension.

Intravenous Vasotec is administered only as an inpatient procedure and generally is not given to a patient unless admitted to the hospital with IV access. IV Vasotec is the quickest acting of the three available types.

How To Take and Store

Exact dosage and frequency will be determined by your healthcare provider but the FDA suggests:

• Take once or twice a day (depending on order).
• Take around the same time every day.
• May be given with or without food.
• Take exactly as directed even if feeling better. 
• Take a missed dose as soon as you think about it.
• Take Vasotec exactly as directed.
• Do not take two doses at the same time or extra doses.

Follow these guidelines for storage:

• Store in the airtight original container
• Protect from light, extreme heat, and extreme cold
• Keep away from moisture (i.e. bathroom)
• Liquid suspension is only good for 30 days from mixing and should be placed into the refrigerator.

Side Effects

As with all medications, there are possible side effects you may experience while taking Vasotec. Common and less severe side effects include:

• Cough
• Dizziness
• Rash
• Weakness
• Hypotension
• Abdominal pain
• Syncope
• Diarrhea
• Urinary tract infection
• Headache
• Rash
• Nausea
• Vertigo
• Fatigue
• Pallor
• Increased thirst
• Loss of appetite
• Insomnia
• Easy bruising
• Vomiting
• Muscle cramps
• Urine frequency
• Rapid weight gain

Even though these may be rare, Vasotec does have side effects that require immediate medical attention as they can be life-threatening:

• Hoarseness
• Orthostatic effects
• Difficulty breathing
• Bronchitis
• Pneumonia
• Difficulty swallowing
• Yellowing of the skin and/or eyes
• Fever
• Sore throat
• Chills
• Asthenia
• Lightheadedness
• Fainting
• Hyperkalemia
• Increased risk of bleeding
• Chest pain
• Kidney problems

Vasotec does warn that 0.5% to 1.0% of patients with hypertension or heart failure in clinical trials presented with the following adverse reactions to the medication. These are the most severe reactions and those requiring immediate attention:

• Cardiac arrest
• Stroke
• Ileus
• Hepatitis
• Hepatic failure
• Neutropenia
• Thrombocytopenia
• Depression
• Renal failure
• Angioedema

Warnings and Interactions

Be aware of these:

• Vasotec crosses the placenta. Do not take if pregnant, planning on getting pregnant, or breastfeeding. Vasotec can cause death or injury to the fetus.
• Do not stop taking the medication until instructed to do so by a healthcare provider.
• Do not co-administer aliskiren with Vasotec in patients with diabetes.
• Some over-the-counter medications can cause an increase in heart failure or worsening heart failure when taken while on Vasotec. These may include cough and cold medications, diet supplements, and NSAIDs such as ibuprofen.