Patients with low blood sugar
Patients who are on treatment with blood sugar lowering agents and Enalapril such as Enalapril are at an increased risk to develop low blood sugar during the first month of the treatment with this combination. Such patients should be informed to closely monitor for reduced levels of sugar in the blood.
Decreased white blood cells (neutrophils, thrombocytes, or agranulocytes)
Patients who are undergoing treatment with Enalapril, who have blood disorders, undergoing immunosuppressant therapy, patients who are on treatment with other drugs such as allopurinol or procainamide, in addition to existing kidney failure are at an increased risk when using this medicine. These patients have experienced a decrease in the number of white blood cells in the blood. Enalapril should be used under careful supervision in such patients and frequent monitoring of white blood cells is advised to patients. They should also be informed to report any sign of infection.
Abnormal thickening of heart muscles
Patients with problems in blood flow from the heart (left ventricular valvular and outflow tract obstruction) are at an increased risk when using this medicine. Such patients who have left ventricular valvular and outflow tract obstruction should take Enalapril with caution. It should be avoided in patients with cardiogenic shock
in which heart cannot pump enough blood to meet the needs of the body and who have significant obstruction of blood.
Anaphylactoid reactions (during desensitization and dialysis)
Patients experiencing low-density lipoprotein apheresis with dextran sulfate absorption, desensitizing therapy with Hymenoptera venom while receiving Enalapril, and patients dialyzed with high-flux membranes and treated in combination with Enalapril are at an increased risk for life-threatening allergic reaction. Dialysis
must be stopped instantly, and aggressive therapy for allergic reactions must be started in such patients. A different kind of dialysis membrane or a distinct class of antihypertensive agent should be considered in such patients.
Swelling in the lower layer of the skin
Patients with a history of swelling of the lower layer of the skin unrelated to ACE inhibitor therapy, combined use of Enalapril and mTOR inhibitor (e.g., temsirolimus, everolimus, and sirolimus) therapy may be at an increased risk. Swelling of the face, lips, extremities, tongue, glottis or larynx, including fatal reactions, have occurred in patients treated with Enalapril. These patients are likely to experience airway obstruction, especially those with a history of airway surgery
. Intestinal swelling has been seen in patients treated with Enalapril. These patients were shown to have stomach pain
with or without vomiting or nausea
; in some cases, there was no history of facial swelling and level of C-1 esterase were normal. Enalapril should be immediately discontinued and proper therapy or monitoring should be given until full and continued purpose of signs and symptoms of swelling of the lower layer of the skin has appeared. Swelling of the lower layer of the skin should be diagnosed by procedures including ultrasound
or abdominal CT scan, or at surgery, and symptoms solved after stopping Enalapril.
Increased potassium level
Patients with high blood sugar (diabetes
mellitus), poor function of the kidneys, and the combined use of potassium-sparing diuretics
, potassium-containing salt
substitutes or potassium
supplements are at an increased risk of a rise of high potassium level. Drugs that block the renin-angiotensin system can cause high potassium level. Potassium levels in the blood should be monitored in patients receiving Enalapril.
Abnormal functioning of kidneys
Patients with narrowing of arteries carrying blood to one or both of the kidneys (kidney artery stenosis
), severe congestive heart failure, long-term kidney disease, and post-heart attack or volume depletion may be at an increased risk of acquiring acute kidney failure when using this medicine. Changes in the functioning of kidneys including acute kidney failure can be induced by Enalapril. Also, such patients are at an increased risk to experience a change in blood levels of creatinine
. Monitoring of the functioning of kidneys is required in patients treated with Enalapril. Discontinuation of the therapy is recommended in patients with a decrease in the functioning of the kidney.
ACE inhibitors including Enalapril have been related to a syndrome
that starts with reduced bile flow from the liver (cholestatic jaundice
) and progresses to a severe abnormality of liver function (hepatic necrosis) and sometimes fatal. Patients taking ACE inhibitors who develop yellowing of the eyes and skin (jaundice) or raised liver enzymes should discontinue ACE inhibitor and seek proper medical follow-up.
Low blood pressure
Patients with severe narrowing of the valve of aorta (aortic stenosis
) or thickening of heart muscle (hypertrophic cardiomyopathy
), heart failure with systolic blood pressure below 100 mmHg, ischemic heart disease, brain disease, low sodium
level, high dose diuretic
therapy, kidney dialysis
, and salt
depletion or severe volume of any cause are at an increased risk when using this medicine. Enalapril can cause symptomatic low blood pressure, sometimes complicated by decreased production of urine, abnormally high levels of nitrogen-containing compounds, acute kidney failure or fatality. In patients undergoing extreme surgery
or while using anesthesia
with agents that produce low blood pressure, Enalapril may block angiotensin II production secondary to renin release. Also, such patients are at an increased risk to experience a change in blood levels of creatinine
. In patients with low blood pressure, Enalapril should be started under close medical supervision, and such patients should be followed nearly for the first two weeks of therapy and whenever Enalapril dose or diuretic dose is raised. In patients undergoing surgery or anesthesia, if low blood pressure occurs and is considered to be through angiotensin II production mechanism, it can be improved by volume expansion.
Pregnant women and newborns are at an increased risk when using this medicine. Use of Enalapril during pregnancy
(second and third trimesters) reduces fetal functioning of kidneys, increases fetal and newborn diseased state and fatality rate. It can result in a deficiency of amniotic fluid which can be related to fetal lung incomplete development (hypoplasia) and skeletal abnormalities. Possible neonatal side effects include an underdeveloped skull, non-passage of urine, low blood pressure, kidney failure, and fatality. Discontinue Enalapril as soon as pregnancy is suspected.
The patients who are on treatment with Enalapril are at an increased risk to develop cough
which disappears after the drug is discontinued.
Patients undergoing surgery or temporary loss of consciousness (anesthesia)
Patients undergoing major surgery
along with drugs that result in reduced blood pressure, Enalapril blocks the formation of angiotensin II, a substance which is responsible for the constriction of vessels. If a reduction in blood pressure occurs due to this mechanism, volume expansion can be used as a correcting measure.
Patients taking lithium
Treatment with lithium
and Enalapril is generally not recommended.
Blockage of the renin-angiotensin-aldosterone system (RASS)
The patients who are on treatment with Enalapril, angiotensin II receptor blockers and aliskiren are at an increased risk. Such patients may develop low blood pressure, increased levels of potassium
in the blood, and decreased functioning of kidneys. Dual blockage of RASS due to the use of Enalapril, angiotensin II receptor blockers and aliskiren in combination is not recommended.
Patients with lactose intolerance
Patients with family history problems of inability to digest galactose (galactose intolerance), deficiency of lactase enzyme (Lapp lactase deficiency) or glucose-galactose intolerance are at an increased risk because Enalapril contains lactose which will not be absorbed if taken by such patients. The use of Enalapril in such patients is not recommended.