Symptomatic congestive heart failure

Active Ingredient: Enalapril

Indication for Enalapril

Population group: only adults (18 years old or older)
Therapeutic intent: Curative procedure

For this indication, competent medicine agencies globally authorize below treatments:

2.5 mg once daily and thereafter dose titration over 2-4 weeks to the maintenance dose of 20 mg/day in a single dose or in 2 divided doses


Dosage regimens

Oral, 2.5 milligrams enalapril, once daily, over the duration of 3 days. Afterwards, oral, 5 milligrams enalapril, divided daily, 2 doses in total, over the duration of 4 days. Afterwards, oral, 10 milligrams enalapril, divided daily, 1 to 2 doses in total, over the duration of 1 week. Afterwards, oral, 20 milligrams enalapril, divided daily, 1 to 2 doses in total. The maximum allowed total dose is 40 milligrams enalapril daily.

Detailed description

In the management of symptomatic heart failure, enalapril is used in addition to diuretics and, where appropriate, digitalis or beta-blockers. The initial dose of enalapril in patients with symptomatic heart failure or asymptomatic left ventricular dysfunction is 2.5 mg, and it should be administered under close medical supervision to determine the initial effect on the blood pressure. In the absence of, or after effective management of, symptomatic hypotension following initiation of therapy with enalapril in heart failure, the dose should be increased gradually to the usual maintenance dose of 20 mg, given in a single dose or two divided doses, as tolerated by the patient. This dose titration is recommended to be performed over a 2 to 4 week period. The maximum dose is 40 mg daily given in two divided doses.

Suggested Dosage Titration of enalapril in Patients with Heart Failure/Asymptomatic Left Ventricular Dysfunction:

WeekDose mg/day
Week 1Days 1 to 3: 2.5 mg/day* in a single dose
Days 4 to 7: 5 mg/day in two divided doses
Week 210 mg/day in a single dose or in two divided doses
Weeks 3 and 420 mg/day in a single dose or in two divided doses

* Special precautions should be followed in patients with impaired renal function or taking diuretics.

Blood pressure and renal function should be monitored closely both before and after starting treatment with enalapril because hypotension and (more rarely) consequent renal failure have been reported. In patients treated with diuretics, the dose should be reduced if possible before beginning treatment with enalapril. The appearance of hypotension after the initial dose of enalapril does not imply that hypotension will recur during chronic therapy with enalapril and does not preclude continued use of the drug. Serum potassium and renal function also should be monitored.

Active ingredient


Enalapril is hydrolysed via hepatic CES 1 to the active metabolite enalaprilat, which acts as an ACE inhibitor. ACE is a peptidyl dipeptidase which catalyses the conversion of angiotensin I to the vasoconstrictor substance angiotensin II and hence inhibition of ACE results in decreased plasma angiotensin II. This also leads to increased plasma renin activity and decreased aldosterone secretion. The mechanism of action of enalapril is therefore primarily via the suppression of the RAAS. However, ACE is identical to kininase II, and so enalapril may also exert its effects by blocking the degradation of bradykinin, a potent vasodepressor peptide.

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