Enalaprilat


Article Author:
Francheska Marte


Article Editor:
Manouchkathe Cassagnol


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/23/2019 12:15:06 AM

Indications

Enalaprilat injection is used in the management of hypertension when oral therapy is not practical.[1]

Mechanism of Action

Enalaprilat is the active metabolite of the oral prodrug enalapril maleate. Enalaprilat is poorly absorbed orally and must be administered intravenously. It inhibits angiotensin I to angiotensin II conversion via competitive inhibition of angiotensin-converting enzyme (ACE).[2] This inhibition disrupts the renin-angiotensin-aldosterone system. Angiotensin II binds to AT1 receptors on smooth muscles to produce vasoconstriction and an increase in blood pressure. Additionally, angiotensin II  stimulates the adrenal cortex to secrete aldosterone. Aldosterone causes the distal tubules and collecting ducts of the kidneys to reabsorb water and sodium in exchange for potassium, which results in an expansion in extracellular volume and an increase in blood pressure. Inhibition of ACE leads to decreased plasma angiotensin II, leading to vasodilation and decreased aldosterone secretion. Angiotensin II also causes vasoconstriction of the afferent and efferent arterioles of the kidney, exerting a more significant effect on the efferent arterioles. Enalaprilat administration in the presence of hypovolemia can cause renal injury due to inadequate renal perfusion.[3] ACE breaks down bradykinin, a peptide that causes vasodilation. ACE inhibitors impede the breakdown of bradykinin, resulting in vasodilation and a bradykinin cough.[4]

Administration

For Heart Failure:

  • Avoid administration in patients with unstable heart failure or acute myocardial infarction

For Hypertension:

  • Intravenous (IV): 1.25 mg/dose given over 5 minutes every 6 hours. A clinical response is typically seen within 15 minutes.
  • Concomitant diuretic therapy: start with 0.625 mg IV over 5 minutes.
    • If the effect is inadequate after 1 hour: repeat the dose and administer 1.25 mg at 6-hour intervals
    • If the effect is adequate after 1 hour: administer 0.625 mg IV every 6 hours
  • Conversion from IV enalaprilat to enalapril:
    • No concomitant diuretic therapy: initiate enalapril 5 mg once daily
    • Concomitant diuretic therapy: initiate enalapril 2.5 mg once daily and titrate as needed

For Renal Impairment:

  • Creatinine Clearance (CrCl) > 30 mL/minute: No dosage adjustment necessary
  • CrCl = 30 mL/minute: initiate 0.625 mg; if after 1 hour clinical response is unsatisfactory, repeat and then administer 1.25 mg every 6 hours
  • Intermittent hemodialysis (IHD): 20-50% dialyzable (moderate)
    • Initial: 0.625 mg IV over 5-60 minutes
  • Conversion from IV enalaprilat to enalapril:
    • CrCl > 30 mL/minute: initiate enalapril 5 mg once daily
    • CrCl = 30 mL/minute: initiate enalapril 2.5 mg once daily

Enalaprilat should be administered IV push undiluted over at least 5 minutes or as an infusion diluted in up to 50 milliliters of D5W or 0.9% NaCl. Avoid salt substitutes or a potassium-rich diet. A dose no greater than 0.625 mg over 5 minutes should be administered in patients with heart failure or hyponatremia, and in patients undergoing intensive diuresis, an increase in diuretic dose or renal dialysis.[5]

Adverse Effects

  • Hypotension (2-5%) is the most common manifestation of overdose, but the incidence of excessive hypotension remains relatively rare. Incidence increases with use in severely salt or volume depleted persons such as patients treated with diuretics or patients on dialysis. Before initiating therapy with enalaprilat, consider eliminating or reducing the diuretic dose. In the event of hypotension, place the patient in the supine position and infuse IV normal saline.
  • Headache (3%)
  • Nausea (1%)
  • Myocardial infarction (< 1%)
  • Cough (< 1%)
  • Constipation (< 1%)
  • Rash (< 1%)
  • Fever (< 1%)
  • Hypersensitivity reactions or anaphylactoid reactions

These adverse reactions may also be associated with enalapril because enalapril undergoes biotransformation to enalaprilat.

Warnings and Precautions

Enalaprilat is pregnancy Category C in the first trimester and Category D in the second and third trimesters. All ACE inhibitors can cause injury and even death to the fetus when used in pregnancy during the second and third trimesters. Hypotension, neonatal skull hypoplasia, anuria, and renal failure can also occur with use in pregnancy.[6] If pregnancy is detected, discontinue enalaprilat should as soon as possible. Enalaprilat has also been detected in human breast milk, which creates a potential for adverse events in nursing infants.[7] The safety and effectiveness of enalaprilat use in children have not been established.[8] In elderly patients, dose selection should be modest and initiated at a low dose. Enalaprilat is substantially excreted by the kidney, and the risk of toxic reactions may be higher in elderly patients with impaired renal function. With severe heart failure patients whose renal function depends on the activity of the renin-angiotensin-aldosterone system, ACE inhibitor therapy may be associated with oliguria, progressive azotemia, acute renal failure or death. In the absence of pre-existing renal vascular disease, it is still possible to develop increases in blood urea and serum creatinine. Hyperkalemia or elevated serum potassium greater than 5.7 mEq/L may be observed in some hypertensive patients.  Additional risk factors for the development of hyperkalemia include renal insufficiency, diabetes mellitus and the concomitant use of potassium supplements or potassium-sparing agents.[9] In patients undergoing major surgery or anesthesia with agents that may cause hypotension, enalaprilat may block angiotensin II formation and hypotension may result. This hypotension can be corrected by volume expansion.[10]

Contraindications

  • Hypersensitivity to enalapril, enalaprilat or any component of the formulation
  • Patients with a history of angioedema resulting from previous treatment with an ACE inhibitor
  • Idiopathic or hereditary angioedema
  • Concomitant aliskiren use in patients with diabetes mellitus

Monitoring

Monitoring parameters include blood pressure, BUN, serum creatinine and potassium. Blood pressure should be closely monitored with first dose administration or change in dose. If the patient has collagen vascular disease or renal impairment, complete blood count with differential should be periodically monitored. Each patient should be assessed for potential interactions with other medications that may impact their fluid balance or cardiac status. Monitoring for anaphylactic reactions, hypovolemia, angioedema, and postural hypotension should also be performed.[5]

Toxicity

Cholestatic jaundice progressing to fulminant hepatic necrosis may occur. If a marked elevation of hepatic transaminases or jaundice occurs, then enalaprilat should be discontinued. Following the first dose or at any time during treatment, angioedema can occur.[11] Angioedema of the face, extremities, lips, tongue, glottis or larynx can lead to airway compromise. African Americans may be at an increased risk of developing angioedema.[12] If angioedema occurs, enalaprilat should be immediately discontinued, and appropriate therapy with antihistamines and monitoring should be provided. When the tongue, glottis or larynx is involved, subcutaneous epinephrine 1:1000 may be administered to reverse airway obstruction. A persistent, dry, hacking, nonproductive cough that occurs within the first few months of treatment can also occur with enalaprilat therapy. ACE inhibitor-induced cough is caused by the inhibition of the degradation of bradykinin and generally resolves within 1-4 weeks after discontinuation.[4] Symptomatic hypotension including syncope can occur with ACE inhibitor therapy. Close monitoring and correction of volume depletion are required before initiating treatment. If hypotension occurs, consider reducing the enalaprilat dose, but do not abruptly discontinue therapy.

Enhancing Healthcare Team Outcomes

Enalaprilat is a widely used drug in the ICU for management of hypertension. It is often prescribed by the nurse practitioner, intensivist, cardiologist and the internist. The drug is effective with a rapid onset of action. However, it is important for nurses to monitor the patient as hypotension can develop quickly. It is preferable to have an arterial line for continuous monitoring of the blood pressure while using enalaprilat.


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Enalaprilat - Questions

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Which of the following angiotensin-converting enzyme inhibitors is poorly absorbed orally and must be administered intravenously?



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What is the most common manifestation of overdose with enalaprilat therapy?



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Which pregnancy categories is enalaprilat in the first, second, and third trimesters of pregnancy?



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Which of the following does not suggest toxicity occurring with high doses of enalaprilat therapy?



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Which of the following is not a contraindication to enalaprilat use?



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Enalaprilat is administered via what route?



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What is the correct dose of enalaprilat for a patient with a creatinine clearance of less than or equal to 30 milliliters/min?



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Enalaprilat - References

References

Cooper WO,Hernandez-Diaz S,Arbogast PG,Dudley JA,Dyer S,Gideon PS,Hall K,Ray WA, Major congenital malformations after first-trimester exposure to ACE inhibitors. The New England journal of medicine. 2006 Jun 8     [PubMed]
"Inactive" ingredients in pharmaceutical products: update (subject review). American Academy of Pediatrics Committee on Drugs. Pediatrics. 1997 Feb     [PubMed]
Santoro A,Mandreoli M, [Hyperkalemia as a limiting factor in the use of drugs that block the Renin Angiotensin Aldosterone System (RAAS)]. Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia. 2018 May     [PubMed]
Sachs B,Meier T,Nöthen MM,Stieber C,Stingl J, [Drug-induced angioedema : Focus on bradykinin]. Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete. 2018 Apr     [PubMed]
Brown T,Gonzalez J,Monteleone C, Angiotensin-converting enzyme inhibitor-induced angioedema: A review of the literature. Journal of clinical hypertension (Greenwich, Conn.). 2017 Dec     [PubMed]
Pongpanich P,Pitakpaiboonkul P,Takkavatakarn K,Praditpornsilpa K,Eiam-Ong S,Susantitaphong P, The benefits of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers combined with calcium channel blockers on metabolic, renal, and cardiovascular outcomes in hypertensive patients: a meta-analysis. International urology and nephrology. 2018 Oct 15     [PubMed]
Verbeeck RK,Kanfer I,Löbenberg R,Abrahamsson B,Cristofoletti R,Groot DW,Langguth P,Polli JE,Parr A,Shah VP,Mehta M,Dressman JB, Biowaiver Monographs for Immediate-Release Solid Oral Dosage Forms: Enalapril. Journal of pharmaceutical sciences. 2017 Aug     [PubMed]
Wolf S,Risler T, [Are all antihypertensive drugs renoprotective?]. Herz. 2004 May     [PubMed]
Forner D,Kulai T,Arnason T,E Gruchy S,MacLeod M, Ramipril-associated cholestasis in the setting of recurrent drug-induced liver injury. Gastroenterology and hepatology from bed to bench. 2017 Spring     [PubMed]
Walker SLM,Abbott TEF,Brown K,Pearse RM,Ackland GL, Perioperative management of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers: a survey of perioperative medicine practitioners. PeerJ. 2018     [PubMed]
Tabacova SA,Kimmel CA, Enalapril: pharmacokinetic/dynamic inferences for comparative developmental toxicity. A review. Reproductive toxicology (Elmsford, N.Y.). 2001 Sep-Oct     [PubMed]
Schubiger G,Flury G,Nussberger J, Enalapril for pregnancy-induced hypertension: acute renal failure in a neonate. Annals of internal medicine. 1988 Feb     [PubMed]

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