Limited data are available for overdosage in humans. The most prominent the features of overdosage that have been reported to date are marked hypotension, beginning some six hours after ingestion of tablets, concomitant with blockade of the renin-angiotensin system and stupor. Symptoms associated with overdosage of ACE inhibitors may include circulatory shock, electrolyte disturbances, renal failure, hyperventilation, tachycardia, palpitations, bradycardia, dizziness, anxiety, and cough. Serum Enalacorat levels 100 times and 200 times higher than usually seen after therapeutic doses have been reported after ingestion of 300 mg and 440 mg of Enalacor, respectively.
The recommended treatment of overdosage is intravenous infusion of normal saline solution. If hypotension occurs, the patient should be placed in the shock position. If available, treatment with angiotensin II infusion and/or intravenous catecholamines may also be considered. If ingestion is recent, take measures aimed at eliminating Enalacor maleate (e.g., emesis, gastric lavage, administration of absorbents, and sodium sulphate). Enalacor can be removed from the general circulation by haemodialysis (See 4.4 'special warnings and precautions for use',haemodialysis patients). Pacemaker therapy is indicated for therapy-resistant bradycardia. Vital signs, serum electrolytes and creatinine concentrations should be monitored continuously.
The concomitant use of Enalacor 10mg tablets with aliskiren-containing products is contraindicated in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73 m2).
Not applicable
Alcohol
Alcohol enhances the hypotensive effect of ACE inhibitors.
Acetyl salicylic acid, thrombolytics and β-blockers
Enalacor can be safely administered concomitantly with acetyl salicylic acid (at cardiologic doses), thrombolytics and β-blockers
4.6 Fertility, preganancy and lactationPregnancy
The use of ACE inhibitors is not recommended during the first trimester of pregnancy. The use of ACE inhibitors is contra-indicated during the second and third trimester of pregnancy.
Epidemiological evidence regarding the risk of teratogenicity following exposure to ACE inhibitors during the first trimester of pregnancy has not been conclusive; however a small increase in risk cannot be excluded. Unless continued ACE inhibitors therapy is considered essential, patients planning pregnancy should be changed to alternative anti-hypertensive treatments which have an established safety profile for use in pregnancy. When pregnancy is diagnosed, treatment with ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started.
ACE inhibitors therapy exposure during the second and third trimesters is known to induce human foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia)..
Should exposure to ACE inhibitors have occurred from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended.
Infants whose mothers have taken ACE inhibitors should be closely observed for hypotension.
Lactation
Limited pharmacokinetic data demonstrate very low concentrations in breast milk. Although these concentrations seem to be clinically irrelevant the use of Enalacor in breast-feeding is not recommended for preterm infants and for the first few weeks after delivery, because of the hypothetical risk of cardiovascular and renal effects and because there is not enough clinical experience. In case of an older infant the use of Enalacor in breast-feeding mother may be considered if this treatment is necessary for the mother and the child is observed for any adverse effect.
4.7 Effects on ability to drive and use machinesWhen driving vehicles or operating machines it should be taken into account that occasionally dizziness or weariness may occur.
4.8 Undesirable effectsUndesirable effects reported for Enalacor include:
[Very common (>1/10); common (>1/100, <1/10); uncommon (>1/1,000, <1/100); rare (>1/10,000, <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).]
Blood and the lymphatic system disorders:
uncommon: anaemia (including aplastic and hemolytic)
rare: neutropenia, decreases in hemoglobin, decreases in hematocrit, thrombocytopenia, agranulocytosis, bone marrow depression, pancytopenia, lymphadenopathy, autoimmune diseases
Endocrine disorders:
not known: syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Metabolism and nutrition disorders:
uncommon: hypoglycaemia (see 4.4 'Special warnings and precautions for use', Hypoglycemia)
Nervous system and psychiatric disorders:
common: headache, depression
uncommon: confusion, somnolence, insomnia, nervousness, paresthaesia, vertigo
rare: dream abnormality, sleep disorders
Eye disorders:
very common: blurred vision
Cardiac and vascular disorders:
very common: dizziness
common: hypotension (including orthostatic hypotension), syncope, chest pain, rhythm disturbances, angina pectoris, tachycardia
uncommon: orthostatic hypotension, palpitations, myocardial infarction or cerebrovascular accident*, possibly secondary to excessive hypotension in high risk patients (see 4.4 'Special warnings and precautions for use')
rare: Raynaud's phenomenon
Respiratory, thoracic and mediastinal disorders:
very common: cough
common: dyspnea
uncommon: rhinorrhea, sore throat and hoarseness, bronchospasm/asthma
rare: pulmonary infiltrates, rhinitis, allergic alveolitis/eosinophilic pneumonia
Gastrointestinal disorders:
very common: nausea,
common: diarrhoea, abdominal pain, taste alteration
uncommon: ileus, pancreatitis, vomiting, dyspepsia, constipation, anorexia, gastric irritations, dry mouth, peptic ulcer
rare: stomatitis/aphthous ulcerations, glossitis
very rare: intestinal angioedema
Hepatobiliary disorders:
rare: hepatic failure, hepatitis - either hepatocellular or cholestatic, hepatitis including necrosis, cholestasis (including jaundice)
Skin and subcutaneous tissue disorders:
common: rash, hypersensitivity/angioneurotic oedema: angioneurotic oedema of the face, extremities, lips, tongue, glottis and/or larynx has been reported (see 4.4 'Special warnings and precautions for use')
uncommon: diaphoresis, pruritus, urticaria, alopecia
rare: erythema multiforme, Stevens-Johnson syndrome, exfoliative dermatitis, toxic epidermal necrolysis, pemphigus, erythroderma
A symptom complex has been reported which may include some or all of the following: fever, serositis, vasculitis, myalgia/myositis, arthralgia/arthritis, a positive ANA, elevated ESR, eosinophilia, and leukocytosis. Rash, photosensitivity or other dermatologic manifestations may occur.
Renal and urinary disorders:
uncommon: renal dysfunction, renal failure, proteinuria
rare: oliguria
Reproductive system and breast disorders:
uncommon: impotence
rare: gynecomastia
General disorders and administration site conditions:
very common: asthenia
common: fatigue
uncommon: muscle cramps, flushing, tinnitus, malaise, fever
Investigations:
common: hyperkalemia, increases in serum creatinine
uncommon: increases in blood urea, hyponatremia
rare: elevations of liver enzymes, elevations of serum bilirubin
* Incidence rates were comparable to those in the placebo and active control groups in the clinical trials
Pre-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity and carcinogenic potential. Reproductive toxicity studies suggest that Enalacor does not have serious adverse effects on fertility and reproductive performance in rats, and is not teratogenic. In a study in which female rats were dosed prior to mating through gestation, an increased incidence of rat pup deaths occurred during lactation. The compound has been shown to cross the placenta and is secreted in milk. Angiotensin converting enzyme inhibitors, as a class, have been shown to be fetotoxic (causing injury and/or death to the fetus) when given in the second or third trimester.
Treatment of hypertension: All grades of essential hypertension and renovascular hypertension.
Treatment of heart failure: Enalacor should be used along with non-potassium-sparing diuretics and, where appropriate digitalis. (Enalacor improves symptoms, retards the progression of the disease, and decreases associated mortality and hospitalisation).
Prevention of symptomatic heart failure: In asymptomatic patients with left ventricular dysfunction Enalacor retards the development of symptomatic heart failure, and also reduces hospitalisation for heart failure.
Two large randomised, comtrolled trials (ONTARGET (Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and VA NEPHRON-D (The Veterans Affairs Nephropathy in Diabetes)) have examined the use of the combination of an ACE-inhibitor with an angiotensin II receptor blocker.
ONTARGET was a study conducted in patient with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes mellitus accompanied by evidence of end-organ damage. VA NEPHRON-D was a study in patients with type 2 diabetes mellitus and diabetic nephropathy.
These studies have shown no significant beneficial effect on renal and/or hypotention as compared to monotherapy was observed. Given their similar pharmacodynamic properties, these results are also relevant for other ACE-inhibitors and angiotensin II receptor blockers.
ACE-inhibitors and angiotensin II receptor blocers should therefore not be used concomitantly in patient with diabetic nephropathy.
ALTITUDE (Aliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints) was a study design to test the benefit of adding aliskiren to a standard therapy of an ACE-inhibitor or an angiotensin II receptor blocker in patient with type 2 diabetes mellitus and chronic kidney disease, cardiovascular disease, or both. The study was terminated early because of an increased risk of adverse outcomes. Cardiovascular death and stroke were both numerically more frequent in the aliskiren group than in the placebo group and adverse events and serious adverse events of interest (hyperkalaemia, hypotention and renal dysfunction) were more frequently reported in the aliskiren group than in the placebo group.
Pharmacotherapeutic Group- Angiotension Converting Enzyme (ACE) inhibitor-
ATC Code: C09AA02
Enalacor maleate is a derivative of two amino acids; L-alanine and L-proline. Angiotensin converting enzyme (ACE) is a peptidyl dipeptidase which catalyses the conversion of angiotensin I to the pressor substance angiotensin II. After absorption, Enalacor is hydrolysed to Enalacorat which inhibits ACE. Inhibition of ACE results in decreased plasma angiotensin II, which leads to increased plasma renin activity (due to removal of negative feedback of renin release), and decreased aldosterone secretion.
ACE is identical to kinase II. Thus 'Enalacor' may therefore also block the degradation of bradykinin, a potent vasodepressor peptide. However, the role that this plays in the therapeutic effects of 'Enalacor' remains to be elucidated.
While the mechanism through which 'Enalacor' lowers blood pressure is believed to be primarily suppression of the renin-angiotensin-aldosterone system, 'Enalacor' is antihypertensive even in patients with low-renin hypertension.
Administration of 'Enalacor' to patients with hypertension results in a reduction of both supine and standing blood pressure without a significant increase in heart rate.
Symptomatic postural hypotension is infrequent. In some patients the development of optimal blood pressure reduction may require several weeks of therapy. Abrupt withdrawal of 'Enalacor' has not been associated with rapid increase in blood pressure.
Effective inhibition of ACE activity usually occurs 2 to 4 hours after oral administration of an individual dose of Enalacor. Onset of antihypertensive activity was usually seen at one hour, with peak reduction of blood pressure achieved by 4 to 6 hours after administration. The duration of effect is dose-related. However, at recommended doses, antihypertensive and haemodynamic effects have been shown to be maintained for at least 24 hours.
In haemodynamic studies in patients with essential hypertension, blood pressure reduction was accompanied by a reduction in peripheral arterial resistance with an increase in cardiac output and little or no change in heart rate. Following administration of 'Enalacor' there was an increase in renal blood flow; glomerular filtration rate was unchanged. There was no evidence of sodium or water retention. However, in patients with low pretreatment glomerular filtration rates, the rates were usually increased.
In short term clinical studies in diabetic and nondiabetic patients with renal disease, decreases in albuminuria and urinary excretion of IgG and total urinary protein were seen after the administration of Enalacor.
When given together with thiazide-type diuretics, the blood pressure-lowering effects of 'Enalacor' are at least additive. 'Enalacor' may reduce or prevent the development of thiazide-induced hypokalemia.
In patients with heart failure on therapy with digitalis and diuretics, treatment with oral or Injection 'Enalacor' was associated with decreases in peripheral resistance and blood pressure. Cardiac output increased, while heart rate (usually elevated in patients with heart failure) decreased. Pulmonary capillary wedge pressure was also reduced. Exercise tolerance and severity of heart failure, as measured by New York Heart Association criteria, improved. These actions continued during chronic therapy.
In patients with mild to moderate heart failure, Enalacor retarded progressive cardiac dilatation/enlargement and failure, as evidenced by reduced left ventricular end diastolic and systolic volumes and improved ejection fraction.
A multicentre, randomised, double-blind, placebo-controlled trial (SOLVD Prevention trial) examined a population with asymptomatic left ventricular dysfunction (LVEF<35%). 4228 patients were randomised to receive either placebo (n=2117) or Enalacor (n=2111). In the placebo group, 818 patients had heart failure or died (38.6%) as compared with 630 in the Enalacor group (29.8%) (risk reduction: 29%; 95% CI; 21 - 36%; p<0.001). 518 patients in the placebo group (24.5%) and 434 in the Enalacor group (20.6%) died or were hospitalised for new or worsening heart failure (risk reduction 20%; 95% CI; 9 - 30%; p<0.001).
A multicentre, randomised, double-blind, placebo-controlled trial (SOLVD Treatment trial) examined a population with symptomatic congestive heart failure due to systolic dysfunction (ejection fraction <35%). 2569 patients receiving conventional treatment for heart failure were randomly assigned to receive either placebo (n=1284) or Enalacor (n=1285). There were 510 deaths in the placebo group (39.7%) as compared with 452 in the Enalacor group (35.2%) (reduction in risk, 16%; 95% CI, 5 - 26%; p=0.0036). There were 461 cardiovascular deaths in the placebo group as compared with 399 in the Enalacor group (risk reduction 18%, 95% CI, 6 - 28%, p<0.002), mainly due to a decrease of deaths due to progressive heart failure (251 in the placebo group vs 209 in the Enalacor group, risk reduction 22%, 95% CI, 6 - 35%). Fewer patients died or were hospitalised for worsening heart failure (736 in the placebo group and 613 in the Enalacor group; risk reduction, 26%; 95% CI, 18 - 34%; p<0.0001). Overall in SOLVD study, in patients with left ventricular dysfunction, 'Enalacor' reduced the risk of myocardial infarction by 23% (95% CI, 11 - 34%; p<0.001) and reduced the risk of hospitalisation for unstable angina pectoris by 20% (95% CI, 9 - 29%; p<0.001).
There is limited experience of the use in hypertensive paediatric patients>6 years. In a clinical study involving 110 hypertensive paediatric patients 6 to 16 years of age with a body weight >20 kg and a glomerular filtration rate>30 ml/min/1.73 m2, patients who weighed <50 kg received either 0.625, 2.5 or 20 mg of Enalacor daily and patients who weighed >50 kg received either 1.25, 5 or 40 mg of Enalacor daily. Enalacor administration once daily lowered trough blood pressure in a dose-dependent manner. The dose-dependent antihypertensive efficacy of Enalacor was consistent across all subgroups (age, Tanner stage, gender, race). However, the lowest doses studied, 0.625 mg and 1.25 mg, corresponding to an average of 0.02 mg/kg once daily, did not appear to offer consistent antihypertensive efficacy. The maximum dose studied was 0.58 mg/kg (up to 40 mg) once daily. The adverse experience profile for paediatric patients is not different from that seen in adult patients.
Absorption
Oral Enalacor maleate is rapidly absorbed, with peak serum concentrations of Enalacor occurring within one hour.Based on urinary recovery, the extent of absorption of oral Enalacor is approximately 60%. Absorption is not affected by food in the gastrointestinal tract.
Following absorption, Enalacor is rapidly and extensively hydrolysed to Enalacorat.,a potent angiotensin converting enzyme inhibitor. Peak serum concentrations of Enalacorat occur 3 to 4 hours after an oral dose of Enalacor. The effective half-life for accumulation of Enalacorat following multiple doses of Enalacor is 11 hours. In subjects with normal renal function, steady-state serum concentrations of Enalacorat were reached after 4 days of treatment.
Distribution
Over the range of concentrations which are therapeutically relevant, Enalacorat binding to human plasma proteins does not exceed 60%.
Biotransformation
Except for conversion to Enalacorat, there is no evidence for significant metabolism of Enalacor.
Elimination
Excretion of Enalacorat is primarily renal. The principal components in urine are Enalacorat, accounting for about 40% of the dose, and intact Enalacor (about 20%).
Renal impairment
The exposure of Enalacor and Enalacorat is increased in patients with renal insufficiency. In patients with mild to moderate renal insufficiency (creatinine clearance 40-60 ml/min) steady state AUC of Enalacorat was approximately two-fold higher than in patients with normal renal function after administration of 5 mg once daily. In severe renal impairment (creatinine clearance ≤30 ml/min), AUC was increased approximately 8-fold. The effective half-life of Enalacorat following multiple doses of Enalacor maleate is prolonged at this level of renal insufficiency and time to steady state is delayed. (See 4.2 'Posology and method of administration'.) Enalacorat may be removed from the general circulation by hemodialysis. The dialysis clearance is 62 ml/min.
Children and adolescents
A multiple dose pharmacokinetic study was conducted in 40 hypertensive male and female pediatric patients aged 2 months to ≤16 years following daily oral administration of 0.07 to 0.14 mg/kg Enalacor maleate. There were no major differences in the pharmacokinetics of Enalacorat in children compared with historic data in adults. The data indicate an increase in AUC (normalised to dose per body weight) with increased age; however, an increase in AUC is not observed when data are normalised by body surface area. At steady state, the mean effective half-life for accumulation of Enalacorat was 14 hours
Lactation: After a single 20 mg oral dose in five postpartum women, the average peak Enalacor milk level was 1.7μg/L (range 0.54 to 5.9 μg/L) at 4 to 6 hours after the dose. The average peak Enalacorat level was 1. 7 μg/L (range 1.2 to 2.3 μg/L); peaks occurred at various times over the 24-hour period. Using the peak milk level data, the estimated maximum intake of an exclusively breastfed infant would be about 0.16% of the maternal weight-adjusted dosage. A woman who had been taking oral Enalacor 10 mg daily for 11 months had peak Enalacor milk levels of 2 μg/L 4 hours after a dose and peak Enalacor at levels of 0.75 μg/L about 9 hours after the dose. The total amount of Enalacor and Enalacorat measured in milk during the 24 hour period was 1.44μg/L and 0.63 μg/L of milk respectively. Enalacorat milk levels were undetectable (<0.2 μg/L) 4 hours after a single dose of Enalacor 5 mg in one mother and 10mg in two mothers; Enalacor levels were not determined.
Dual blockade of the rennin-angiotensin-aldosterone system (RASS)
There is evidence that the concomitant use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function (including acute renal failure). Dual blockade of RASS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is therefore not recommended.
If dual blockade therapy is considered absolutely necessary, this should only occur under specialist supervision and subject to frequent close monitoring of renal function, electrolytes and blood pressure. ACE-inhibitors and angiotensin II receptor blockers should not be used concomitantly in patients with diabetic nephropathy.
Symptomatic Hypotension
Symptomatic hypotension is rarely seen in uncomplicated hypertensive patients. In hypertensive patients receiving Enalacor, symptomatic hypotension is more likely to occur if the patient has been volume - depleted, e.g., by diuretic therapy, dietary salt restriction, dialysis, diarrhoea or vomiting. In patients with heart failure, with or without associated renal insufficiency, symptomatic hypotension has been observed. This is most likely to occur in those patients with more severe degrees of heart failure, as reflected by the use of high doses of loop diuretics, hyponatraemia or functional renal impairment. In these patients, therapy should be started under medical supervision and the patients should be followed closely whenever the dose of Enalacor and/or diuretic is adjusted. Similar considerations may apply to patients with ischemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in a myocardial infarction or cerebrovascular accident.
If hypotension occurs, the patient should be placed in the supine position and, if necessary, should receive an intravenous infusion of normal saline. A transient hypotensive response is not a contraindication to further doses, which can be given usually without difficulty once the blood pressure has increased after volume expansion.
In some patients with heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with Enalacor. This effect is anticipated, and usually is not a reason to discontinue treatment. If hypotension becomes symptomatic, a reduction of dose and/or discontinuation of the diuretic and/or Enalacor may be necessary.
Aortic or Mitral Valve Stenosis/Hypertrophic Cardiomyopathy
As with all vasodilators, ACE inhibitors should be given with caution in patients with left ventricular valvular and outflow tract obstruction and avoided in cases of cardiogenic shock and haemodynamically significant obstruction.
Renal Function Impairment
In cases of renal impairment (creatinine clearance <80 ml/min) the initial Enalacor dosage should be adjusted according to the patient's creatinine clearance and then as a function of the patient's response to treatment.).
Renovascular hypertension
There is an increased risk of hypotension and renal insufficiency when patients with bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney are treated with ACE inhibitors. Loss of renal function may occur with only mild changes in serum creatinine. In these patients, therapy should be initiated under close medical supervision with low doses, careful titration, and monitoring of renal function.
Kidney Transplantation
There is no experience regarding the administration of Enalacor in patients with a recent kidney transplantation. Treatment with Enalacor is therefore not recommended.
Hepatic failure
Rarely, ACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice or hepatitis and progresses to fulminant hepatic necrosis and (sometimes) death. The mechanism of this syndrome is not understood. Patients receiving ACE inhibitors who develop jaundice or marked elevations of hepatic enzymes should discontinue the ACE inhibitor and receive appropriate medical follow-up.
Neutropenia/Agranulocytosis
Neutropenia/agranulocytosis, thrombocytopenia and anaemia have been reported in patients receiving ACE inhibitors. In patients with normal renal function and no other complicating factors, neutropenia occurs rarely. Enalacor should be used with extreme caution in patients with collagen vascular disease, immunosuppressant therapy, treatment with allopurinol or procainamide, or a combination of these complicating factors, especially if there is pre-existing impaired renal function. Some of these patients developed serious infections which in a few instances did not respond to intensive antibiotic therapy. If Enalacor is used in such patients, periodic monitoring of white blood cell counts is advised and patients should be instructed to report any sign of infection.
Hypersensitivity/Angioneurotic oedema
Angioneurotic oedema of the face, extremities, lips, tongue, glottis and/or larynx has been reported in patients treated with angiotensin converting enzyme inhibitors, including Enalacor. This may occur at any time during treatment. In such cases, Enalacor should be discontinued promptly and appropriate monitoring should be instituted to ensure complete resolution of symptoms prior to dismissing the patient. Even in those instances where swelling of only the tongue is involved, without respiratory distress, patients may require prolonged observation since treatment with antihistamines and corticosteroids may not be sufficient.
Very rarely, fatalities have been reported due to angioedema associated with laryngeal oedema or tongue oedema. Patients with involvement of the tongue, glottis or larynx are likely to experience airway obstruction, especially those with a history of airway surgery. Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, appropriate therapy, which may include subcutaneous epinephrine solution 1:1000 (0.3 ml to 0.5 ml) and/or measures to ensure a patent airway, should be administered promptly.
Black patients receiving ACE inhibitors have been reported to have a higher incidence of angioedema compared to non-blacks.
Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor.
Anaphylactoid Reactions during Hymenoptera Desensitisation
Rarely, patients receiving ACE inhibitors during desensitisation with hymenoptera venom have experienced life-threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE-inhibitor therapy prior to each desensitisation.
Anaphylactoid Reactions during LDL Apheresis
Rarely, patients receiving ACE inhibitors during low density lipoprotein (LDL)-apheresis with dextran sulfate have experienced life-threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE-inhibitor therapy prior to each apheresis.
Haemodialysis Patients
Anaphylactoid reactions have been reported in patients dialysed with high-flux membranes (e.g., AN 69®) and treated concomitantly with an ACE inhibitor. In these patients consideration should be given to using a different type of dialysis membrane or a different class of antihypertensive agent.
Hypoglycaemia
Diabetic patients treated with oral antidiabetic agents or insulin starting an ACE inhibitor, should be told to closely monitor for hypoglycaemia, especially during the first month of combined use.
Cough
Cough has been reported with the use of ACE inhibitors. Characteristically, the cough is nonproductive, persistent and resolves after discontinuation of therapy. ACE inhibitor-induced cough should be considered as part of the differential diagnosis of cough.
Surgery/Anaesthesia
In patients undergoing major surgery or during anaesthesia with agents that produce hypotension, Enalacor blocks angiotensin II formation secondary to compensatory renin release. If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.
Hyperkalaemia
Elevations in serum potassium have been observed in some patients treated with ACE inhibitors, including Enalacor. Risk factors for the development of hyperkalaemia include those with renal insufficiency, worsening of renal function, age (>70 years) diabetes mellitus, inter-current events in particular dehydration, acute cardiac decompensation, metabolic acidosis and concomitant use of potassium-sparing diuretics (e.g., spironolactone, eplerenone, triamterene, or amiloride), potassium supplements or potassium-containing salt substitutes; or those patients taking other drugs associated with increases in serum potassium (e.g. heparin). The use of potassium supplements, potassium-sparing diuretics, or potassium-containing salt substitutes particularly in patients with impaired renal function may lead to a significant increase in serum potassium. Hyperkalaemia can cause serious, sometimes fatal arrhythmias. If concomitant use of Enalacor and any of the above-mentioned agents is deemed appropriate, they should be used with caution and with frequent monitoring of serum potassium.
Lithium
The combination of lithium and Enalacor is generally not recommended.
Lactose
Enalacor contains lactose and therefore should not be used by patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption. Enalacor contains less than 200 mg of lactose per tablet.
Paediatric Use
There is limited efficacy and safety experience in hypertensive children >6 years old, but no experience in other indications. Limited pharmacokinetic data are available in children above 2 months of age. Enalacor is not recommended in children in other indications than hypertension.
Enalacor is not recommended in neonates and in paediatric patients with glomerular filtration rate <30 ml/min/1.73 m2, as no data are available.
Pregnancy and lactation
ACE inhibitors should not be initiated during pregnancy. Unless continued ACE inhibitor therapy is considered essential, patients planning pregnancy should be changed to alternative antihypertensive treatments which have an established safety profile for use in pregnancy. When pregnancy is diagnosed, treatment with ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started.
Use of Enalacor is not recommended during breast feeding.
Ethnic differences
As with other angiotensin converting enzyme inhibitors, Enalacor is apparently less effective in lowering blood pressure in black people than in non-blacks, possibly because of a higher prevalence of low-renin states in the black hypertensive population.
When driving vehicles or operating machines it should be taken into account that occasionally dizziness or weariness may occur.
Food does not interfere with the absorption of Enalacor.
The dose should be individualized according to patient profile and blood pressure response.
Hypertension
The initial dose is 5 to maximally 20 mg, depending on the degree of hypertension and the condition of the patient (see below). Enalacor is given once daily. In mild hypertension, the recommended initial dose is 5 to 10 mg. Patients with a strongly activated renin-angiotensin-aldosterone system (e.g., renovascular hypertension, salt and/or volume depletion, cardiac decompensation, or severe hypertension) may experience an excessive blood pressure fall following the initial dose. A starting dose of 5 mg or lower is recommended in such patients and the initiation of treatment should take place under medical supervision.
Prior treatment with high dose diuretics may result in volume depletion and a risk of hypotension when initiating therapy with Enalacor. A starting dose of 5 mg or lower is recommended in such patients. If possible, diuretic therapy should be discontinued for 2-3 days prior to initiation of therapy with Enalacor. Renal function and serum potassium should be monitored.
The usual maintenance dose is 20 mg daily. The maximum maintenance dose is 40 mg daily.
Heart Failure/Asymptomatic Left Ventricular Dysfunction
In the management of symptomatic heart failure, Enalacor is used in addition to diuretics and, where appropriate, digitalis or beta-blockers. The initial dose of Enalacor 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 Enalacor 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 Enalacor in Patients with Heart Failure/Asymptomatic Left Ventricular Dysfunction
| Week | Dose mg/day |
| Week 1 | Days 1 to 3: 2.5 mg/day* in a single dose Days 4 to 7: 5 mg/day in two divided doses |
| Week 2 | 10 mg/day in a single dose or in two divided doses |
| Weeks 3 and 4 | 20 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 Enalacor 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 Enalacor. The appearance of hypotension after the initial dose of Enalacor does not imply that hypotension will recur during chronic therapy with Enalacor and does not preclude continued use of the drug. Serum potassium and renal function also should be monitored.
Dosage in Renal Insufficiency
Generally, the intervals between the administration of Enalacor should be prolonged and/or the dosage reduced.
| Creatinine Clearance (CrCL) mL/min | Initial Dose mg/day |
| 30 <CrCL <80 ml/min. | 5 - 10 mg |
| 10 <CrCL≤ 30 ml/min. | 2.5 mg |
| CrCL≤ 10 ml/min. | 2.5 mg on dialysis days* Enalacorat is dialysable. Dosage on nondialysis days should be adjusted depending on the blood pressure response. Use in Elderly The dose should be in line with the renal function of the elderly patient. Use in paediatrics There is limited clinical trial experience of the use of Enalacor in hypertensive paediatric patients. For patients who can swallow tablets, the dose should be individualised according to patient profile and blood pressure response. The recommended initial dose is 2.5 mg in patients 20 to <50 kg and 5 mg in patients >50 kg. Enalacor is given once daily. The dosage should be adjusted according to the needs of the patient to a maximum of 20 mg daily in patients 20 to <50 kg and 40 mg in patients >50 kg. Enalacor is not recommended in neonates and in paediatric patients with glomerular filtration rate <30 ml/min/1.73 m2, as no data are available. |
None
