ACE inhibitor Pregnancy: ACE inhibitors not recommended in the first trimester and contraindicated in the second and third trimesters (known human fetotoxicity and neonatal toxicity). Not recommended in breastfeeding for preterm infants and the first few weeks after delivery.

Enalapril maleate

Brand names: Innovace

Enalapril maleate is an ACE inhibitor used for hypertension and chronic heart failure.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Hypertension: initial 5 mg (5-10 mg in mild hypertension), usual maintenance 20 mg daily

Route: Oral

Frequency: Once daily (may be given in two divided doses in heart failure)

Max: 40 mg daily

Dose individualised to patient profile and blood pressure response. Hypertension: initial 5 to maximally 20 mg once daily; in patients with a strongly activated renin-angiotensin-aldosterone system (renovascular hypertension, salt/volume depletion, cardiac decompensation, severe hypertension) or on high-dose diuretics, start at 5 mg or lower under medical supervision; usual maintenance 20 mg daily, maximum maintenance 40 mg daily. Heart failure/asymptomatic left ventricular dysfunction: initial 2.5 mg under close medical supervision, titrated over 2-4 weeks to usual maintenance 20 mg daily (single or two divided doses), maximum 40 mg daily in two divided doses. In diuretic-treated patients, if possible discontinue the diuretic for 2-3 days before starting. Absorption not affected by food. Paediatric (patients who can swallow tablets): initial 2.5 mg for 20 to <50 kg and 5 mg for >=50 kg once daily, adjusted to a maximum of 20 mg daily (20 to <50 kg) or 40 mg daily (>=50 kg); not recommended in neonates or in children with GFR <30 ml/min/1.73 m2.

Dose adjustments

Renal

Prolong the dosing interval and/or reduce the dose. Initial dose by creatinine clearance: 5-10 mg/day for CrCl >30 to <=80 ml/min; 2.5 mg/day for CrCl <=30 ml/min; 2.5 mg on dialysis days for CrCl <=10 ml/min (enalapril is dialysable). Adjust non-dialysis-day dosing to blood pressure response.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

US labelling (FDA)

Reference — US labelling, may differ from UK

DOSAGE AND ADMINISTRATION Hypertension In patients who are currently being treated with a diuretic, symptomatic hypotension occasionally may occur following the initial dose of enalapril maleate. The diuretic should, if possible, be discontinued for two to three days before beginning therapy with enalapril maleate to reduce the likelihood of hypotension (see WARNINGS, Hypotension ). If the patient's blood pressure is not controlled with enalapril maleate alone, diuretic therapy may be resumed. If the diuretic cannot be discontinued an initial dose of 2.5 mg should be used under medical supervision for at least two hours and until blood pressure has stabilized for at least an additional hour …

Source: US FDA prescribing information (openFDA / DailyMed), label dated 2023-10-09. Accessed 2026-06-12. US dosing and indications can differ from UK practice — use UK sources for prescribing decisions.

Contraindications

Hypersensitivity to enalapril, any excipient, or any other ACE inhibitor
History of angioedema associated with previous ACE inhibitor therapy
Hereditary or idiopathic angioedema
Second and third trimesters of pregnancy
Concomitant aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR <60 ml/min/1.73 m2)
Combination with sacubitril/valsartan; do not administer within 36 hours of switching to or from a neprilysin inhibitor

Side effects

Dizziness; headache
Hypotension (including orthostatic hypotension)
Cough; dyspnoea
Nausea, diarrhoea, abdominal pain
Hyperkalaemia; angioneurotic oedema (face, extremities, lips, tongue, glottis and/or larynx); blurred vision; asthenia/fatigue

Interactions

Neprilysin inhibitors (e.g. sacubitril): increased risk of angioedema
Dual RAS blockade (ARBs, ACE inhibitors, aliskiren): increased risk of hypotension, hyperkalaemia and changes in renal function; generally avoid combined use
Diuretics: patients (especially recently started) may experience excessive blood pressure reduction after initiation
Potassium supplements, potassium salt substitutes or potassium-sparing diuretics: may increase serum potassium

Clinical monograph

How it works

It is a prodrug hydrolysed to the active enalaprilat, which inhibits angiotensin-converting enzyme, reducing angiotensin II and aldosterone and thereby lowering vasoconstriction and sodium retention.

Prescribing in practice

Pronounced first-dose hypotension can occur, especially in patients on diuretics, those who are volume- or salt-depleted, or in heart failure—consider initiating under supervision in higher-risk patients.
Dry cough and, rarely, angioedema can occur; hyperkalaemia is a recognised risk.
Avoid in pregnancy and in bilateral renal artery stenosis; check renal function and potassium before starting and after dose changes.

Monitoring

Monitor renal function, serum potassium and blood pressure before starting, after each dose change and periodically thereafter, with closer review in heart failure or renal impairment.

Counselling the patient

The first dose may cause dizziness; take care standing up and consider taking the initial dose at bedtime if advised.
Report a persistent dry cough or any swelling of the face, lips or throat (seek urgent help), and avoid potassium-based salt substitutes.

Evidence & guidelines

Guideline-recommended for hypertension and heart failure (NICE NG136, NG106).

Reference: NICE NG136; NICE NG106; ESC HF guidelines; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways