Dosing & Uses
Dosage Forms & Strengths
10-40 mg/12.5-50 mg (enalapril/HCTZ)/day PO qDay or divided q12hr
Severe (CrCl <30 mL/min) : Not recommended; use loop diuretic instead
CrCl ≥30 mL/min: No dose adjustment necessary
Safety and efficacy not established
Serious - Use Alternative
Significant - Monitor Closely
- Dizziness (4-8%)
- Hypotension (0.9-6.7%)
- Headache (2-5%)
- Chest pain (2%)
- Cough (1-2%)
- Rash (1.5%)
- Epigastric distress
Black Box Warnings
Discontinue as soon as possible when pregnancy is detected; affects renin-angiotensin system causing oligohydramnios, which may result in fetal injury and/or death
Hypersensitivity to ACE inhibitors, thiazides or sulfonamides
ACE-inibitor induced angioedema, hereditary or idiopathic angioedema
Pregnancy (2nd and 3rd trimesters): significant risk of fetal/neonatal morbidity and mortality (due to enalapril)
Renal stenosis or anuria
Do not coadminister with aliskiren in patients with diabetes
Begin combination therapy only after failed monotherapy
Severe renal impairment, hepatic impairment
Risk of hypotension, especially in CHF patients
Dual blockade of the renin angiotensin system with ARBs, ACE inhibitors, or aliskiren associated with increased risk for hypotension, hyperkalemia, and renal function changes (including acute renal failure) compared to monotherapy
Angioedema of the face, extremities, lips, tongue, glottis, and larynx has been reported in patients treated with angiotensin-converting enzyme inhibitors
If laryngeal stridor or angioedema of the face, tongue, or glottis occurs discontinue therapy and institute appropriate therapy immediately
Patients receiving coadministration of ACE inhibitor and mTOR (mammalian target of rapamycin) inhibitor (e.g. temsirolimus, sirolimus, everolimus) therapy may be at increased risk for angioedema
Intestinal angioedema has been reported in patients treated with ACE inhibitors
Cholestatic jaundice may occur, which may progress to fulminant hepatic necrosis; discontinue
Dry hacking nonproductive cough may occur within few months of treatment; consider other causes of cough prior to discontinuation
Hyperkalemia may occur with ACE inhibitors; risk factors include renal dysfunction, diabetes mellitus, and concomitant use of potassium sparing diuretics and potassium supplements; use cautiously if at all with these agents
Thiazide diuretics may cause hypokalemia, hypochloremic alkalosis, hypomagnesemia, and hyponatremia
Hydrochlorothiazide may precipitate gout in patients with familial predisposition to gout or chronic renal failure
Symptomatic hypotension with or without syncope can occur with Ace inhibitors; mostly observed in volume depleted patients, correct volume depletion prior to initiation; monitor closely when initiating and increasing dosing
Agranulocytosis, neutropenia, or leukopenia with myeloid hypoplasia reported with other ACE inhibitor; patients with renal impairment are at high risk; monitor CBC with differential in these patients
Photosensitization may occur
Hydrochlorothiazide may cause acute transient myopia and acute angle-closure glaucoma that may occur within hours of initiating therapy; discontinue therapy immediately in patients with acute decreases in visual acuity or ocular pain; additional treatment may be needed if uncontrolled intraocular pressure persists
Use caution in patients with severe aortic stenosis; may reduce coronary perfusion resulting in ischemia
Use hydrochlorothiazide with caution in patients with diabetes or at risk of diabetes; may see increase in glucose
Use caution in patients collagen vascular disease, especially in patients with concomitant renal impairment
Thiazide diuretics may decrease renal calcium excretion; consider avoiding use in patients with hypercalcemia
Increased cholesterol and triglyceride levels reported with thiazides; use caution in patients with moderate to high cholesterol concentrations
Pathologic changes in parathyroid glands with hypercalcemia and hypophosphatemia reported with prolonged use; discontinue prior to testing for parathyroid function
Pregnancy & Lactation
Pregnancy Category: C (1st trimester); D (2nd & 3rd trimesters)
Lactation: enters breast milk/not recommended
A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA:Information not available.
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The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.
|1||This drug is available at the lowest co-pay. Most commonly, these are generic drugs.|
|2||This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.|
|3||This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.|
|4||This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.|
|5||This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.|
|6||This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.|
|NC||NOT COVERED – Drugs that are not covered by the plan.|
Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
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Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.