Enalaprilat

VASOTEC IV

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What it isActive enalapril metabolite and intravenous ACE inhibitor; hypertension when oral treatment is unavailable.

Why it mattersIt is the only IV ACE inhibitor, but its delayed and variable response limits emergency titration.

What it changesRenal clearance can prolong hypotension; hyperkalemia, kidney injury, angioedema, and fetal toxicity remain class risks.

FDA label

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BOXED WARNING Fetal toxicity: ACE inhibitors in 2nd/3rd trimester can cause injury and death to the developing fetus — discontinue as soon as pregnancy is detected

FDA dosing	Population	Start	Target	Max
Hypertension	Adults	IV 1.25 mg q6h, given over 5 min	IV 1.25 mg q6h	IV 5 mg q6h (well tolerated up to 36 h); inadequate experience >20 mg/day
Hypertension — on diuretics or at risk of excessive hypotension (HF, hyponatremia, high-dose diuretics, dialysis, volume/salt depletion)	Adults	IV 0.625 mg over >=5 min (preferably up to 1 h), under close supervision	IV 1.25 mg q6h after initial response	IV 1.25 mg q6h

Titration If clinical response inadequate 1 h after a 0.625 mg dose, may repeat 0.625 mg once; subsequent doses 1.25 mg q6h

Renal CrCl >30 mL/min: 1.25 mg q6h; CrCl <=30 mL/min (SCr >=3 mg/dL): start 0.625 mg (repeat after 1 h if inadequate, then 1.25 mg q6h); dialysis: use hypotension-risk dosing (start <=0.625 mg)

Hepatic Undefined

Not administered >48 h in hypertension studies (up to 7 days in other studies)

Instructions

IV administration only; give as slow IV infusion over >=5 min, as supplied or diluted in up to 50 mL compatible diluent
Compatible/stable 24 h at room temp in D5W, 0.9% NaCl, 0.9% NaCl in D5W, D5 in Lactated Ringer's, Isolyte E
Response usually within 15 min; peak effect of first dose may take up to 4 h (later doses may exceed the first)
Conversion to oral enalapril: 5 mg QD (2.5 mg QD if responded to 0.625 mg q6h or CrCl <=30 mL/min), then adjust to BP

Contraindications

History of angioedema related to previous ACE inhibitor treatment
Hereditary or idiopathic angioedema

Cautions

Fetal toxicity (boxed) — discontinue when pregnancy detected
Angioedema incl. potentially fatal laryngeal edema (higher incidence in Black patients) — discontinue and treat immediately
Excessive hypotension risk in heart failure, hyponatremia, high-dose diuretics, recent intensive diuresis, dialysis, volume/salt depletion (doses as low as 0.2 mg have caused excessive hypotension)
Anaphylactoid reactions during membrane exposure (dialysis)
Enalapril class effects reported: hepatic failure/hepatitis, neutropenia/bone marrow depression, cough, renal dysfunction

Adverse reactions

Hypotension (3.4% overall; 5.2% in CHF patients)
Headache (2.9%), nausea (1.1%)
0.5-1%: MI, fatigue, dizziness, fever, rash, constipation
Angioedema; cough

Pregnancy Category C (1st trimester)/D (2nd-3rd trimesters); 2nd-3rd trimester exposure can injure or kill the fetus — discontinue as soon as pregnancy detected

Lactation Undefined

⚠ BOXED WARNING