Source: European Medicines Agency (EU) Revision Year: 2023 Publisher: Proveca Pharma Limited, 2 Dublin Landings, North Wall Quay, Dublin 1, Ireland
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 AQUMELDI and/or diuretic is adjusted. Similar considerations may apply to patients with ischaemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in a myocardial infarction or cerebrovascular accident.
In some patients with heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with AQUMELDI. 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 AQUMELDI may be necessary.
If hypotension occurs, the patient should be placed in the supine position and, if necessary, should receive an intravenous infusion of sodium chloride 9 mg/ml (0.9%) solution for injection. 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.
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 failure has been reported in association with enalapril and has been seen mainly in patients with severe heart failure or underlying renal disease, including renal artery stenosis. If recognised promptly and treated appropriately, renal failure when associated with enalapril therapy is usually reversible (see section 4.8).
Some hypertensive patients, with no apparent pre-existing renal disease have developed increases in blood urea and creatinine when enalapril has been given concurrently with a diuretic. Dose reduction of enalapril and/or discontinuation of the diuretic may be required (see section 4.2). This situation should raise the possibility of underlying renal artery stenosis (see renovascular hypertension below).
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.
There is no experience regarding the administration of AQUMELDI in patients with a recent kidney transplantation. Treatment with AQUMELDI is therefore not recommended.
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, 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. Enalapril 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 enalapril 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.
Angioedema of the face, extremities, lips, tongue, glottis and/or larynx has been reported in patients treated with ACE inhibitors, including enalapril. This may occur at any time during treatment. In such cases, AQUMELDI must 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 1:1 000 (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 (see section 4.3).
Caution should be used when starting racecadotril, mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus) and vildagliptin in a patient already taking an ACE inhibitor. Patients receiving concomitant ACE inhibitor and neprilysin inhibitor therapy (e.g., sacubitril, racecadotril) may be at increased risk for angioedema (see section 4.5). The combination of enalapril with sacubitril/valsartan is contraindicated due to the increased risk of angioedema (see section 4.3). Sacubitril/valsartan must not be initiated until 36 hours after taking the last dose of enalapril therapy. If treatment with sacubitril/valsartan is stopped, enalapril therapy must not be initiated until 36 hours after the last dose of sacubitril/valsartan (see sections 4.3 and 4.5).
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.
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.
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 antihypertensives.
Diabetic patients treated with oral antidiabetics or insulin starting an ACE inhibitor should be told to closely monitor for hypoglycaemia, especially during the first month of combined use (see section 4.5).
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.
In patients undergoing major surgery or during anaesthesia with medicinal products that produce hypotension, enalapril 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.
Elevations in serum potassium have been observed in some patients treated with ACE inhibitors, including enalapril. Risk factors for the development of hyperkalaemia include those patients with renal insufficiency, worsening of renal function, age (>70 years), diabetes mellitus, intercurrent 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 medicinal products associated with increases in serum potassium (e.g., heparin, trimethoprimcontaining products such as cotrimoxazole). Neonates are at increased risk of developing hyperkalaemia.
The use of potassium supplements, potassium-sparing diuretics, potassium-containing salt substitutes, or other medicinal products that may increase serum potassium, 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 enalapril and any of the abovementioned agents is deemed appropriate, they should be used with caution and with frequent monitoring of serum potassium (see section 4.5).
The combination of lithium and enalapril is generally not recommended (see section 4.5).
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). Blockade of RAAS through the combined use of ACE inhibitors, angiotensin II receptor blockers or aliskiren is therefore not recommended (see sections 4.5 and 5.1).
If dual blockade therapy is considered absolutely necessary, this should only occur under specialist supervision and be 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.
ACE inhibitors should not be initiated during pregnancy. Unless continued ACE inhibitor therapy is considered essential, patients planning pregnancy should be changed to alternative treatments which have an established safety profile for use in pregnancy. When pregnancy is diagnosed, treatment with ACE inhibitors must be stopped immediately, and, if appropriate, alternative therapy should be started (see sections 4.3 and 4.6).
As with other ACE inhibitors, enalapril is apparently less effective in lowering blood pressure in black people than in non-black, possibly because of a higher prevalence of low-renin states in the black hypertensive population.
AQUMELDI is not recommended in children in indications other than heart failure. Caution is advised in children below 1 month of age as they may be very sensitive to the medical product. Data on the use of Aqumeldi in children below 1 month of age in the clinical studies is scarce (n=4). Any signs of adverse events and electrolytes should be closely monitored.
No data is available for treatment of paediatric subjects with pre-existing liver conditions. Therefore, paediatric subjects with pre-existing liver conditions should only be treated with enalapril under strict monitoring. Treatment of children below the age of 1 month with hepatic impairment is not recommended.
This medicinal product contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially “sodium free”.
No interaction studies have been performed with AQUMELDI in the adult or paediatric population. Interaction studies with enalapril have only been performed in adults.
Clinical study data have shown that dual blockade of the renin-angiotensin-aldosterone-system (RAAS) through the combined use of ACE inhibitors, angiotensin II receptor blockers or aliskiren is associated with a higher frequency of adverse events such as hypotension, hyperkalaemia and decreased renal function (including acute renal failure) compared to the use of a single RAAS-acting agent (see sections 4.3, 4.4 and 5.1).
ACE inhibitors attenuate diuretic induced potassium loss. Potassium sparing diuretics (e.g., spironolactone, eplerenone, triamterene or amiloride), potassium supplements, potassium-containing salt substitutes, or other medicinal products that may increase serum potassium (e.g., heparin, trimethoprim-containing products such as cotrimoxazole) may lead to significant increases in serum potassium. If concomitant use of enalapril and any of the above-mentioned agents is deemed appropriate, they should be used with caution and with frequent monitoring of serum potassium (see section 4.4).
Prior treatment with high dose diuretics may result in volume depletion and a risk of hypotension when initiating therapy with enalapril (see section 4.4). The hypotensive effects can be reduced by discontinuation of the diuretic, by increasing volume or salt intake or by initiating therapy with a low dose of enalapril.
Concomitant use of these medicinal products may increase the hypotensive effects of enalapril. Concomitant use with nitroglycerine and other nitrates, or other vasodilators, may further reduce blood pressure.
Reversible increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with ACE inhibitors. Concomitant use of thiazide diuretics may further increase lithium levels and enhance the risk of lithium toxicity with ACE inhibitors. Use of enalapril with lithium is not recommended, but if the combination proves necessary, careful monitoring of serum lithium levels should be performed (see section 4.4).
Concomitant use of certain anaesthetic medicinal products, tricyclic antidepressants and antipsychotics with ACE inhibitors may result in reduction of blood pressure (see section 4.4).
Non-steroidal anti-inflammatory drugs (NSAIDs) including selective cyclooxygenase-2 inhibitors (COX-2 inhibitors) may reduce the effect of diuretics and other antihypertensives. Therefore, the antihypertensive effect of angiotensin II receptor antagonists or ACE inhibitors may be attenuated by NSAIDs including selective COX-2 inhibitors.
The co-administration of NSAIDs (including COX-2 inhibitors) and angiotensin II receptor antagonists or ACE inhibitors exert an additive effect on the increase in serum potassium and may result in a deterioration of renal function. These effects are usually reversible. Rarely, acute renal failure may occur, especially in patients with compromised renal function (such as the elderly or patients who are volume-depleted, including those on diuretic therapy). Therefore, the combination should be administered with caution in patients with compromised renal function. Patients should be adequately hydrated and consideration should be given to monitoring renal function after initiation of concomitant therapy and periodically thereafter.
Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients on therapy with injectable gold (sodium aurothiomalate) and concomitant ACE inhibitor therapy including enalapril.
Patients taking concomitant mTOR inhibitor (e.g., temsirolimus, sirolimus, everolimus) therapy may be at increased risk for angioedema (see section 4.4).
Patients receiving concomitant ACE inhibitor and neprilysin inhibitor therapy (e.g., sacubitril, racecadotril) may be at increased risk for angioedema (see section 4.4). The concomitant use of enalapril with sacubitril/valsartan is contraindicated, as the concomitant inhibition of neprilysin and ACE may increase the risk of angioedema. Sacubitril/valsartan must not be started until 36 hours after taking the last dose of enalapril therapy. Enalapril therapy must not be started until 36 hours after the last dose of sacubitril/valsartan (see sections 4.3 and 4.4).
Sympathomimetics may reduce the antihypertensive effects of ACE inhibitors.
Epidemiological studies have suggested that concomitant administration of ACE inhibitors and antidiabetics (insulins, oral hypoglycaemic agents) may cause an increased blood-glucose-lowering effect with risk of hypoglycaemia. This phenomenon appeared to be more likely to occur during the first weeks of combined treatment and in patients with renal impairment (see sections 4.4 and 4.8). Patients taking concomitant vildagliptin therapy may be at increased risk for angioedema (see section 4.4).
Alcohol enhances the hypotensive effect of ACE inhibitors.
Enalapril can be safely administered concomitantly with acetyl salicylic acid (at cardiologic doses), thrombolytics and β-blockers.
Hyperkalaemia may occur during concomitant use of ACE inhibitors with ciclosporin. Monitoring of serum potassium is recommended.
Hyperkalaemia may occur during concomitant use of ACE inhibitors with heparin. Monitoring of serum potassium is recommended.
Based on human experience ACE inhibitors including enalapril cause congenital malformations (decreased renal function, oligohydramnios, skull ossification retardation, limb contractures, craniofacial deformations and hypoplastic lung development) and neonatal toxicity (renal failure, hypotension, hyperkalaemia) when administered during pregnancy.
AQUMELDI is contraindicated during the second and third trimester of pregnancy and is not recommended in the first trimester (see section 4.3 and 4.4).
Women of childbearing potential must use effective contraception during and up to 1 week after treatment.
Maternal oligohydramnios, presumably representing decreased foetal renal function, has occurred and may result in limb contractures, craniofacial deformations and hypoplastic lung development. 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 (see sections 4.3 and 4.4).
AQUMELDI and its metabolites are excreted in human milk to such an extent that effects on the breastfed newborns/infants cannot be excluded (see section 5.2).
A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from AQUMELDI therapy considering the benefit of breast feeding for the child and the benefit of therapy for the woman.
No human data on the effect of enalapril on fertility are available. In rats, there was no effect on mating or fertility with enalapril treatment (see section 5.3).
AQUMELDI has minor influence on the ability to drive and use machines. Dizziness or weariness may occur which may affect concentration and co-ordination. This may alter the performance at skilled tasks such as driving, riding a bicycle, or using machines.
The most frequent drug related adverse reactions reported in children were cough (5.7%), vomiting (3.1%), microalbuminuria (3.1%), hyperkalaemia (2.9%), hypotension (1.4%), and postural dizziness (1.2%).
The adverse reaction frequency listed in Table 1 is derived from the clinical studies in children receiving AQUMELDI for heart failure. In total 86 children in these studies received enalapril for up to 1 year; as such the data are limited.
The adverse reactions are listed below by SOC (system organ class) and by frequency, most frequent reactions first, with the following guidelines: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1 000 to <1/100), rare (≥1/10 000 to <1/1 000), very rare (<1/10 000), not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in the order of decreasing seriousness.
Table 1. List of adverse reactions in children with heart failure:
| Adverse reactions | Frequency |
|---|---|
| Nervous system disorders | |
| Dizziness postural | Common |
| Vascular disorders | |
| Hypotension | Common |
| Respiratory, thoracic and mediastinal disorders | |
| Cough | Common |
| Gastrointestinal disorders | |
| Vomiting | Common |
| Investigations | |
| Hyperkalaemia | Common |
| Microalbuminuria | Common |
Enalapril tablets have been evaluated for safety in more than 10 000 adult patients and in controlled clinical studies involving 2 314 hypertensive patients and 363 patients with congestive heart failure. Adverse reactions and frequency in the adult population is listed in Table 2.
Table 2. List of adverse reactions in the adult population:
| Adverse reactions | Frequency |
|---|---|
| Blood and lymphatic system disorders | |
| Aplastic anaemia | Uncommon |
| Haemolytic anaemia | Uncommon |
| Anaemia | Uncommon |
| Bone marrow depression | Rare |
| Neutropenia | Rare |
| Agranulocytosis | Rare |
| Pancytopenia | Rare |
| Thrombocytopenia | Rare |
| Lymphadenopathy | Rare |
| Haemoglobin decreased | Rare |
| Haematocrit decreased | Rare |
| Immune system disorders | |
| Angioedema | Common |
| Autoimmune diseases | Rare |
| Endocrine disorders | |
| Syndrome of inappropriate antidiuretic hormone secretion (SIADH) | Unknown |
| Metabolism and nutrition disorders | |
| Hypoglycaemia | Uncommon |
| Psychiatric disorders | |
| Depression | Common |
| Confusion | Uncommon |
| Nervousness | Uncommon |
| Insomnia | Uncommon |
| Abnormal dreams | Rare |
| Sleep disorders | Rare |
| Nervous system disorders | |
| Dizziness | Very common |
| Headache | Common |
| Syncope | Common |
| Taste alteration | Common |
| Paraesthesia | Uncommon |
| Somnolence | Uncommon |
| Vertigo | Uncommon |
| Eye disorders | |
| Blurred vision | Very common |
| Ear and labyrinth disorders | |
| Tinnitus | Uncommon |
| Cardiac disorders | |
| Chest pain | Common |
| Rhythm disturbances | Common |
| Angina pectoris | Common |
| Tachycardia | Common |
| Myocardial infarction | Uncommon |
| Cerebrovascular accident | Uncommon |
| Palpitations | Uncommon |
| Vascular disorders | |
| Hypotension | Common |
| Orthostatic hypotension | Uncommon |
| Flushing | Uncommon |
| Raynaud’s phenomenon | Rare |
| Respiratory, thoracic and mediastinal disorders | |
| Cough | Very common |
| Dyspnoea | Common |
| Asthma | Uncommon |
| Bronchospasm | Uncommon |
| Sore throat | Uncommon |
| Rhinorrhoea | Uncommon |
| Hoarseness | Uncommon |
| Pulmonary infiltrates | Rare |
| Allergic alveolitis | Rare |
| Eosinophilic pneumonia | Rare |
| Rhinitis | Rare |
| Gastrointestinal disorders | |
| Nausea | Very common |
| Diarrhoea | Common |
| Abdominal pain | Common |
| Vomiting | Common |
| Ileus | Uncommon |
| Pancreatitis | Uncommon |
| Peptic ulcer | Uncommon |
| Constipation | Uncommon |
| Anorexia | Uncommon |
| Gastric irritation | Uncommon |
| Dyspepsia | Uncommon |
| Dry mouth | Uncommon |
| Stomatitis | Rare |
| Aphthous ulceration | Rare |
| Glossitis | Rare |
| Intestinal angioedema | Very rare |
| Hepatobiliary disorders | |
| Hepatic failure | Rare |
| Cholestasis | Rare |
| Hepatitis | Rare |
| Skin and subcutaneous tissue disorders | |
| Rash | Common |
| Pruritis | Uncommon |
| Diaphoresis | Uncommon |
| Alopecia | Uncommon |
| Erythema multiforme | Rare |
| Stevens-Johnson syndrome | Rare |
| Exfoliative dermatitis | Rare |
| Toxic epidermal necrolysis | Rare |
| Pemphigus | Rare |
| Erythroderma | Rare |
| Severe skin reactions* | Unknown |
| Hypersensitivity reactions | Unknown |
| Musculoskeletal and connective tissue disorders | |
| Muscle cramps | Uncommon |
| Renal and urinary disorders | |
| Renal failure | Uncommon |
| Renal dysfunction | Uncommon |
| Proteinuria | Uncommon |
| Oliguria | Rare |
| Reproductive system and breast disorder | |
| Impotence | Uncommon |
| Gynaecomastia | Rare |
| General disorders and administration site conditions | |
| Aesthenia | Very common |
| Fatigue | Common |
| Fever | Uncommon |
| Malaise | Uncommon |
| Investigations | |
| Hyperkalaemia | Common |
| Microalbuminuria | Common |
| Increased serum creatinine | Common |
| Increased blood urea | Uncommon |
| Hyponatraemia | Uncommon |
| Increased liver enzymes | Rare |
| Increased serum bilirubin | Rare |
* 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 leucocytosis. Rash, photosensitivity or other dermatologic manifestations may occur.
Following the first ingestion of AQUMELDI no changes were reported in blood pressure or heart rate in naïve or ACEi pre-treated paediatric heart failure patients during the 8-h observation period. Over the first 8 weeks of treatment, mean values of blood pressure did not change over time. The same trend was observed for heart rate. Mean arterial pressure (MAP), based on systolic and diastolic blood pressure, increased in every age group throughout the duration of the subsequent 10-month study period except for children aged 6-12 months where it showed a minor decrease.
Over the 12-month study period treatment, serum creatinine, blood urea nitrogen (BUN), GFR and potassium levels were generally within normal range and constant in paediatric patients with heart failure. The only difference being in children aged from birth to 3 months where BUN levels were significantly higher at the end of the study compared to the start, mean (± standard deviation (SD)) 4.4 (±1.8) vs 2.8 (±1.4), p=0,0001). In paediatric patients with heart failure, microalbuminuria was consistently reported in only one patient with dilated cardiomyopathy from the first study visit. As this patient prematurely left the study and was lost to follow-up, only limited data are available.
Microalbuminuria was incidentally reported in three other cases, but at other visits microalbumin was within normal range. For the remaining patients values were similar in all age groups throughout the study.
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in Appendix V.
Not applicable.
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