enalapril and Abnormalities--Drug-Induced

Heart failure affects ≈5.7 million people in the United States alone. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and aldosterone antagonists have improved mortality in patients with heart failure and reduced ejection fraction, but mortality remains high. In July 2015, the US Food and Drug Administration approved the first of a new class of drugs for the treatment of heart failure: Valsartan/sacubitril (formerly known as LCZ696 and currently marketed by Novartis as Entresto) combines the angiotensin receptor blocker valsartan and the neprilysin inhibitor prodrug sacubitril in a 1:1 ratio in a sodium supramolecular complex. Sacubitril is converted by esterases to LBQ657, which inhibits neprilysin, the enzyme responsible for the degradation of the natriuretic peptides and many other vasoactive peptides. Thus, this combined angiotensin receptor antagonist and neprilysin inhibitor addresses 2 of the pathophysiological mechanisms of heart failure: activation of the renin-angiotensin-aldosterone system and decreased sensitivity to natriuretic peptides. In the Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, valsartan/sacubitril significantly reduced mortality and hospitalization for heart failure, as well as blood pressure, compared with enalapril in patients with heart failure, reduced ejection fraction, and an elevated circulating level of brain natriuretic peptide or N-terminal pro-brain natriuretic peptide. Ongoing clinical trials are evaluating the role of valsartan/sacubitril in the treatment of heart failure with preserved ejection fraction and hypertension. We review here the mechanisms of action of valsartan/sacubitril, the pharmacological properties of the drug, and its efficacy and safety in the treatment of heart failure and hypertension.

Topics: Abnormalities, Drug-Induced; Aminobutyrates; Angioedema; Angiotensin Receptor Antagonists; Biphenyl Compounds; Bradykinin; Contraindications; Drug Combinations; Drug Costs; Drug Synergism; Enalapril; Enzyme Inhibitors; Female; Follow-Up Studies; Heart Failure; Humans; Hyperkalemia; Hypertension; Kidney; Multicenter Studies as Topic; Natriuretic Peptides; Neprilysin; Pregnancy; Prodrugs; Prospective Studies; Pyridines; Randomized Controlled Trials as Topic; Stroke Volume; Tetrazoles; Thiazepines; Valsartan

A pregnant patient is taking enalapril for primary hypertension. How safe are angiotension-converting enzyme inhibitors (ACEI) during pregnancy?. Evidence of whether ACEIs cause problems during the first trimester of pregnancy is reassuring. There is evidence that they cause severe renal and other problems during the second and third trimesters, however. These drugs should be avoided during pregnancy.

Topics: Abnormalities, Drug-Induced; Angiotensin-Converting Enzyme Inhibitors; Animals; Enalapril; Female; Humans; Hypertension; Infant, Newborn; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Trimesters

To assess the teratogenic potential of angiotensin-converting enzyme (ACE) inhibitors, we report on 20 prospective pregnancies and 85 identified from articles in the literature. The anomaly rate was 20.6% in small series <10 entrants (95% CI 8.7-37.9%) and 1.4% in larger series > or =10 entrants (95% CI 0.03-7.3%) p=0.0016. The most consistent anomaly seen, skull hypoplasia, along with renal dysfunction appear to be more related to prolonged or late pregnancy exposure than to first trimester exposure. There is little supportive evidence that ACE inhibitors (captopril or enalapril) are teratogenic. There seems to be no absolute reason to discontinue these 2 medications prior to pregnancy, nor to create anxiety when a patient is identified with the combination of early pregnancy and treatment with these medications. There appears to be reason to discontinue the medication in pregnancy but the adverse event rate cannot be assessed because of inadequate prospective information.

Topics: Abnormalities, Drug-Induced; Angiotensin-Converting Enzyme Inhibitors; Captopril; Enalapril; Female; Humans; Pregnancy; Pregnancy Trimester, First; Pregnancy Trimester, Second; Pregnancy Trimester, Third

To review reports on the use of angiotensin-converting enzyme inhibitors (ACE-I) during pregnancy in order to determine the incidence, nature, and potential mechanisms of fetal complications in an attempt to establish recommendations related to the use of these drugs during gestation.. Relevant English-language articles identified through a Medline search and bibliographies found in recent articles.. Large number of reports both on animals and on humans have consistently shown a high degree of morbidity and even mortality in fetuses or newborns exposed to ACE-I during pregnancy. The reported complications include oligohydramnios, intrauterine growth retardation, premature labor, fetal and neonatal renal failure, bony malformations, limb contractures, persistent patent ductus arteriosus, pulmonary hypoplasia, respiratory distress syndrome, prolonged hypotension, and neonatal death. A high incidence of fetal complications was related to the use of ACE-I at all trimesters of pregnancy.. The gestational use of ACE-I may be associated with a high degree of fetal and newborn morbidity and even mortality. The use of these drugs should be avoided at all trimesters of pregnancy.

Topics: Abnormalities, Drug-Induced; Animals; Blood Pressure; Captopril; Ductus Arteriosus, Patent; Enalapril; Female; Fetal Death; Fetus; Goats; Kidney; Maternal-Fetal Exchange; Oligohydramnios; Pregnancy; Rabbits; Regional Blood Flow; Renal Insufficiency; Risk Factors; Sheep; Uterus; Vascular Resistance

Topics: Abnormalities, Drug-Induced; Adolescent; Angiotensin-Converting Enzyme Inhibitors; Enalapril; Female; Gestational Age; Humans; Kidney; Time Factors

Adverse pregnancy outcomes following the use of angiotensin-converting enzyme (ACE) inhibitors, including enalapril, have been reported in descriptive studies. However, no analytical studies on the relationship between the adverse outcomes and enalapril gestational exposures are available.. To explore the association between enalapril exposure and adverse outcomes in pregnancy, taking into account other possible risk factors.. We analyzed a series of all usable cases reported to the FDA between 1986 and 2000 in which enalapril was a suspect drug for the observed adverse outcomes (N = 110). Parameters of exposure and reported outcomes as well as information on potentially confounding variables were systematically abstracted from this series by a single physician. Because exposure to ACE inhibitors after the first trimester of pregnancy had been associated with adverse outcomes in the existing literature, we divided the cases into those exposed in the first trimester only (considered as the baseline group) and cases exposed beyond or after this time. Frequency of reported adverse outcomes in the second group was compared with those in the baseline group; odds ratios were computed, taking account of potentially confounding variables by logistic regression where appropriate.. Exposure to enalapril after the first trimester of pregnancy was strongly associated with oligohydramnios and specific adverse outcomes thought to be secondary to reduced amniotic fluid volume (limb deformities, cranial ossification deficits, lung hypoplasia), as well as with neonatal renal failure. The relationship did not change after taking numerous potential confounders into account, including duration of exposure, concomitant drug use, maternal age, concurrent disease, neonatal gender, and gestational age at birth. Such a pattern of abnormalities is considered to be a consequence of the effect of ACE inhibition on fetal renal function that develops after the first trimester.. The specificity and temporality of the observed adverse manifestations suggest a causal relationship to enalapril exposure.

Topics: Abnormalities, Drug-Induced; Adult; Adverse Drug Reaction Reporting Systems; Angiotensin-Converting Enzyme Inhibitors; Enalapril; Female; Humans; Infant, Newborn; Pregnancy; Pregnancy Outcome; United States; United States Food and Drug Administration

An intact renin-angiotensin system (RAS) during nephrogenesis is essential for normal renal development. We have shown previously that neonatal inhibition of the RAS, either with ANG II type 1-receptor blockade or angiotensin-converting enzyme (ACE) inhibition, induces irreversible renal abnormalities. The aim of the present study was to investigate whether an interrupted RAS can be compensated for by exogenous administration of another important renal growth-promoting factor, the insulin-like growth factor-I (IGF-I). Rats were treated daily with either the ACE inhibitor enalapril (10 mg/kg), recombinant human IGF-I (3 mg/kg), or the combination enalapril + IGF-I from perinatal day 3 to 13. Urinary concentrating ability, renal function, and renal morphology were assessed at adult age. The gene expression and localization of IGF-I, its receptor, and the growth hormone receptor (GHR) were investigated during ongoing ACE inhibition. The present study demonstrates normalized renal function and histology in enalapril + IGF-I-treated animals. Ongoing ACE inhibition suppressed the medullary IGF-I mRNA expression and altered the local distribution of both IGF-I and GHR. Thus the present study provides evidence for an interaction between the RAS and GH/IGF-I axis in renal development.

Topics: Abnormalities, Drug-Induced; Angiotensin-Converting Enzyme Inhibitors; Animals; Animals, Newborn; Enalapril; Gene Expression Regulation, Developmental; Insulin-Like Growth Factor I; Kidney Concentrating Ability; Kidney Cortex; Kidney Function Tests; Kidney Medulla; Male; Osmolar Concentration; Peptidyl-Dipeptidase A; Rats; Rats, Wistar; Receptor, IGF Type 1; Receptors, Somatotropin; Renal Circulation; Renin-Angiotensin System; RNA, Messenger

Enalapril (MK, 421), an angiotensin converting enzyme inhibitor, was tested for teratogenicity using Wistar rats. The drug was given by oral intubation, from 6-15 days of gestation, at the doses of 0, 3, 10 and 30 mg/kg/day. Reduction in body weight and food consumption were observed in the treated dams. However, food efficiency index, assessed at different periods of gestation was found to be unaffected. On day 20 of gestation, all the dams were sacrificed by cervical dislocation and sign of maternal toxicity, reproduction indices and fetal measures were recorded. The dams treated with enalapril at only the doses of 10 and 30 mg/kg, produced significant decrease in numbers of implants, litter size and incidence of reabsorbed fetuses, and also reduced neonatal growth. No such effects were observed at the lowest dose level (3 mg/kg) used. External, visceral and skeletal examinations of the fetuses of enalapril-treated dams showed several types of variations in all groups, but no consistent pattern were observed. However, a slight increase in skeletal variations was seen with the highest dose (30 mg/kg) group. The data of the present study under the conditions described herein and at the doses employed, revealed no evidence of teratogenesis, but numerous deleterious effects on the fetus were evident.

Topics: Abnormalities, Drug-Induced; Administration, Oral; Animals; Body Weight; Drinking; Eating; Embryonic and Fetal Development; Enalapril; Female; Male; Pregnancy; Rats; Rats, Wistar