Enalapril

Oral health effects

• Angioedema

  Class effect: orofacial swelling that can threaten the airway.

  Mechanism: Bradykinin accumulation from ACE inhibition.

  Clinical management: Treat airway-threatening angioedema as an emergency; refer.

• Dysgeusia

  Altered or metallic taste, sometimes loss of taste.

  Clinical management: Usually reversible; reassure and coordinate with prescriber.

• Persistent dry cough (ACE inhibitor cough)

  A dry, tickly, non-productive cough is a class effect of ACE inhibitors caused by bradykinin accumulation; it can start weeks to months after starting and resolves within days to weeks of stopping. Label: cough in 1.3% (hypertension) and 2.2% (heart failure) of enalapril-treated patients in controlled trials.

  Clinical management: Ask about chronic cough at medical history review. Cough can be triggered by water spray, prophy paste or supine positioning: use high-volume suction, a more upright chair position and short breaks. Persistent cough is a reason for the patient to discuss alternatives (e.g. an ARB) with their prescriber; do not advise stopping the medication.

• Dizziness on standing (orthostatic hypotension)

  Orthostatic effects were reported in 1.2% of hypertensive and 2.2% of heart-failure patients on enalapril (vs 0–0.3% on placebo), with syncope in 2.2% in heart failure.

  Clinical management: Raise the chair back slowly at the end of the appointment, let the patient sit upright for 1–2 minutes before standing, and steady them as they get up. Take extra care in older patients, after long supine procedures and when other blood-pressure-lowering drugs are taken.