Enalapril Maleate 5mg/5ml Oral Solution

• Keep this leaflet.You may need to read it again.
• If you have any further questions, ask your doctor or pharmacist.
• This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
• If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.

1. What Enalapril Maleate Oral Solution is and what it is used for
2. What you need to know before you take Enalapril Maleate Oral Solution
3. How to take Enalapril Maleate Oral Solution
4. Possible side effects
5. How to store Enalapril Maleate Oral Solution
6. Contents of the pack and other information

• If you are allergic to enalapril maleate or any of the other ingredients of this medicine (listed in section 6)
• If you have ever had an allergic reaction to a type of medicine similar to this medicine called an ACE inhibitor
• If you have ever had swelling of your face, lips, mouth, tongue or throat which caused difficulty in swallowing or breathing (angioedema) when the reason why was not known or it was inherited
• If you have diabetes or impaired kidney function and you are treated with a blood pressure lowering medicine containing aliskiren
• If you are more than 3 months pregnant. (It is also better to avoid enalapril in early pregnancy – see Pregnancy section)
• If you have taken or are currently taking sacubitril/valsartan, a medicine used to treat a type of long-term (chronic) heart failure in adults, as the risk of angioedema (rapid swelling under the skin in an area such as the throat) is increased.

Do not take this medicine if any of the above apply to you. If you are not sure, talk to your doctor or pharmacist before taking this medicine.

Talk to your doctor or pharmacist before taking Enalapril Maleate Oral Solution:

• If you have a heart problem
• If you have a condition involving the blood vessels in the brain
• If you have a blood problem such as low or lack of white blood cells (neutropenia/agranulocytosis), low blood platelet count (thrombocytopenia) or a decreased number of red blood cells (anaemia)
• If you have a liver problem
• If you have a kidney problem (including kidney transplantation), are on a salt-restricted diet, are taking potassium supplements, potassium-sparing agents, potassium-containing salt substitutes, or other drugs that may increase potassium in your blood (e.g., heparin [a medicine used to prevent blood clots], trimethoprim-containing products such as cotrimoxazole [medicines used to treat infections]).These may lead to higher levels of potassium in your blood which can be serious.Your doctor may need to adjust your dose of enalapril or monitor your blood level of potassium. See also information under the heading “Other medicines and Enalapril Maleate Oral Solution”
• If you are having dialysis
• If you have been very sick (excessive vomiting) or had bad diarrhoea recently
• If you have diabetes.You should monitor your blood for low blood glucose levels, especially during the first month of treatment.The level of potassium in your blood can also be higher
• If you have ever had an allergic reaction with swelling of the face, lips, tongue or throat with difficulty in swallowing or breathing.You should be aware that black patients are at increased risk of these types of reactions to ACE inhibitors
• If you have low blood pressure (you may notice this as faintness or dizziness, especially when standing)
• If you have collagen vascular disease (e.g., lupus erythematosus, rheumatoid arthritis or scleroderma), are on therapy that suppresses your immune system, are taking the drugs allopurinol or procainamide, or any combinations of these
• If you are taking any of the following medicines, the risk of angioedema may be increased:
  • Racecadotril, a medicine used to treat diarrhoea.
  • Medicines used to prevent organ transplant rejection and for cancer (e.g., temsirolimus, sirolimus, everolimus).
  • Vildagliptin, a medicine used to treat diabetes.
• If you are taking any of the following medicines used to treat high blood pressure:
  • An angiotensin II receptor blocker (ARB) (also known as sartans - for example valsartan, telmisartan, irbesartan, etc.), in particular if you have diabetes-related kidney problems.
  • Aliskiren.

Your doctor may check your kidney function, blood pressure, and the amount of electrolytes (e.g., potassium) in your blood at regular intervals.

See also information under the heading “Do not take Enalapril Maleate Oral Solution.”

You must tell your doctor if you think you are (or might become) pregnant.This medicine is not recommended in early pregnancy and must not be taken if you are more than 3 months pregnant, as it may cause serious harm to your baby if used at that stage (see Pregnancy section).

You should be aware that this medicine lowers the blood pressure in black patients less effectively than in non-black patients.

If you are not sure if any of the above applies to you, talk to your doctor or pharmacist before taking this medicine.

If you are about to have any of the following, tell your doctor that you are taking Enalapril Maleate Oral Solution:

• Any surgery or receive anaesthetics (even at the dentist).
• A treatment to remove cholesterol from your blood called ‘LDL apheresis’.
• A desensitisation treatment, to lower the effect of an allergy to bee or wasp stings.

If any of the above applies to you, talk to your doctor or dentist before the procedure.

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines.This includes herbal medicines.This is because enalapril can affect the way some medicines work. Also, some other medicines can affect the way enalapril works.Your doctor may need to change your dose and/or to take other precautions.

In particular tell your doctor or pharmacist if you are taking any of the following medicines:

• An angiotensin II receptor blocker (ARB) or aliskiren (see also information under the headings “Do not take Enalapril Maleate Oral Solution” and “Warnings and precautions”)
• Other medicines to lower blood pressure, such as beta-blockers or water tablets (diuretics)
• Potassium supplements (including salt substitutes), potassium-sparing diuretics and other medicines that can increase the amount of potassium in your blood (e.g. trimethoprim and co-trimoxazole for infections caused by bacteria; ciclosporin, an immunosuppressant medicine used to prevent organ transplant rejection; and heparin, a medicine used to thin blood to prevent clots). See also information under the heading “Warnings and precautions”
• Medicines for diabetes (including oral antidiabetic medicines and insulin)
• Lithium (a medicine used to treat a certain kind of depression)
• Medicines for depression called ‘tricyclic antidepressants’
• Medicines for mental problems called ‘antipsychotics’
• Certain cough and cold medicines and weight reducing medicines which contain something called a ‘sympathomimetic agent’
• Certain pain or arthritis medicines including gold therapy
• An mTOR inhibitor (e.g., temsirolimus, sirolimus, everolimus; medicines used to treat certain types of cancer or to prevent the body’s immune system from rejecting a transplanted organ). See also information under the heading “Warnings and precautions”
• A medicine containing a neprilysin inhibitor such as sacubitril (available as fixed-dose combination with valsartan), racecadotril or vidagliptin. The risk of angioedema (swelling of the face, lips, tongue or throat with difficulty in swallowing or breathing) may be increased. See also information under the headings “Do not take Enalapril Maleate Oral Solution” and “Warnings and precautions”
• Non-steroidal anti-inflammatory drugs, including COX-2-inhibitors (medicines that reduce inflammation, and can be used to help relieve pain)
• Aspirin (acetylsalicylic acid)
• Medicines used to dissolve blood clots (thrombolytics)
• Alcohol.

If you are not sure if any of the above applies to you, talk to your doctor or pharmacist before taking Enalapril Maleate Oral Solution.

Enalapril can be taken with or without food. If you drink alcohol while taking enalapril it may cause your blood pressure to drop too much and you may feel dizzy, light-headed or faint.Take care with the amount of alcohol you drink.

Pregnancy

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor for advice before taking this medicine.Your doctor will normally advise you to stop taking enalapril before you become pregnant or as soon as you know you are pregnant and will advise you to take another medicine instead of enalapril.This medicine is not recommended in early pregnancy and must not be taken when more than 3 months pregnant, as it may cause serious harm to your baby if used after the third month of pregnancy.

Breast-feeding

Tell your doctor if you are breast-feeding or about to start breast-feeding. Breast-feeding newborn babies (first few weeks after birth), and especially premature babies, is not recommended whilst taking this medicine. In the case of an older baby your doctor should advise you on the benefits and risks of taking this medicine whilst breast-feeding, compared to other treatments.

You may feel dizzy or sleepy while taking this medicine. If this happens, do not drive or use any tools or machines.

This medicine contains less than 1 mmol sodium (23 mg) per 5 ml, that is to say essentially ‘sodium-free’.

This medicine contains 4.70 mg sodium benzoate (E211) in each 5 ml.

• The usual starting dose ranges from 5 mg to 20 mg (5 ml to 20 ml) taken once a day.
• Some patients may need a lower starting dose.
• The usual long-term dose is 20 mg (20 ml) taken once a day.
• The maximal long-term dose is 40 mg (40 ml) taken once a day.

• The usual starting dose is 2.5 mg (2.5 ml) taken once a day.
• Your doctor will raise this amount step by step until the dose that is right for you has been achieved.
• The usual long-term dose is 20 mg (20 ml) each day, taken in one or two doses.
• The maximal long-term dose is 40 mg (40 ml) each day, divided in two doses.

Your dose of medicine will be changed depending on how well your kidneys are working:

• Moderate kidney problems - 5 mg to 10 mg (5ml to 10 ml) each day
• Severe kidney problems - 2.5 mg (2.5 ml) each day
• If you are having dialysis - 2.5 mg (2.5 ml) each day. On days you are not having dialysis, your dose may be changed depending on how low your blood pressure is.

Your dose will be decided by your doctor and will be based on how well your kidneys are working.

Experience in the use of enalapril in children with high blood pressure is limited.The dose will be worked out using the child’s weight and blood pressure.The usual starting doses are:

• Between 20 kg and 50 kg – 2.5 mg (2.5 ml) each day
• More than 50 kg – 5 mg (5 ml) each day.

The dose can be changed according to the needs of the child:

• A maximum of 20 mg (20 ml) daily can be used in children who are between 20 kg and 50 kg
• A maximum of 40 mg (40 ml) daily can be used in children who are more than 50 kg.

This medicine is not recommended in newborn babies (first few weeks after birth) and in children with kidney problems.

This medicine should be taken by mouth.Take Enalapril Oral Solution with a glass of water. Use the syringe supplied in the pack Where higher doses are to be administered, dosing cups should be considered.These can be provided by your pharmacist.

Instructions for use of syringe

1. To open the bottle, press the cap down and turn it anti-clockwise (Figure 1).
2. Put the syringe adaptor into the bottle neck (Figure 2).
3. Take the syringe and put it into the adaptor opening (Figure 3).
4. Turn the bottle upside down (Figure 4).
5. Fill the syringe with a small amount of solution by pulling the plunger down (Figure 4A).Then push the plunger upward in order to remove any possible bubbles (Figure 4B). Finally, pull the plunger down to the graduation mark corresponding to the quantity in millilitres (ml) prescribed by your doctor.This is given in ml (Figure 4C).
6. Turn the bottle the right way up (Figure 5A).
7. Remove the syringe from the adaptor (Figure 5B).
8. Put the end of the syringe into your mouth and push the plunger slowly back in to take the medicine (Figure 6).
9. Wash the syringe with water and let it dry before you use it again.
10. Close the bottle with the plastic screw cap – leave the syringe adaptor in the bottle

If you take more enalapril than you should, talk to your doctor or go to a hospital straight away.Take the medicine pack with you.The following effects may happen: feeling of light-headedness or dizziness.This is due to a sudden or excessive drop in blood pressure.

• If you forget to take a dose, skip the missed dose.
• Take the next dose as usual.
• Do not take a double dose to make up for a forgotten dose.

Do not stop taking your medicine unless your doctor tells you to.

• Swelling of your face, lips, tongue or throat which may cause difficulty in breathing or swallowing
• Swelling of your hands, feet or ankles
• If you develop a raised red skin rash (hives).

You should be aware that black patients are at increased risk of these types of reactions. If any of the above happen, stop taking Enalapril Maleate Oral Solution and talk to a doctor straight away.

When you start taking this medicine you may feel faint or dizzy. If this happens, it will help to lie down.This is caused by your blood pressure lowering. It should improve as you continue to take the medicine. If you are worried, please talk to your doctor.

Other side effects include:

Very Common (may affect more than 1 in 10 people)

• Feeling dizzy, weak or sick
• Blurred vision
• Cough.

Common (may affect up to 1 in 10 people)

• Light-headedness due to low blood pressure, changes in heart rhythm, fast heartbeat, angina or chest pain
• Headache, depression, fainting (syncope), change in sense of taste
• Shortness of breath
• Diarrhoea, abdominal pain
• Tiredness (fatigue)
• Rash, allergic reactions with swelling of the face, lips, tongue or throat with difficulty in swallowing or breathing
• High levels of potassium in the blood, increased levels of creatinine in your blood (both are usually detected by a test).

Uncommon (may affect up to 1 in 100 people)

• Flushing
• Sudden fall in blood pressure
• Fast or uneven heart beats (palpitations)
• Heart attack (possibly due to very low blood pressure in certain high-risk patients, including those with blood flow problems of the heart or brain)
• Stroke (possibly due to very low blood pressure in high-risk patients)
• Anaemia (including aplastic and haemolytic)
• Confusion, sleeplessness or sleepiness, nervousness
• Feeling your skin prickling or being numb
• Vertigo (spinning sensation)
• Ringing in your ears (tinnitus)
• Runny nose, sore throat or hoarseness
• Asthma-associated tightness in chest
• Slow movement of food through your intestine (ileus), inflammation of your pancreas
• Being sick (vomiting), indigestion, constipation, anorexia
• Irritated stomach (gastric irritations), dry mouth, ulcer
• Muscle cramps
• Impaired kidney function, kidney failure
• Increased sweating
• Itching or nettle rash
• Hair loss
• Generally feeling unwell (malaise), high temperature (fever)
• Impotence
• High level of proteins in your urine (measured in a test)
• Low level of blood sugar or sodium, high level of blood urea (all measured in a blood test).

Rare (may affect up to 1 in 1,000 people)

• ‘Raynaud’s phenomenon’ where your hands and feet may become very cold and white due to low blood flow
• Changes in blood values such as a lower number of white and red blood cells, lower haemoglobin, lower number of blood platelets
• Bone marrow depression
• Swollen glands in neck, armpit or groin
• Autoimmune diseases
• Strange dreams or sleep problems
• Accumulation of fluid or other substances in the lungs (as seen on X-rays)
• Inflammation of your nose
• Inflammation of the lungs causing difficulty breathing (pneumonia)
• Inflammation of the cheeks, gums, tongue, lips, throat
• Reduced amount of urine
• Rash that looks like targets (erythema multiforme)
• ‘Stevens-Johnson syndrome’ and ‘toxic epidermal necrolysis’ (serious skin conditions where you have reddening and scaling of your skin, blistering or raw sores), exfoliative dermatitis/erythroderma (severe skin rash with flaking or peeling of the skin), pemphigus (small fluid-filled bumps on the skin)
• Liver or gallbladder problems such as lower liver function, inflammation of your liver, jaundice (yellowing of the skin or eyes), high levels of liver enzymes or bilirubin (measured in a blood test)
• Enlargement of breasts in males (gynaecomastia).

Very Rare (may affect up to 1 in 10,000 people)

• Swelling in your intestine (intestinal angioedema).

Not known (frequency cannot be estimated from the available data)

• Overproduction of antidiuretic hormone, which causes fluid retention, resulting in weakness, tiredness or confusion
• A symptom complex has been reported which may include some or all of the following: fever, inflammation of the blood vessels (serositis/vasculitis), muscle pain (myalgia/myositis), joint pain (arthralgia/arthritis). Rash, photosensitivity or other skin manifestations may occur.

If you get any side effects, talk to your doctor or pharmacist or nurse.This includes any possible side effects not listed in this leaflet.You can also report side effects directly via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. By reporting side effects you can help provide more information on the safety of this medicine.

• The active substance is enalapril maleate. Each 5ml of the solution contains 5mg enalapril maleate.
• The other ingredients are citric acid monohydrate (E330), sodium citrate (E331), sodium benzoate (E211), sucralose (E995), strawberry flavour, and purified water.

Enalapril Maleate 5mg/5ml Oral Solution is a clear colourless solution. It comes in a brown glass bottle holding 150ml of solution with 10ml syringe and bottle adaptor.