Fixed-dose combination: ACE inhibitor plus thiazide diuretic
ATC code: C09BA02 (Enalapril and diuretics)
Enalapril inhibits ACE – angiotensin I is not converted to active angiotensin II, aldosterone falls, vessels dilate, and BP drops. Hydrochlorothiazide excretes sodium, chloride, and water via distal tubules. Enalapril offsets thiazide-induced potassium loss and RAAS activation.
Second line
Essential hypertension uncontrolled on enalapril monotherapy. Per ESH/ 2023 and SEH-LELHA 2023, ACE inhibitor + thiazide is a well-proven second-line pair with long-term outcome data (HOPE, PROGRESS). Dose: 10/25, 20/12.5, 20/25 mg once daily. Full effect at 2-4 weeks. In Black patients, ACE inhibitor efficacy is lower than CCBs or thiazides in monotherapy, but the thiazide component of the combination compensates.
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Contraindicated from the 2nd trimester (ACE inhibitor fetopathy: oligohydramnios, fetal renal failure, skull hypoplasia). Switch to methyldopa, labetalol, or slow-release nifedipine in advance.
Enalapril is compatible (RID 0.2%, Hale L2). High-dose thiazide may reduce milk supply in the first postpartum weeks; at standard 12.5 mg no effect is typical. After 6-8 weeks of breastfeeding the combination is well tolerated.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
Enalapril + Hydrochlorothiazide is evaluated for the following indications with varying evidence strength: Hypertension (evidence tier A). See the full indication matrix with dosing and citations above on this page.
Common side effects of Enalapril + Hydrochlorothiazide (≥ 1 in 100): Dry cough (10-15%), Dizziness, Hypotension, Hyperkalemia, Hyponatremia, Hyperuricemia. See the Safety section for uncommon and serious reactions.
FDA category D. Contraindicated from the 2nd trimester (ACE inhibitor fetopathy: oligohydramnios, fetal renal failure, skull hypoplasia). Switch to methyldopa, labetalol, or slow-release nifedipine in advance.
Enalapril is compatible (RID 0.2%, Hale L2). High-dose thiazide may reduce milk supply in the first postpartum weeks; at standard 12.5 mg no effect is typical. After 6-8 weeks of breastfeeding the combination is well tolerated.
Enalapril + Hydrochlorothiazide is contraindicated in: Hypersensitivity; History of angioedema (including hereditary); Pregnancy (2nd-3rd trimester); Severe hepatic and renal impairment; Bilateral renal artery stenosis. Full list in the Safety section.