ramipril (ram´
pril),drug class: angiotensin-converting enzyme (ACE) inhibitor;
action: selectively suppresses renin-angiotensin-aldosterone system; inhibits ACE; prevents conversion of angiotensin I to angiotensin II; results in dilation of arterial and venous vessels;
uses: hypertension, alone or in combination with thiazide diuretics; congestive heart failure immediately after myocardial infarction.
ramipril
Altace, Tritace (UK)
Pharmacologic class: Angiotensin-converting enzyme (ACE) inhibitor
Therapeutic class: Antihypertensive
Pregnancy risk category C (first trimester), D (second and third trimesters)
FDA Boxed Warning
• When used during second or third trimester of pregnancy, drug may cause fetal harm or death. Discontinue as soon as pregnancy is detected.
Action
Inhibits conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. Increases plasma renin levels and reduces aldosterone levels, causing systemic vasodilation and decreased cardiac output.
Availability
Capsules: 1.25 mg, 2.5 mg, 5 mg, 10 mg
⊘Indications and dosages
➣ Hypertension
Adults: Initially, 2.5 mg P.O. daily in patients not receiving diuretics; may increase dosage slowly p.r.n. according to response. For maintenance, 2.5 to 20 mg/day P.O. as a single dose or in two equally divided doses. If ramipril alone doesn't control blood pressure, a diuretic may be added.
➣ To reduce the risk of myocardial infarction (MI), cerebrovascular accident, or death from cardiovascular causes
Adults: Initially, 2.5 mg P.O. daily for 1 week, followed by 5 mg P.O. daily for the next 3 weeks, then increased as tolerated to a maintenance dosage of 10 mg P.O. daily. In hypertensive patients and those who've had a recent MI, may divide maintenance dose.
➣ Heart failure after MI
Adults: Initially, 2.5 mg P.O. b.i.d.; may decrease to 1.25 mg b.i.d. if higher dosage causes hypotension. Titrate toward target dosage of 5 mg b.i.d. at 3-week intervals.
Dosage adjustment
• Renal impairment
• Concurrent diuretic use
Off-label uses
• Angina associated with syndrome X
• Atherosclerosis
• Mitral insufficiency
• Renovascular hypertension
• Diabetic or nondiabetic nephropathy
• Erythrocytosis
Contraindications
• Hypersensitivity to drug or other ACE inhibitors
• Angioedema with previous ACE inhibitor use
• Pregnancy (second and third trimesters)
Precautions
Use cautiously in:
• autoimmune diseases, aortic stenosis, hypertrophic cardiomyopathy, cerebrovascular or cardiac insufficiency, collagen vascular disease, febrile illness, hepatic or renal impairment, hypotension, neutropenia, chronic cough, proteinuria, renal artery stenosis
• family history of angioedema
• concurrent immunosuppressant or diuretic therapy
• black patients
• elderly patients
• pregnant (first trimester) or breastfeeding patients
• children (safety not established).
Administration
• If possible, discontinue diuretics 2 to 3 days before ramipril therapy begins to prevent severe hypotension.
• If patient can't swallow capsule, open it and mix contents in water or apple juice or sprinkle in small amount of applesauce.
• Know that drug may be used alone or with other antihypertensives.
| Route | Onset | Peak | Duration |
| P.O. | 1-2 hr | 2-4 hr | 24 hr |
Adverse reactions
CNS: dizziness, light-headedness, fatigue, headache, vertigo, asthenia
CV: hypotension, orthostatic hypotension, angina pectoris, tachycardia, MI, heart failure
EENT: blurred vision, sinusitis
GI: nausea, vomiting, diarrhea
Hematologic: purpura, agranulocytosis
Metabolic: hyperkalemia
Musculoskeletal: muscle cramps
Respiratory: cough, asthma, upper respiratory tract infection, bronchospasm
Skin: rash, pruritus, urticaria, photosensitivity, angioedema, anaphylactoid reactions
Other: fever
Interactions
Drug-drug. Allopurinol: increased risk of hypersensitivity reaction
Antacids: decreased ramipril absorption
Digoxin, lithium: increased blood levels and risk of toxicity from these drugs
Diuretics, other antihypertensives: increased hypotension
Indomethacin: reduced hypotensive effect of ramipril
Phenothiazines: increased pharmacologic effects of ramipril
Potassium-sparing diuretics, potassium supplements: increased risk of hyperkalemia
Tetracyclines: decreased tetracycline absorption
Drug-diagnostic tests. Alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase, bilirubin, blood urea nitrogen, creatinine, potassium: increased levels
Drug-food. Any food: decreased rate (but not extent) of drug absorption
Salt substitutes containing potassium: increased risk of hyperkalemia
Drug-herbs. Capsaicin: increased incidence of cough
Ephedra (ma huang): decreased drug efficacy, exacerbation of hypertension
Yohimbe: interference with drug's antihypertensive effect
Drug-behaviors. Alcohol use: increased hypotension
Patient monitoring
• Assess vital signs and cardiovascular status. Ask patient if he's experiencing angina.
• Monitor CBC and liver function tests.
• Closely monitor potassium level. Watch for signs and symptoms of hycClosely monitor potassium level. Watch for signs and symptoms of hyperkalemia.
☞ Stay alert for signs and symptoms of hypersensitivity reactions (including angioedema), especially in black patients after first dose
• Evaluate for dry, nonproductive cough.
Patient teaching
• Tell patient he may take with or without food.
☞ Instruct patient to immediately report swelling of tongue or face or difficulty breathing.
• Teach patient how to monitor and record blood pressure.
• Tell patient drug may cause dry, nonproductive cough. Instruct him to report this problem if it becomes bothersome.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
• Advise patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood pressure decrease.
• Inform patient that excessive fluid loss (as from sweating, vomiting, or diarrhea) and inadequate fluid intake increase risk of light-headedness (especially in hot weather).
• Tell patient to avoid salt substitutes containing potassium and herbs.
• Advise female patient to tell prescriber if she is pregnant. Caution her not to take drug during third trimester or when breastfeeding.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.
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