ramipril

ramipril /ra·mi·pril/ (rah-mi´pril) an angiotensin-converting enzyme inhibitor used in treatment of hypertension and congestive heart failure and the prevention of a major cardiovascular event in high-risk patients.

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ramipril (ram´pril),

n brand name: Altace;
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.

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ramipril

an angiotensin-converting enzyme inhibitor used in the management of heart failure in dogs.

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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.