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Pharmacologic class: Angiotensinconverting enzyme (ACE) inhibitor
Therapeutic class: Antihypertensive
Pregnancy risk category D
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.
Capsules: 1.25 mg, 2.5 mg, 5 mg, 10 mg
Indications and dosages
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.
• Renal impairment
• Concurrent diuretic use
• Angina associated with syndrome X
• Mitral insufficiency
• Renovascular hypertension
• Diabetic or nondiabetic nephropathy
• Hypersensitivity to drug or other ACE inhibitors
• Angioedema with previous ACE inhibitor use or history of hereditary or idiopathic angioedema
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
• risk factors for development of hyperkalemia (including renal insufficiency, diabetes mellitus, concurrent use of potassium-sparing diuretics, potassium supplements, or potassium-containing salt substitutes)
• family history of angioedema
• concurrent immunosuppressant or diuretic therapy
• black patients
• elderly patients
• pregnant patients
• breastfeeding patients (avoid use)
• children (safety not established).
• 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.
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
Musculoskeletal: muscle cramps
Respiratory: cough, asthma, upper respiratory tract infection, bronchospasm
Skin: rash, pruritus, urticaria, photosensitivity, angioedema, anaphylactoid reactions
Drug-drug. Diuretics, other antihypertensives: increased hypotension
Gold (sodium aurothiomalate): increased risk of rare nitritoid reactions (including facial flushing, nausea, vomiting, and hypotension)
Lithium: increased lithium blood level and risk of toxicity
Nonsteroidal anti-inflammatory drugs: may result in deterioration of renal function, including acute renal failure and attenuated ACE inhibitor antihypertensive effect
Potassium-sparing diuretics, potassium supplements: increased risk of hyperkalemia
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
• 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 hyperkalemia.
☞ Stay alert for signs and symptoms of hypersensitivity reactions (including angioedema), especially in black patients after first dose
• Evaluate for dry, nonproductive cough.
• 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.
• 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.
Pharmacologic: ace inhibitors
Time/action profile (effect on BP—single dose†)
|PO||within 1–2 hr||3–6 hr||24 hr|
Adverse Reactions/Side Effects
Central nervous system
- cough (most frequent)
- hypotension (most frequent)
- chest pain
- impaired renal function
Fluid and Electrolyte
- angioedema (life-threatening)
Drug-Drug interactionExcessive hypotension may occur with concurrent use of diuretics.Additive hypotension with other antihypertensive agents.↑ risk of hyperkalemia with concurrent use of potassium supplements,potassium-sparing diuretics, or potassium-containing salt substitutes.↑ risk of hyperkalemia, renal dysfunction, hypotension, and syncope with concurrent use of angiotensin II receptor antagonists or aliskiren ; avoid concurrent use with aliskiren in patients with diabetes or CCr <60 mL/minNSAIDs and selective COX-2 inhibitors may blunt the antihypertensive effect and ↑ the risk of renal dysfunction.↑ levels and may ↑ the risk of lithium toxicity.↑ risk of renal dysfunction when used with telmisartan ; concurrent use not recommended.↑ risk of angioedema with temsirolimus or everolimus
Heart Failure Post-Myocardial Infarction
Reduction in Risk of MI, Stroke, and Death from Cardiovascular Causes
Renal ImpairmentOral (Adults) CCr < 40 mL/min—Initiate therapy at 1.25 mg once daily, may be slowly titrated up to 5 mg/day in 1–2 divided doses.
Availability (generic available)
- Hypertension: Monitor BP and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes.
- Monitor frequency of prescription refills to determine compliance.
- Assess patient for signs of angioedema (dyspnea, facial swelling).
- Heart Failure: Monitor weight and assess patient routinely for resolution of fluid overload (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
- Lab Test Considerations: Monitor renal function. May cause ↑ BUN and serum creatinine.
- May cause hyperkalemia.
- Monitor CBC periodically during therapy in patients with collagen vascular disease and/or renal disease. May rarely cause ↓ in hemoglobin and hematocrit as well as neutropenia and eosinophilia.
- May cause ↑ AST, ALT, alkaline phosphatase, serum bilirubin, uric acid, and glucose.
Potential Nursing DiagnosesDecreased cardiac output (Indications, Side Effects)
Deficient knowledge, related to medication regimen (Patient/Family Teaching)
Noncompliance (Patient/Family Teaching)
- Correct volume depletion, if possible, before initiation of therapy. Precipitous drop in BP during first 1–3 hr following first dose may require volume expansion with normal saline. Discontinuing diuretic therapy or cautiously increasing salt intake 2–3 days prior to initiation may decrease risk. Monitor closely for at least 1 hr after BP has stabilized. Resume diuretics if BP is not controlled.
- Oral: Capsules may be opened and sprinkled on applesauce, or dissolved in 4 oz water or apple juice for patients with difficulty swallowing. Effectiveness is same as capsule. Pre-prepared mixtures can be stored for up to 24 hr at room temperature or up to 48 hr if refrigerated.
- Emphasize the importance of continuing to take medication as directed at the same time each day, even if feeling well. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses. Warn patient not to discontinue ACE inhibitor therapy unless directed by health care professional.
- Caution patient to avoid salt substitutes containing potassium or foods containing high levels of potassium or sodium unless directed by health care professional (see ).
- Caution patient to change positions slowly to minimize orthostatic hypotension. Use of alcohol, standing for long periods, exercising, and hot weather may increase orthostatic hypotension.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications especially cough, cold, or allergy medications.
- May cause dizziness. Caution patient to avoid driving and other activities requiring alertness until response to medication is known.
- Advise patient to inform health care professional of medication regimen prior to treatment or surgery.
- Instruct patient to notify health care professional if rash; mouth sores; sore throat; fever; swelling of hands or feet; irregular heartbeat; chest pain; dry cough; hoarseness; swelling of face, eyes, lips, or tongue; or if difficulty swallowing or breathing occurs. Persistent dry cough may occur and may not subside until medication is discontinued. Consult health care professional if cough becomes bothersome. Also notify health care professional if nausea, vomiting, or diarrhea occurs and continues.
- Advise women of childbearing age to use contraception and notify health care professional if pregnancy is planned or suspected or if breastfeeding. If pregnancy is detected, discontinue medication as soon as possible.
- Emphasize the importance of follow-up examinations to evaluate effectiveness of medication.
- Hypertension: Encourage patient to comply with additional interventions for hypertension (weight reduction, low-sodium diet, discontinuation of smoking, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension.
- Instruct patient and family on correct technique for monitoring BP. Advise them to check BP at least weekly and to report significant changes to health care professional.
- Decrease in BP without appearance of side effects.
- Reduction in risk of myocardial infarction, stroke, or death from cardiovascular causes in patients at high-risk for these events.
- Reduction of risk of death, progression of heart failure, or heart failure-related hospitalizations following myocardial infarction.