ramipril

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 or history of hereditary or idiopathic angioedema

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

• 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).

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.

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. 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

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 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.

• 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.