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ramipril (Rx)Brand and Other Names:Altace

 
 
 

Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule

  • 1.25mg
  • 2.5mg
  • 5mg
  • 10mg
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Hypertension

Initial (not on diuretic): 2.5 mg PO qDay

Initial (with diuretic): 1.25 mg PO qDay

Maintenance: 2.5-20 mg/day PO qDay or divided q12hr

Heart Failure (Post-Myocardial Infarction)

Stable patients with CHF signs within a few days of acute MI

Initial: 2.5 mg PO q12hr; may titrate to 5 mg PO q12hr; decrease to 1.25 mg q12hr if hypotension occurs; monitor for >2 hr after initial dose and reduce concomitant diuretic if hypotension occurs

Maintenance: After 1 week, increase dose (if tolerated) to target dose of 5 mg q12hr

Myocardial Infarction/Stroke Prevention

Reduce risk of MI, stroke, or death from cardiovascular causes in patients ≥55 years

Initial: 2.5 mg PO qDay for 1 week, THEN 5 mg qDay for 3 weeks

Maintenance: Increase as tolerated to 10 mg qDay; for hypertensive or recently post-MI patients, give 5 mg PO BID

Dosing considerations

  • Reduce risk of MI, stroke, or death from cardiovascular causes in patients ≥55 years at high risk of developing a major cardiovascular event because of a history of coronary artery disease, stroke, or peripheral vascular disease, or of diabetes that is accompanied by at least 1 other cardiovascular risk factor (hypertension, elevated total cholesterol levels, low HDL levels, cigarette smoking, or documented microalbuminuria)

Diabetic Nephropathy (Off-label)

Initial (not on diuretic): 2.5 mg PO qDay

Initial (with diuretic): 1.25 mg PO qDay

Maintenance: 2.5-20 mg PO qDay; daily dose may be either increased or divided BID if antihypertensive effect is diminished toward the end of the dosing interval

Dosing Modifications

Renal impairment

  • CrCl <40 mL/min and concomitant diuretic therapy: Not to exceed 5 mg/day (25% of normal dose)
  • Renal/heart failure: 1.25 mg PO qDay; may increase to 1.25 mg q12hr and to a maximum dose of 2.5 mg q12hr depending on clinical response and tolerability
  • Renal failure and hypertension: 1.25 mg PO qDay initially; may titrate upward, not to exceed 5 mg/day
  • Geriatric patients: At increased risk for renal dysfunction; adjust dose to renal clearance and monitor closely

Dosing Considerations

Requires weeks for full effect; to start, use low dose and titrate every 1-2 weeks

qDay dosing may result in diminished antihypertensive effect at end of day in some patients; consider increase in dosage or dosing interval (q12hr)

If BP is not adequately treated, consider adding diuretic

Consider ACE inhibitor in high-risk patients, even if no hypertension or CHF

Abrupt discontinuance not associated with rapid increase in BP  

Administration

Swallow capsule whole; can also open capsule and sprinkle contents on small amount of applesauce or mixed in 120 mL of water or apple juice; mixture can be stored for <24 hours at room temperature or <48 hours under refrigeration

Safety and efficacy not established

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Interactions

Interaction Checker

ramipril and

No Results

     
     activity indicator 
    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Cough (7-8%)

            Hypotension (2-11%)

            1-10%

            Headache (1-5%)

            Angina pectoris (3%)

            Dizziness (2-4%)

            Nausea (2%)

            Vomiting (2%)

            Postural hypotension (2%)

            Syncope (2%)

            Vertigo (2%)

            Abnormal kidney function (1%)

            Diarrhea (1%)

            <1%

            Angioedema (0.3%)

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            Warnings

            Black Box Warnings

            Discontinue as soon as possible when pregnancy is detected; affects renin-angiotensin system, causing oligohydramnios, which may result in fetal injury and/or death

            Contraindications

            Hypersensitivity to drug or other ACE inhibitors

            Do not coadminister with aliskiren in patients with diabetes mellitus or with renal impairment (ie, GFR <60 mL/min/1.73 m²)

            Cautions

            Anaphylactoid and related reactions (head and neck/intestinal angioedema, anaphylaxis during desensitizing treatment with Hymenoptera venom, anaphylaxis during membrane exposure with high-flux membrane dialysis, and low-density lipoprotein apheresis with dextran sulfate absorption)

            (Rare) risk of hepatic failure, which starts as cholestatic jaundice and progresses to sometimes fatal fulminant hepatic necrosis; discontinue if patient develops jaundice or marked elevations of hepatic enzymes

            Excessive hypotension if on concomitant diuretics, hypovolemia, hyponatremia; increased risk in CHF patients; treat by placing patient in supine position and treating with IV infusion of physiologic saline if necessary

            Increased hypotension risk in patients undergoing surgery or during anesthesia with agents that produce hypotension; correct by volume expansion in such situations

            Coadministration with mTOR inhibitors (eg, temsirolimus) may increased risk for angioedema

            African American patients may have a smaller average reduction in BP than other populations

            Changes in renal function due to blockage of renin-angiotensin-aldosterone system; severe CHF patients are at increased risk for oliguria or progressive azotemia and (rarely) for acute renal failure or death; increase in BUN/SCr may occur in patients with unilateral or bilateral renal artery stenosis; monitor closely

            Reduction in RBC and hemoglobin content with rare cases of agranulocytosis, pancytopenia and bone marrow depression reported; collagen-vascular disease (SLE, scleroderma) patients with impaired renal function are at increased risk; monitor closely

            Dual blockade of the renin angiotensin system with ARBs, ACE inhibitors, or aliskiren associated with increased risk for hypotension, hyperkalemia, and renal function changes (including acute renal failure) compared to monotherapy

            Risk of hyperkalemia, especially in patients with renal impairment, DM, concomitant use of K+-elevating drugs

            Reversible, persistent, nonproductive cough thought to be due to inhibition of degradation of endogenous bradykinin

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            Pregnancy & Lactation

            Pregnancy category: D

            Discontinue as soon as pregnancy detected; during the second and third trimesters of pregnancy, therapy can result in fetal injury (eg, hypotension, neonatal skull hypoplasia, anuria, reversible and irreversible renal failure) and death

            Lactation: Possibly excreted in breast milk; nursing not recommended

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Competitively inhibits angiotensin-converting enzymes, resulting in decreased plasma angiotensin II concentrations; BP may be reduced in part through decreased vasoconstriction, increased renin activity, and decreased aldosterone secretion; increases renal blood flow

            Absorption

            Bioavailability: 50-60%; not affected by food

            Peak plasma time: 1 hr (ramipril); 2-4 hr (ramiprilat)

            Distribution

            Protein bound: 73% (ramipril), 56% (ramiprilat)

            Metabolism

            Metabolized by liver through cleavage of ester group

            Metabolite: Ramiprilat (active metabolite)

            Elimination

            Half-life: 13-17 hr (ramiprilat)

            Excretion: Urine (60%), feces (40%)

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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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