ramipril: prescribing and clinical use
Focused clinical detail for use alongside current product information, local policy and patient-specific assessment.
ramipril: clinical details
Prescribing considerations
- Assess volume or salt depletion and the risk of hypotension.
- Review renal and hepatic function, frailty, diabetes, concomitant medicines and previous angioedema.
- Use additional caution around major surgery, anaesthesia, desensitisation and extracorporeal treatments.
- If angioedema is suspected, discontinue ramipril immediately and do not restart it.
Contraindications and cautions
- Hypersensitivity to ramipril, an excipient or another ACE inhibitor.
- Hereditary, idiopathic or previous ACE-inhibitor/angiotensin-receptor-antagonist-associated angioedema.
- Concomitant sacubitril/valsartan use or switching without the required separation period.
- Significant bilateral renal artery stenosis, or stenosis affecting a single functioning kidney.
- Second or third trimester of pregnancy.
- Hypotensive or haemodynamically unstable states.
- Specified extracorporeal treatments involving negatively charged surfaces.
- Concomitant aliskiren in patients with diabetes or qualifying renal impairment.
Monitoring
- Check blood pressure, renal function, potassium and sodium before treatment and after initiation or prescription changes.
- Repeat checks during acute illness that may compromise renal function and periodically once stable.
- Monitor more frequently with heart failure, kidney disease, older age, diabetes or interacting medicines.
- Investigate clinically important creatinine or potassium increases.
Clinical pharmacology
Ramipril is a prodrug converted to ramiprilat. Ramiprilat inhibits ACE, reducing angiotensin II and aldosterone while slowing bradykinin breakdown. Metabolites are cleared mainly through the kidneys.
Formulation and product differences
- The selected tablet contains lactose, can be divided into equal halves and should not be chewed or crushed.
- The selected capsule contains gelatin and colourants. Opening capsules for swallowing difficulty is an off-label option, and the contents may taste unpleasant.
- Licensed oral solutions vary in concentration, excipients, measuring devices, tube suitability, refrigeration and expiry after opening; check the specific product information.
- Some oral solutions can be given through specified NG or PEG tubes under product-specific instructions.
ramipril preparations and strengths
Capsule
Route: Oral
Strengths: 1.25 mg, 2.5 mg, 5 mg, 10 mg
Oral solution
Route: Oral
Strengths: 2.5 mg/5 mL, 5 mg/5 mL, 10 mg/5 mL
ramipril interactions
Tell the prescriber or pharmacist about all medicines, supplements and salt substitutes. Important examples include:
Sacubitril/valsartan
The combination is contraindicated because it substantially increases angioedema risk.
Potassium supplements, potassium salt substitutes and potassium-sparing diuretics
These may dangerously raise blood potassium.
NSAIDs such as ibuprofen or indometacin
These can reduce the blood-pressure effect and increase kidney impairment and high potassium risks.
Sources
These sources were used to prepare and review this medicine page.
Prepared and reviewed by the iatroX editorial team.