Adult Dosing
Hypertension
Adults: Without concomitant diuretics
- Initial: 2.5 mg PO qd
- Titrate: Adjust dosage based on blood pressure response; usually at intervals of at least 2 weeks
- Maintenance: 2.5-20 mg PO qd or two equally divided doses (Max: 20 mg/day)
Note:
- Consider adding a diuretic if blood pressure is not controlled with ramipril alone
Reduction in risk of MI, stroke, and death from cardiovascular causes
- Initial: 2.5 mg qd x 1 wk, then 5 mg qd for next 3 wks, and then titrate to a maintenance dose of 10 mg qd, as tolerated
Note:
- May be given as a divided dose if the patient is hypertensive or recently post MI
Heart failure post-myocardial infarction
- Initial: 2.5 mg PO bid
- If hypotension occurs at 5 mg/day dose, taper the dose to 1.25 mg PO bid x 1 wk, then titrate the dose as tolerated to 5 mg PO bid, with dosage increases at 3-week intervals
Pediatric Dosing
- Safety and efficacy in pediatric patients have not been established
[Outline]
Renal Dose Adjustment (Based on CrCl)
<40 mL/min
- Hypertension:
- Initial: 1.25 mg PO qd
- Titrate the dose as per the blood pressure response or up to a maximum of 5 mg/day
- Heart failure following myocardial infarction:
- Initial: 1.25 mg PO qd
- Titrate the dose based on clinical response and tolerability to 1.25 mg PO bid and up to a maximum of 2.5 mg PO bid
- Hemodialysis: Give 20% usual dose as supplement
Hepatic Dose Adjustment
- Hepatic impairment: Dose adjustments not defined; caution advised
See Supplemental Patient Information
- ACE inhibitors can cause fetal/neonatal morbidity and mortality when administered to pregnant women [US Black Box Warning]
- Angioedema involving the extremities, face, lips, tongue, glottis, larynx and also intestinal angioedema have been reported in patients treated with ACE inhibitors. If airway obstruction occurs, promptly institute emergency therapy. The incidence of angioedema is higher in black patients receiving ACE inhibitors
- Increased risk for angioedema has been reported in patients taking concomitant mTOR inhibitor therapy
- Rarely, ACE inhibitors can cause cholestatic jaundice progressing to fulminant hepatic necrosis and sometimes death; discontinue therapy if marked elevations of hepatic enzymes occur
- Levels of BUN and serum creatinine may be elevated in hypertensive patients with renal impairment after initiation of therapy
- Concomitant use with diuretics may also increase BUN levels and serum creatinine in hypertensive patients without apparent pre-existing renal vascular disease; this risk is high in patients with pre-existing renal impairment. In such cases, dosage reduction of ramipril and/or discontinuation of the diuretic may be required
- Reductions in RBC count, hemoglobin content, white blood cell or platelet counts and in rare cases agranulocytosis, pancytopenia, and bone marrow depression may occur during therapy. Patients with collagen vascular disease and renal impairment are at a higher risk for hematological complications
- Ramipril may cause symptomatic hypotension, either after the initial dose or when the dose has been increased. This occurs mostly in patients who have been volume- or salt-depleted due to prolonged diuretic therapy, dietary salt restriction, dialysis, diarrhea, or vomiting
- Excessive hypotension may occur in patients with CHF, with or without associated renal insufficiency, which may be associated with oliguria or azotemia and rarely with acute renal failure and death; initiate therapy under close medical supervision
- The use of ramipril during the second and third trimesters of pregnancy has been associated with fetal and neonatal injury including hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, and death. Oligohydramnios has also been reported, mostly associated with decreased fetal renal function
- Concomitant use of telmisartan should be avoided because it is associated with a higher incidence of clinically significant renal dysfunction (death, doubling of serum creatinine, or dialysis)
- Monitor renal and hepatic functions prior to and during therapy
- Hyperkalemia may occur in hypertensive patients receiving ramipril
- A persistent dry cough may occur during therapy and generally does not subside unless the drug is discontinued
- Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function. Closely monitor blood pressure, renal function and electrolytes in patients on ramipril and other agents that affect the RAS
Cautions: Use cautiously in
- Renal artery stenosis
- CAD
- Severe liver cirrhosis and/or ascites
- Aortic stenosis
- Hyponatremia
- Hypertrophic cardiomyopathy
- Elderly patients
- Cerebrovascular disease
- Surgery/anesthesia (hypotension may be exaggerated)
- Dialysis with high-flux membranes
- LDL apheresis with dextran
- Antigen desensitization therapy
Supplemental Patient Information
- Advise female patients of childbearing age to report pregnancies to their physicians as soon as possible and inform them about the consequences of exposure to ACE inhibitors during pregnancy
- Caution patients about the light-headedness that may occur during the first days of therapy. Advise patients to report such occurrences to their physicians. Inform patients to stop treatment if syncope occurs, and to follow up with their health care providers
- Advise patients not to take salt substitutes containing potassium without consulting their physician
- Instruct patients to promptly report any indication of infection such as sore throat and fever, which could be a sign of neutropenia
Pregnancy Category:C (first trimester), D (second and third trimesters)
Breastfeeding: An alternate drug may be preferred, especially while nursing a newborn or preterm infant. This information is based upon LactMed database (available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT last accessed 11 April 2011). As per manufacturer's data, women receiving ramipril should not breast feed.
Pricing data from www.DrugStore.com in U.S.A.
- Altace 10 MG CAPS [Bottle] (MONARCH PHARMACEUTICALS)
30 mg = $90.99
90 mg = $250.96 - Altace 5 MG CAPS [Bottle] (MONARCH PHARMACEUTICALS)
30 mg = $81.99
90 mg = $217.98 - Ramipril 5 MG CAPS [Bottle] (WATSON LABS)
30 mg = $52.99
90 mg = $149.99 - Altace 2.5 MG CAPS [Bottle] (MONARCH PHARMACEUTICALS)
30 mg = $77.99
90 mg = $213.98 - Ramipril 1.25 MG CAPS [Bottle] (LUPIN PHARMACEUTICALS)
100 mg = $99.99
300 mg = $275.97 - Altace 1.25 MG CAPS [Bottle] (MONARCH PHARMACEUTICALS)
30 mg = $67.99
90 mg = $185.97 - Ramipril 2.5 MG CAPS [Bottle] (WATSON LABS)
30 mg = $49.99
90 mg = $139.97 - Ramipril 10 MG CAPS [Bottle] (WATSON LABS)
30 mg = $62.99
90 mg = $179.97
Warning: This pricing information is subject to change at the sole discretion of DS Pharmacy. For the most current and up-to-date pricing information, please visit drugstore.com.
