Ramipril is an ACE inhibitor that works similarly to captopril in terms of pharmacology and blocks the production of angiotensin II from angiotensin I.

• Heart failure post-myocardial infarction:
  • It is employed to treat heart failure (HF) following myocardial infarction (MI)
• Hypertension:
  • It is used in the treatment of hypertension
• Reduction of myocardial infarction, stroke, and death:
  • In individuals under the age of 55 who are at a high risk of experiencing serious cardiovascular events, it is used to lower the risk of MI, stroke, and mortality.
• Off Label Use Ramipril in Adults:
• Also used in:
  • Stable coronary artery disease
  • Non–ST-elevation acute coronary syndrome
  • ST-elevation acute coronary syndrome
  • Heart failure with reduced ejection fraction

Ramipril dose in adults

• If you're taking another medicine called a diuretic along with Ramipril, your doctor might suggest stopping or reducing the diuretic when you start Ramipril.
• If you can't stop or reduce the diuretic, your doctor might give you a smaller amount of Ramipril at first.
• They'll keep a close watch on your blood pressure until it's stable.
• This is to make sure your blood pressure doesn't drop too low when you start Ramipril.

Treatment of Heart failure post-myocardial infarction:

• Start with an initial dose of 2.5 mg taken orally twice a day.
• If you experience low blood pressure (hypotension), your doctor may lower the dose to 1.25 mg taken twice daily.
• Stick to the initial dose for one week.
• After that, your doctor will gradually increase the dose every three weeks, as long as you tolerate it well.
• The goal is to reach a target dose of 5 mg taken twice daily.

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Ttreatment of Hypertension:

• Begin with an initial dose of 2.5 mg taken orally once a day.
• After 2 to 4 weeks, your doctor will assess your response to the medication.
• They may gradually increase the dose based on how you're doing.
• The maximum daily dose can go up to 20 mg, which may be divided into one or two doses per day.

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Treatment of reduction in risk of MI, stroke, and death from cardiovascular causes:

• Start with an initial dose of 2.5 mg taken orally once a day for one week.
• After the first week, increase the dose to 5 mg taken orally once a day for the next three weeks.
• If you tolerate this dose well, your doctor may further increase it as needed.
• The maintenance dose is typically 10 mg taken orally once a day.
• In some cases, particularly for hypertensive (high blood pressure) or recently post-heart attack (MI) patients, the doctor may divide the daily dose into smaller doses as necessary.

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Dose in the treatment of Heart failure with reduced ejection fraction (off-label):

• Begin with an initial dose of 1.25 to 2.5 mg taken orally once a day.
• The goal is to reach a target dose of 10 mg taken once a day.
• If you have a condition called volume depletion (when your body doesn't have enough fluids), your doctor will start with an even lower initial dose of 1.25 mg taken once a day.

Ramipril Dose in Childrens

Treatment of hypertension:

The recommended dose of ramipril for children is unknown. The typical dosage is 2.5 mg (5ml) once daily, though.

Ramipril Pregnancy Risk Factor: D

• Ramipril, and other drugs that affect the renin-angiotensin system, can harm and even lead to the death of a developing fetus.
• If a woman becomes pregnant while taking Ramipril, she should stop using it as soon as she knows she's pregnant.
• Ramipril can pass through the placenta to the developing baby, potentially causing problems.
• These drugs can cause a condition called oligohydramnios in pregnant women, which results from reduced fetal kidney function and can lead to underdeveloped fetal lungs and skeletal abnormalities.
• Using these drugs during pregnancy can also lead to anuria (lack of urine production), low blood pressure, kidney failure, underdeveloped skulls, and fetal or neonatal death.
• There may be birth defects if a woman takes an ACE inhibitor like Ramipril during the first trimester of pregnancy, but this could also be due to the woman's underlying medical condition.
• Even if the problems with amniotic fluid (oligohydramnios) aren't obvious until later in pregnancy, the fetal harm may already be done.
• Babies exposed to ACE inhibitors in the womb should be monitored for high levels of potassium, low blood pressure, and reduced urine production.
• In severe cases, treatments like exchange transfusions or dialysis might be necessary, but there's limited information on how effective these treatments are for newborns.
• ACE inhibitors are generally not recommended for treating uncomplicated hypertension during pregnancy.
• Some guidelines specifically say ACE inhibitors should not be used for hypertension or chronic heart failure during pregnancy.
• In general, it's best to avoid ACE inhibitors in women of reproductive age.
• If a pregnant woman needs treatment for hypertension or chronic heart failure, other medications should be considered instead.

Ramipril use during breastfeeding:

• After a single oral dose of 10 mg of Ramipril, neither Ramipril itself nor its breakdown products were found in breast milk.
• However, it's uncertain whether taking Ramipril multiple times might lead to detectable levels in breast milk.
• The manufacturer does not recommend breastfeeding while using Ramipril.
• If you are taking Ramipril and considering breastfeeding, it's important to consult with your healthcare provider. They can provide guidance on the best approach to ensure the safety of both you and your baby.

Ramipril dose in Kidney disease:

For Patients with Creatinine Clearance (CrCl) Greater than 40 mL/minute:

• No dosage adjustment is necessary.

For Patients with CrCl Less than 40 mL/minute:

• Administer 25% of the normal dose.

For Heart Failure Post-Myocardial Infarction:

• Initial dose: 1.25 mg once daily.
• Your doctor may increase the dose to 1.25 mg twice daily.
• If needed and tolerated, the maximum dose can be increased to 2.5 mg twice daily.

For Hypertension:

• Initial dose: 1.25 mg once daily.
• Your doctor will adjust the dose as needed and as you tolerate it.
• The maximum daily dose should not exceed 5 mg.

For Renal Artery Stenosis:

• Begin with an initial dose of 1.25 mg once daily.
• Your doctor may adjust the dose based on your response and tolerance.

Please note that these are general guidelines, and your specific dosing may vary based on your individual medical condition and how well you respond to the medication.

Ramipril Dose in Liver disease:

• The manufacturer's instructions for Ramipril don't include specific dosage adjustments.
• However, it's important to know that Ramipril is mainly processed by the liver.
• If someone has liver problems, their body might not break down Ramipril properly.
• This could lead to very high levels of Ramipril in their blood, which could be risky.
• If you have liver issues, it's essential to talk to your doctor about the right dosage or whether Ramipril is suitable for you.

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• Data from trials on hypertension and heart failure are included in the frequency ranges.
• Patients with heart failure have often been found to experience higher rates of adverse effects.
• In this demographic, however, there are also more harmful effects linked to placebos.

Common Side Effects of Ramipril Include:

• Cardiovascular:
  • Hypotension
• Respiratory:
  • Increased Cough

Less Common Side Effects of Ramipril Include:

• Cardiovascular:
  • Syncope
  • Orthostatic Hypotension
  • Angina Pectoris
• Central Nervous System:
  • Dizziness
  • Vertigo
  • Fatigue
  • Noncardiac Chest Pain
  • Headache
• Endocrine & Metabolic:
  • Hyperkalemia
• Gastrointestinal:
  • Vomiting
  • Nausea
• Renal:
  • Renal Insufficiency
  • Increased Serum Creatinine
  • Increased Blood Urea Nitrogen
• Respiratory:
  • Cough

Contraindication to Ramipril Include:

For All Patients:

• Hypersensitivity or severe allergic reactions to Ramipril, other ACE inhibitors, or any component of the medication.

For All Patients, Especially Those with Certain Medical Conditions:

• Hereditary or unexplained angioedema (swelling under the skin) or a history of angioedema related to previous use of ACE inhibitors.
• Concomitant use with aliskiren in patients with diabetes mellitus.
• Concomitant use or use within 36 hours of switching to or from a neprilysin inhibitor (like sacubitril).

Additional Contraindications in Canadian Labeling (Not in US Labeling):

• Hemodynamically relevant bilateral renal artery stenosis or unilateral stenosis in a single functioning kidney.
• Hypotensive (very low blood pressure) or hemodynamically unstable states.
• Concomitant use with aliskiren in patients with moderate to severe renal impairment (a certain level of kidney function) or congestive heart failure who are hypotensive.
• Concomitant use with angiotensin II receptor blockers (ARBs) in patients with diabetes and end-organ damage, moderate to severe renal impairment, hyperkalemia (high blood potassium levels), or congestive heart failure who are hypotensive.
• Combination with extracorporeal treatments that involve contact of blood with negatively charged surfaces (such as certain types of dialysis or apheresis).
• Use during pregnancy.
• Use during breastfeeding.

These contraindications mean that Ramipril should not be used in individuals who meet these criteria because it could be harmful or not effective for them.

Warnings and precautions

Angioedema

• When taking ACE inhibitors like Ramipril, angioedema can rarely happen at any time during treatment.
• Angioedema can affect the head and neck, potentially blocking the airway, or it can involve the intestine, leading to abdominal pain.
• Black patients, as well as those with hereditary angioedema or previous angioedema due to ACE inhibitors, might have a higher risk.
• The risk can also go up if you're using certain other medications like mTOR inhibitors (e.g., everolimus) or neprilysin inhibitors (e.g., sacubitril).
• If the tongue, glottis (part of the throat), or larynx (voice box) is involved in angioedema, it can cause airway blockage, which is very dangerous.
• Patients with a history of airway surgery are at a greater risk of airway blockage during angioedema.
• It's crucial to monitor for angioedema symptoms closely, especially if it affects the airway. If this happens, quick and appropriate treatment is vital.
• If you've had angioedema before because of ACE inhibitor therapy, using Ramipril is not recommended because it could happen again.

Cholestatic jaundice

• ACE inhibitors like Ramipril can very rarely lead to a condition called cholestatic jaundice.
• Cholestatic jaundice can cause a yellowing of the skin and eyes (jaundice) due to problems with the flow of bile in the liver.
• In some severe cases, it can progress to a serious liver condition called fulminant hepatic necrosis, which can be fatal.
• If you experience a significant increase in liver enzymes or notice jaundice (yellowing of the skin or eyes), you should stop taking Ramipril immediately.
• It's crucial to seek medical attention promptly if you have these symptoms to assess the severity of the liver problem and determine the appropriate course of action.

Cough:

• Some people taking ACE inhibitors like Ramipril may develop a specific type of cough.
• This cough is usually dry, persistent, and doesn't produce mucus.
• It typically starts within the first few months of taking the medication.
• However, the good news is that this cough often goes away within 1 to 4 weeks after you stop taking the ACE inhibitor.
• Before discontinuing the medication, your doctor will consider other potential causes of cough, especially if you have heart failure.
• They'll make sure to rule out conditions like lung congestion before making any changes to your treatment plan.

Hematologic effects

• Some ACE inhibitors, like captopril, have been linked to certain blood-related issues.
• These issues include neutropenia, which is a low level of white blood cells with myeloid hypoplasia (reduced production of certain white blood cells) and agranulocytosis (severely low levels of white blood cells).
• Anemia (low red blood cell count) and thrombocytopenia (low platelet count) have also been reported.
• Patients with kidney problems are more likely to develop neutropenia.
• Those with both kidney issues and collagen vascular diseases like systemic lupus erythematosus are at even higher risk of neutropenia.
• It's essential to regularly check a complete blood count (CBC) with a differential in these patients to monitor their blood cell levels.
• This monitoring helps detect any blood-related problems early so that appropriate action can be taken.

Hyperkalemia:

• Taking ACE inhibitors like Ramipril can sometimes lead to a condition called hyperkalemia, which means having too much potassium in the blood.
• Several factors can increase the risk of hyperkalemia when using ACE inhibitors:
  • Kidney problems or renal impairment.
  • Diabetes mellitus (diabetes).
  • Using potassium-sparing diuretics (water pills), potassium supplements, or potassium-containing salts at the same time.
• If you have any of these risk factors, your doctor will use ACE inhibitors cautiously, if at all.
• Regular monitoring of your potassium levels will be important to make sure they stay within a healthy range.

Hypersensitivity reactions

• When taking ACE inhibitors like Ramipril, hypersensitivity reactions can occur.
• These reactions can be severe and may resemble anaphylactic reactions, which are severe allergic responses.
• In rare cases, particularly during certain medical procedures, severe anaphylactoid reactions can happen. These include reactions during hemodialysis with specific high-flux dialysis membranes like AN69.
• Also, although very uncommon, anaphylactoid reactions have been reported during low-density lipoprotein apheresis with dextran sulfate cellulose.
• There have been rare instances where people undergoing sensitization treatment for bee or wasp venom while on ACE inhibitors have experienced anaphylactoid reactions.

Hypotension/syncope

• When starting ACE inhibitors like Ramipril, some people may experience low blood pressure (hypotension) with or without fainting (syncope).
• This is more likely to happen, especially in the beginning, typically within the first few doses.
• It's most common in patients who have reduced blood volume, so it's important to correct any volume depletion before starting the medication.
• Close monitoring of the patient is necessary, especially when they first begin taking the medication and when the dose is increased.
• Lowering blood pressure should be done at a pace that is safe for the patient's specific health condition.
• Sometimes, it might be necessary to reduce the dose of the medication.
• However, it's important to note that low blood pressure or syncope is not a reason to stop using ACE inhibitors, particularly in patients with heart failure, where a decrease in systolic blood pressure can be beneficial.

Renal function deterioration:

• Taking ACE inhibitors like Ramipril can sometimes lead to a decline in kidney function or an increase in serum creatinine levels, especially in patients with certain conditions.
• This risk is higher in individuals with reduced blood flow to the kidneys, such as those with renal artery stenosis (narrowing of the renal arteries) or heart failure.
• In some cases, kidney function can deteriorate to the point of oliguria (low urine output), acute renal failure, or increasing levels of waste products in the blood (progressive azotemia).
• It's possible to experience minor increases in serum creatinine when you first start taking the medication.
• However, discontinuing Ramipril is typically considered only if there is a noticeable and significant decline in kidney function over time.

Aortic stenosis

• If you have severe aortic stenosis, be cautious when using ACE inhibitors like Ramipril.
• These medications may reduce the blood supply to the coronary arteries, which could lead to a condition called ischemia (reduced blood flow and oxygen supply to the heart muscle).
• It's crucial to work closely with your healthcare provider, who can monitor your condition and make sure that the use of Ramipril is appropriate for you.

Ascites:

• If you have ascites, which is the accumulation of fluid in the abdomen, especially due to cirrhosis or refractory ascites (fluid that doesn't respond to treatment), it's generally best to avoid using ACE inhibitors like Ramipril.
• However, in some cases where Ramipril is considered necessary, careful monitoring is essential.
• Monitoring should include keeping a close watch on blood pressure and kidney function.
• This monitoring helps prevent the rapid development of kidney failure, which can be a concern when using ACE inhibitors in patients with ascites due to cirrhosis.

Cardiovascular disease

• If you have ischemic heart disease (heart disease caused by reduced blood flow) or cerebrovascular disease (disease affecting blood vessels in the brain) and are starting therapy with ACE inhibitors like Ramipril, it's important to be closely monitored.
• There is a risk of a drop in blood pressure, which could have serious consequences such as a heart attack (MI) or stroke.
• If your blood pressure drops significantly, your healthcare provider may need to give you fluids to restore your blood pressure to a safe level.
• After stabilizing your blood pressure, they may consider resuming therapy with Ramipril.
• However, if hypotension (low blood pressure) keeps recurring, discontinuing Ramipril may be necessary.

Collagen vascular disease:

• If you have collagen vascular disease (a group of autoimmune diseases affecting connective tissues) and are considering using ACE inhibitors like Ramipril, it's important to exercise caution.
• This caution is especially important if you also have kidney problems (renal impairment).
• Patients with collagen vascular disease and kidney issues may have a higher risk of experiencing hematologic toxicity (blood-related problems) when using ACE inhibitors.

Hepatic impairment

• If you have hepatic impairment (problems with your liver), it's important to exercise caution when using ACE inhibitors like Ramipril.
• Ramipril is mainly processed by the liver's enzymes, so individuals with liver issues might experience significantly higher levels of Ramipril in their blood.
• This elevated level could potentially lead to adverse effects.
• When you have hepatic impairment, your healthcare provider will need to carefully consider the dosage and use of Ramipril based on your specific condition.

Hypertrophic cardiomyopathy (HCM)

• If you have hypertrophic cardiomyopathy (HCM) with outflow tract obstruction, be cautious when considering the use of ACE inhibitors like Ramipril.
• ACE inhibitors can reduce the resistance your heart has to pump against (afterload), and this reduction in afterload may potentially worsen the symptoms associated with HCM, especially if there is an outflow tract obstruction.
• It's crucial to work closely with your healthcare provider, who can assess your specific condition and determine the most appropriate treatment plan.

Renal artery stenosis

• If you have unstented unilateral (one-sided) or bilateral (both sides) renal artery stenosis (narrowing of the renal arteries without stents), it's essential to use ACE inhibitors like Ramipril with caution.
• In cases where this type of renal artery stenosis is confirmed or suspected, it is usually best to avoid using ACE inhibitors.
• This is because there is a higher risk of worsening kidney function, unless there are substantial potential benefits that outweigh the risks.

Renal impairment

• If you have renal impairment (kidney problems), it's important to use ACE inhibitors like Ramipril with caution.
• You may require a dosage adjustment based on the severity of your kidney issues.
• Avoid rapidly increasing the dosage of Ramipril, as this can potentially worsen your kidney function.

Ramipril: Drug Interaction

Risk Factor C (Monitor therapy)
Alfuzosin	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Amphetamines	May lessen the effectiveness of antihypertensive agents.
Angiotensin II	The therapeutic efficacy of angiotensin II may be enhanced by angiotensin-converting enzyme inhibitors.
Antipsychotic Agents (Second Generation [Atypical])	Antipsychotic drugs' hypotensive effects may be enhanced by blood pressure-lowering medications (Second Generation [Atypical]).
Aprotinin	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
AzaTHIOprine	AzaTHIOprine's myelosuppressive effects may be enhanced by angiotensin-converting enzyme inhibitors.
Barbiturates	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Benperidol	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Brigatinib	May lessen the effectiveness of antihypertensive agents. Antihypertensive Agents' bradycardic action may be strengthened by brutinib.
Brimonidine (Topical)	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Dapoxetine	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Dexmethylphenidate	May lessen the effectiveness of antihypertensive agents.
Diazoxide	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Dipeptidyl Peptidase-IV Inhibitors	May worsen angiotensin-converting enzyme inhibitors' toxic or severe effects. Particularly, there may be a higher incidence of angioedema.
Drospirenone	Drospirenone's hyperkalemic impact may be enhanced by angiotensin-converting enzyme inhibitors.
DULoxetine	The hypotensive impact of DULoxetine may be enhanced by blood pressure lowering medications.
Eplerenone	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Everolimus	May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. Particularly, there may be a higher incidence of angioedema.
Ferric Gluconate	Angiotensin-Converting Enzyme Inhibitors might make ferric gluconate more harmful or poisonous.
Ferric Hydroxide Polymaltose Complex	Ferric Hydroxide Polymaltose Complex may have a more negative or toxic effect when taken with angiotensin-converting enzyme inhibitors. In particular, there may be an elevated risk for angioedema or allergic responses.
Gelatin (Succinylated)	Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Gelatin (Succinylated). Specifically, the risk of a paradoxical hypotensive reaction may be increased.
Gold Sodium Thiomalate	Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Gold Sodium Thiomalate. An increased risk of nitritoid reactions has been appreciated.
Heparin	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Heparins (Low Molecular Weight)	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Herbs (Hypertensive Properties)	May lessen the effectiveness of antihypertensive agents.
Herbs (Hypotensive Properties)	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Hypotension-Associated Agents	Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents.
Icatibant	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Levodopa-Containing Products	Levodopa-Containing Products' hypotensive effects may be strengthened by blood pressure-lowering medications.
Loop Diuretics	May strengthen angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by loop diuretics.
Lormetazepam	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Methylphenidate	May lessen the effectiveness of antihypertensive agents.
Molsidomine	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Naftopidil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nicergoline	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nicorandil	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Nicorandil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nitroprusside	Nitroprusside's hypotensive impact may be strengthened by blood pressure-lowering medications.
Nonsteroidal Anti-Inflammatory Agents	Nonsteroidal Anti-Inflammatory Agents' negative/toxic effects may be increased by angiotensin-converting enzyme inhibitors. In particular, the combination may cause a marked decline in renal function. Angiotensin-Converting Enzyme Inhibitors' antihypertensive effects may be lessened by nonsteroidal anti-inflammatory drugs.
Pentoxifylline	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Pholcodine	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Phosphodiesterase 5 Inhibitors	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Potassium Salts	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Potassium-Sparing Diuretics	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Pregabalin	Angiotensin-Converting Enzyme Inhibitors may intensify Pregabalin's negative/toxic effects. Particularly, there may be a higher incidence of angioedema.
Prostacyclin Analogues	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Quinagolide	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Racecadotril	May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. In particular, this combination may make angioedema more likely.
Ranolazine	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Salicylates	May intensify angiotensin-converting enzyme inhibitors' nephrotoxic effects. The therapeutic benefit of angiotensin-converting enzyme inhibitors may be reduced by salicylates.
Sirolimus	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Tacrolimus (Systemic)	Tacrolimus's effect of making you more hyperkalemic may be enhanced by angiotensin-converting enzyme inhibitors (Systemic).
Temsirolimus	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Thiazide and Thiazide-Like Diuretics	May increase the angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by thiazide and thiazide-like diuretics.
TiZANidine	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Tolvaptan	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Trimethoprim	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Yohimbine	May lessen the effectiveness of antihypertensive agents.
Risk Factor D (Consider therapy modification)
Aliskiren	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects. Angiotensin-Converting Enzyme Inhibitors' hypotensive effects may be strengthened by aliskiren. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be made worse by aliskiren. Treatment: It is not advised for diabetic patients to take aliskiren along with ACEIs or ARBs. Combination therapy should be avoided in other patients, especially when CrCl is less than 60 mL/min. If combined, keep a close eye on your blood pressure, potassium, and creatinine levels.
Allopurinol	Angiotensin-Converting Enzyme Inhibitors might make Allopurinol more likely to cause allergic or hypersensitive reactions.
Amifostine	Amifostine's hypotensive impact may be strengthened by blood pressure lowering medications. Treatment: Blood pressure-lowering drugs need to be avoided for 24 hours before amifostine is administered when used at chemotherapeutic doses. Amifostine should not be given if blood pressure lowering treatment cannot be stopped.
Angiotensin II Receptor Blockers	May worsen angiotensin-converting enzyme inhibitors' toxic or severe effects. Angiotensin-Converting Enzyme Inhibitors' serum levels may rise in response to angiotensin II receptor blockers. Management: According to US labelling, it is not advisable to take telmisartan and ramipril. It is unclear whether another ACE inhibitor and ARB combo would be any safer. When possible, take into account alternatives to the mix.
Grass Pollen Allergen Extract (5 Grass Extract)	Grass pollen allergen extract may have a more negative or toxic effect if angiotensin-converting enzyme inhibitors are used (5 Grass Extract). With regard to grass pollen allergen extract, ACE inhibitors may specifically enhance the likelihood of a severe allergic reaction (5 Grass Extract).
Iron Dextran Complex	Angiotensin-Converting Enzyme Inhibitors might make Iron Dextran Complex more harmful or poisonous. Patients taking an ACE inhibitor may be more susceptible to events of the anaphylactic variety. Management: Adhere strictly to the instructions for iron dextran administration, including the use of a test dose before the initial therapeutic dose and the availability of resuscitation tools and qualified people.
Lanthanum	May lower angiotensin-converting enzyme inhibitors' serum concentration. Angiotensin-converting enzyme inhibitors should be given at least two hours before or after lanthanum.
Lithium	The serum concentration of lithium may rise in response to angiotensin-converting enzyme inhibitors. Management: After adding an ACE inhibitor, lithium dosage decreases will probably be required. Following the addition or discontinuation of concurrent ACE inhibitor therapy, carefully monitor the patient's response to lithium.
Obinutuzumab	The hypotensive effects of blood pressure-lowering medications may be strengthened. Management: Take into account temporarily stopping blood pressure-lowering drugs 12 hours before the start of the obinutuzumab infusion and keeping them off until 1 hour after the infusion is finished.
Sodium Phosphates	The nephrotoxic impact of sodium phosphates may be enhanced by angiotensin-converting enzyme inhibitors. In particular, there may be an increased risk of acute phosphate nephropathy. Treatment: You might want to temporarily stop taking ACEIs or look into alternatives to the oral sodium phosphate bowel preparation in order to prevent this combo. Maintaining appropriate hydration and properly monitoring renal function should be done if the combination cannot be avoided.
Urapidil	Angiotensin-Converting Enzyme Inhibitors may interact with them through an unidentified method. Avoid taking urapidil and ACE inhibitors simultaneously as a management strategy.
Risk Factor X (Avoid combination)
Bromperidol	The hypotensive impact of bromperidol may be enhanced by blood pressure lowering medications. Blood Pressure Lowering Agents' hypotensive effects may be lessened by bromperidol.
Sacubitril	The negative or hazardous effects of sacubitril may be increased by angiotensin-converting enzyme inhibitors. In particular, this combination may raise the risk of angioedema.
Telmisartan	Could make Ramipril's harmful or hazardous effects worse. Ramipril's serum levels may be raised by telmisartan. Ramiprilat, the active metabolite, may also have higher concentrations.

Monitor:

Blood Pressure Monitoring:

• Regularly check your blood pressure.

Kidney Function and Electrolytes (BUN, Serum Creatinine, and Potassium):

• Monitor kidney function and potassium levels.
• If you have collagen vascular disease or renal impairment, also periodically check your blood count (CBC with differential).

Heart Failure Post-Myocardial Infarction:

• After starting Ramipril, monitor for at least 2 hours and continue monitoring for an additional hour after your blood pressure stabilizes.

Heart Failure:

• Reassess renal function and serum potassium within 1 to 2 weeks of starting Ramipril.
• Repeat these assessments periodically, especially if you have preexisting hypotension, hyponatremia, diabetes mellitus, azotemia, or take potassium supplements.

Hypertension:

• Follow specific blood pressure targets based on your condition:
  • If you have confirmed hypertension and known cardiovascular disease (CVD) or a high risk of CVD, aim for a blood pressure less than 130/80 mm Hg.
  • If you have confirmed hypertension without markers of increased CVD risk, a target blood pressure less than 130/80 mm Hg may be reasonable.
  • If you have diabetes and hypertension, your target blood pressure may vary based on your age, overall health, and CVD risk.

How to administer Ramipril?

• When taking this medication orally (by mouth), you have two options for how to take it:

Option 1: Swallow the Capsule Whole

• Simply take the capsule with a glass of water as you would with any other medication.

Option 2: Opening the Capsule

• Alternatively, you can open the capsule.
• After opening it, mix the contents with a larger amount of liquid or a soft food, such as 120 mL (about 4 ounces) of water, apple juice, or applesauce.
• This can make it easier to take, especially if you have difficulty swallowing whole capsules.

Mechanism of action Ramipril:

• Ramipril is an ACE inhibitor.
• It works similarly to captopril.
• In the liver, ramipril is converted into its active form called ramiprilat through a process called enzymatic saponification.
• Ramiprilat binds tightly and competitively to angiotensin-converting enzyme (ACE), preventing the production of angiotensin II, which is a potent blood vessel constrictor.
• The complex formed between ACE and ramiprilat remains attached for a long time, making it highly effective and long-lasting.
• Ramipril's blood pressure-lowering effect may involve the central nervous system (CNS) because angiotensin II can increase adrenergic activity from the CNS.
• ACE inhibitors like ramipril may also reduce the activity of vasoactive kallikreins, which are enzymes that play a role in hormone production related to blood pressure regulation.

Onset of Action:

• Ramipril starts working within 1 to 2 hours after you take it.

Duration:

• Its effects last for about 24 hours.

Absorption:

• When you take Ramipril by mouth, your body absorbs it quite well, with about 50% to 60% of the medication being taken up by your body.

Distribution:

• Ramipril levels in your blood decrease in three phases:
  • The first phase involves a rapid drop as the medication spreads throughout your body's tissues and plasma proteins. This phase has a half-life of 2-4 hours.
  • The second phase is about the clearance of free ramiprilat, the active form of the medication. This phase has a half-life of 9-18 hours.
  • The final phase is the terminal elimination phase, where there is a balance between the medication binding to tissues and it detaching from them.

Protein Binding:

• In your bloodstream, Ramipril is bound to proteins to some extent. About 73% of Ramipril and 56% of Ramiprilat bind to proteins.

Metabolism:

• Your liver is responsible for converting Ramipril into its active form, ramiprilat.

Bioavailability:

• When you take Ramipril, your body gets about 28% of the medication, while for Ramiprilat, it's about 44%.

Half-life Elimination:

• The time it takes for half of the active form, ramiprilat, to be effectively eliminated from your body is 13-17 hours. The terminal elimination phase is even longer, with a half-life of more than 50 hours.

Time to Peak in Your Blood:

• After you take Ramipril, it reaches its peak levels in your blood in about 1 hour. For Ramiprilat, it takes a bit longer, around 2-4 hours.

Excretion:

• Your body gets rid of Ramipril and its metabolites mainly through your urine (60%) and to a lesser extent through your feces (40%).

International Brands of Ramipril:

• Altace
• ACT Ramipril
• AG-Ramipril
• Altace
• APO-Ramipril
• Auro-Ramipril
• DOM-Ramipril
• JAMP-Ramipril
• Mar-Ramipril
• MINT-Ramipril
• MYLAN-Ramipril
• Pharma-Ramipril
• PMS-Ramipril
• PRIVARamipril
• PRO-Ramipril-1.25
• PRO-Ramipril-10
• PRO-Ramipril-2.5
• PRO-Ramipril-5
• Ramace
• Ramipril-10
• Ramipril-2.5
• Ramipril-5
• RAN-Ramipril
• SANDOZ Ramipril
• TEVARamipril
• VAN-Ramipril
• Acovil
• Acuril
• Altace
• Amipril
• Ampril
• Anexia
• Anhiram
• Bigastus
• Cardace
• Cardika
• Cardipril
• Cartace
• Corpril
• Decapril
• Delix
• Hartil
• Heartprilprotect
• Hyperil
• Hypren
• Intemipril
• Lostapres
• Naprix
• Normopril
• Piramil
• Polapril
• Pramace
• Pril
• Prilace
• Primace
• Prohytens
• Quark
• Ramace
• Ramey
• Ramicard
• Ramicor
• Ramily
• Ramipres
• Ramiprin
• Ramipro
• Ramitace
• Ramitens
• Ramixal
• Rampil
• Ramtace
• Redutens
• Servace
• Sipo
• Syntace
• Topril
• Triatec
• Triateckit
• Triltec
• Tripril
• Tritace
• Tritace Protect
• Tryzan
• Unipril
• Vaspril
• Vesdil
• Zenra

Ramipril brands in Pakistan:

Ramipril [Tabs 5 Mg]
Adytum	Macter International (Pvt) Ltd.
Hiace	Himont Pharmaceuticals (Pvt) Ltd.
Hyperace	Werrick Pharmaceuticals
Lipra	Pfizer Laboratories Ltd.
Mevlon	Helix Pharma (Private) Limited
Normipil	Standpharm Pakistan (Pvt) Ltd.
Ramipace	Pharmevo (Pvt) Ltd.
Ramipraz	Fozan Pharmaceuticals Industriers (Pvt) Ltd
Ramiproz	Fozan Pharmaceuticals Industriers (Pvt) Ltd
Ramitace 3h	Hamaz Pharmaceutical (Pvt) Ltd.
Rampro	Ferroza International Pharmaceuticals (Pvt) Ltd.
Ramril	English Pharmaceuticals Industries
Ramy	Getz Pharma Pakistan (Pvt) Ltd.
Tritace	Sanofi Aventis (Pakistan) Ltd.

 

Ramipril [Tabs 10 Mg]
B.P.Ace	Polyfine Chempharma (Pvt) Ltd.
Lipra	Pfizer Laboratories Ltd.
Normipil	Standpharm Pakistan (Pvt) Ltd.
Ramipace	Pharmevo (Pvt) Ltd.
Ramy	Getz Pharma Pakistan (Pvt) Ltd.
Tritace	Sanofi Aventis (Pakistan) Ltd.

Ramipril [Tabs 2.5 Mg]
Adytum	Macter International (Pvt) Ltd.
Adytum	Macter International (Pvt) Ltd.
Hiace	Himont Pharmaceuticals (Pvt) Ltd.
Hyperace	Werrick Pharmaceuticals
Lipra	Pfizer Laboratories Ltd.
Mapril	Kurative Pak (Pvt) Ltd
Mevlon	Helix Pharma (Private) Limited
Normipil	Standpharm Pakistan (Pvt) Ltd.
Prepace	Medicaids Pakistan (Pvt) Ltd.
Prepace	Medicaids Pakistan (Pvt) Ltd.
Ramipace	Pharmevo (Pvt) Ltd.
Ramipace	Pharmevo (Pvt) Ltd.
Ramipraz	Fozan Pharmaceuticals Industriers (Pvt) Ltd
Ramiproz	Fozan Pharmaceuticals Industriers (Pvt) Ltd
Ramiscot	Scotmann Pharmaceuticals
Ramitace 3h	Hamaz Pharmaceutical (Pvt) Ltd.
Rampro	Ferroza International Pharmaceuticals (Pvt) Ltd.
Ramril	English Pharmaceuticals Industries
Ramy	Getz Pharma Pakistan (Pvt) Ltd.
Tritace	Sanofi Aventis (Pakistan) Ltd.

Ramipril [Tabs 1.25 Mg]
Adytum	Macter International (Pvt) Ltd.
Hiace	Himont Pharmaceuticals (Pvt) Ltd.
Lipra	Pfizer Laboratories Ltd.
Mapril	Kurative Pak (Pvt) Ltd
Mevlon	Helix Pharma (Private) Limited
Normipil	Standpharm Pakistan (Pvt) Ltd.
Ramipace	Pharmevo (Pvt) Ltd.
Ramipace	Pharmevo (Pvt) Ltd.
Ramiscot	Scotmann Pharmaceuticals
Ramitace 3h	Hamaz Pharmaceutical (Pvt) Ltd.
Rampro	Ferroza International Pharmaceuticals (Pvt) Ltd.
Ramril	English Pharmaceuticals Industries
Ramy	Getz Pharma Pakistan (Pvt) Ltd.