Ramipril (tritace) - Complete Drug Information

Ramipril is an ACE inhibitor that prevents the formation of angiotensin II from angiotensin I and shows pharmacologic effects that are similar to captopril.

  • Heart failure post-myocardial infarction:

    • It is used in the treatment of heart failure (HF) after myocardial infarction (MI)
  • Hypertension:

    • It is used in the treatment of hypertension
  • Reduction in risk of myocardial infarction, stroke, and death from CVD:

    • It is used to reduce the risk of MI, stroke, and death in patients ≥55 years of age at high risk of developing major cardiovascular events.
  • Off Label Use Ramipril in Adults:

  • It is also used in :
    • Heart failure with reduced ejection fraction;
    • Non–ST-elevation acute coronary syndrome;
    • Stable coronary artery disease;
    • ST-elevation acute coronary syndrome

Ramipril dose in Adults

  • Discontinue or reduce the dose of concomitant diuretic when initiating ramipril.
  • If the diuretic cannot be stopped or the dose reduced, consider reduced initial ramipril dose.

Ramipril dose in the treatment of Heart failure post-myocardial infarction:

  • The initial dose is  2.5 mg twice daily
  • It can be reduced to 1.25 mg twice daily for hypotension.
  • Continue initial dose for 1 week then titrate upward every 3 weeks as tolerated to the target dose of 5 mg twice daily.

Ramipril dosage in the treatment of Hypertension:

  • Initially, 2.5 mg is given once daily
  • Titration is done based on the patient response after 2 to 4 weeks up to 20 mg daily in 1 or 2 divided doses

Ramipril dosage in the treatment of reduction in risk of MI, stroke, and death from cardiovascular causes:

  • The initial dose is  2.5 mg once daily for 1 week
  • Then 5 mg once daily for the next 21 days
  • Then increase as tolerated to the maintenance dose of 10 mg once daily
  • It may be administered in divided doses in hypertensive or recently post-MI patients.

Off Label dosage in the treatment of Heart failure with reduced ejection fraction:

  • The initial dose is  1.25 to 2.5 mg once daily
  • the target dose is  10 mg once daily
  • Dosage adjustment for patients with volume depletion:

    • Initially, 1.25 mg is given once daily
    • Titrate as tolerated to effect.

Ramipril Dose in Childrens

Ramipri dose in the treatment of hypertension:

Ramipril dose in children has not been established. However, the usual dose is 2.5 mg (5ml) once daily.

Ramipril Pregnancy Risk Factor: D

  • Drugs that affect the renin-angiotensin systems can cause death and injury to the developing foetus.
  • Once you are aware that you are pregnant, stop immediately.
  • Ramipril crosses the placenta
  • Oligohydramnios are often associated with drugs that affect the RAAS system.
  • Oligohydramnios can cause fetal kidney dysfunction and skeletal malformations.
  • These drugs can also cause skull hypoplasia and anuria in pregnancy.
  • Although teratogenic effects may occur following maternal use of an ACE-inhibiting drug during the first trimester (although this finding could be confounded by maternal diseases),
  • Exposure later in pregnancy can lead to adverse fetal outcomes. Therefore, pregnant women should not use ACE inhibitors.
  • Children exposed to ACE inhibitors in utero need to be tested for hypotension, hyperkalemia, and oliguria.
  • After an irreversible fetal trauma, Oligohydramnios may not be apparent.
  • Although data on the effectiveness of dialysis or exchange transfusions in neonates are limited, it is possible to reverse hypotension and improve renal function with dialysis or transfusions.
  • Side effects of chronic maternal hypertension can also be experienced by the mother and the baby.
  • Women of reproductive age should not be given ACE inhibitors.
  • Other agents should be considered if treatment is needed for hypertension and chronic heart failure during pregnancy.

Ramipril use during breastfeeding:

  • After a single oral dose (10 mg), Ramipril or its metabolites weren't found in breast milk.
  • It is unknown if multiple doses can produce detectable levels.
  • The manufacturer does not recommend breastfeeding.

Ramipril dose in Kidney disease:

  • CrCl >40 mL/minute:

    • No dosage adjustment required.
  • CrCl <40 mL/minute:

    • Give 25% of normal dose.
  • Heart failure post-MI:

    • The initial dose is  1.25 mg once daily
    • It may be increased to 1.25 mg twice daily and then up to a maximum of 2.5 mg twice daily as tolerated.
  • Hypertension:

    • The initial dose is  1.25 mg once daily, titrated as tolerated to effect
    • The maximum dose is 5 mg/day.
  • Renal artery stenosis:

    • Initially, 1.25 mg is given once daily
    • titrate as tolerated to effect.

Ramipril dose in Liver disease:

  • There are no dosage adjustments given in the manufacturer's labeling
  • Patients with hepatic impairment can develop markedly elevated plasma levels of ramipril.

  • Frequency ranges include data from hypertension and heart failure trials.
  • Higher rates of adverse reactions have generally been noted in patients with cardiac failure.
  • However, the frequency of adverse effects associated with placebo is also increased in this population.

Common Side Effects of Ramipril Include:

  • Cardiovascular:

    • Hypotension
  • Respiratory:

    • Increased Cough

Less Common Side Effects of Ramipril Include:

  • Cardiovascular:

    • Angina Pectoris
    • Orthostatic Hypotension
    • Syncope
  • Central Nervous System:

    • Headache
    • Dizziness
    • Fatigue
    • Vertigo
    • Noncardiac Chest Pain
  • Endocrine & Metabolic:

    • Hyperkalemia
  • Gastrointestinal:

    • Nausea
    • Vomiting
  • Renal:

    • Increased Blood Urea Nitrogen
    • Increased Serum Creatinine
    • Renal Insufficiency
  • Respiratory:

    • Cough

Contraindication to Ramipril Include:

  • Hypersensitivity to ramipril or other ACE inhibitors or any component of the formulation
  • hereditary/idiopathic angioedema
  • Angioedema history related to treatment with an ACE inhibitor in the past
  • concomitant use with aliskiren in patients having diabetes mellitus
  • concomitant use or within 36 hours of switching to or from sacubitril (a neprilysin inhibitor).
  • Hemodynamically relevant bilateral renal arterial stenosis (or unilateral in one kidney)
  • Hypotensive and hemodynamically unstable states
  • concomitant use with aliskiren in patients having moderate to severe renal impairment (GFR <60 mL/minute/1.73 m ),
  • hyperkalemia (>5 mMol/L)
  • Hypotensive patients with congestive heart disease and hypotensive patients
  • concomitant use with angiotensin II receptor blockers (ARBs) in patients having diabetes end-organ damage
  • Combination with extracorporeal treatment that results in blood contact with negatively charged surfaces (dialysis, hemofiltration with certain highflux membranes [eg, Polyacrylonitrile] and low-density lipoprotein Apheresis using dextran).
  • pregnancy
  • Breastfeeding

Warnings and precautions

  • Angioedema

    • Angioedema may occur at any time, especially after the first dose.
    • It could involve the head, neck, or intestines (possibly compromising the airway).
    • Patients of color, patients with idiopathic angioedema, or patients who have had angioedema as a result of ACE inhibitor therapy, are at greater risk.
    • Concomitant use mTOR inhibitors (eg everolimus) and neprilysin inhibits (eg sacubitril), can increase the risk.
    • Frequent and prolonged monitoring may be necessary due to the possibility of airway obstruction. This is especially true if larynx, tongue, glottis or glottis are involved.
    • Patients who have had previous airway surgery are at greater risk for obstruction.
    • Patients with angioedema from ACE inhibitor therapy are strictly prohibited.
  • Cholestatic jaundice

    • Cholestatic jaundice is a rare side effect of ACE inhibitors.
    • It could lead to fulminant liver necrosis (some even fatal).
    • If you notice a marked increase in hepatic transaminases and jaundice, stop immediately.
  • Cough:

    • An ACE inhibitor causes dry, nonproductive and hacking coughs.
    • It usually occurs within the first few months of treatment and should generally resolve within 1 to 4 weeks after discontinuation of the ACE inhibitor.
    • You should also consider other causes of cough (eg, pulmonary congestion for patients with heart disease) before discontinuing treatment.
  • Hematologic effects

    • It has been linked to neutropenia, myeloid hypoplasia, agranulocytosis, and anemia.
    • Patients with severe renal impairment are at higher risk for neutropenia.
    • Patients with renal impairment or collagen vascular disease (eg systemic lupus-erythematosus), are more at risk for developing neutropenia.
    • Monitor CBC regularly with a differential in such patients.
  • Hyperkalemia:

    • Patients may develop hyperkalemia
    • Risk factors for hyperkalemia include
      • Renal impairment
      • diabetes mellitus,
      • Use of potassium-sparing diuretics in conjunction
      • Potassium supplements and/or
      • Potassium-containing salts
    • These agents should be used with caution and potassium should be monitored closely.
  • Hypersensitivity reactions

    • Anaphylactic/anaphylactoid reactions might occur with ACE inhibitors.
    • Severe allergic reactions can occur during hemodialysis (eg CVVHD), high-flux dialysis membranes, (eg AN69), or, rarely, during low density lipoprotein (low-density) apheresis using dextran sulfatecellulose.
    • Rarely have patients who are subject to sensitization with Hymenoptera (bee or wasp) venom and receive ACE inhibitors developed severe allergic reactions.
  • Hypotension/syncope

    • Hypotension may be symptomatic with or without syncope. This is usually the case after several doses.
    • These effects are most common in patients with low volume.
    • correct volume depletion before initiation
    • Particularly with the initial dose and subsequent dosing increases, close supervision of patients is important.
    • Blood pressure should be reduced at a pace that is appropriate for the patient's medical condition.
    • Hypotension, even though it is necessary to reduce doses, is not a reason to stop future ACE inhibitor usage.
    • This is especially true for patients with heart disease where a decrease in systolic pressure is desirable.
  • Renal function deterioration:

    • It could be linked to deterioration in renal function and/or an increase in serum creatinine.
    • This is most common in patients with low renal flow (eg, kidney artery stenosis or heart failure) whose GFR depends on efferent arterial vasoconstriction via angiotensin 2.
    • Progressive azotemia, acute renal failure, or oliguria can result from deterioration.
    • After initiation, small increases in serum creatinine may occur.
    • Patients with significant and progressive deterioration of renal function should be considered for treatment.
  • Aortic stenosis

    • Patients with severe aorticstenosis should be cautious. It may cause decreased coronary perfusion, which can lead to ischemia.
  • Ascites:

    • Patients with ascites due cirrhosis, refractory or other causes should not be given this medication.
    • If patients suffering from ascites or cirrhosis cannot avoid the use of the drug, it is important to monitor blood pressure and kidney function closely to prevent rapid progression to renal failure.
  • Cardiovascular disease

    • Patients with ischemic heart disease and cerebrovascular diseases should be closely monitored due to possible consequences of falling blood pressure (eg stroke, MI).
    • Fluid replacement may restore blood pressure. Therapy can then be resumed.
    • Stop treating hypotension-recurring patients.
  • Collagen vascular disease:

    • Patients with collagen vascular disease, especially those with concomitant kidney impairment, should be cautious.
    • These patients could be at higher risk of hematologic toxicities.
  • Hepatic impairment

    • Ramipril is metabolized mainly by the liver so patients with hepatic impairment should not use it.
  • Hypertrophic cardiomyopathy with outflow tract obstruction (HCM)

    • Patients with HCM or outflow tract obstruction should be cautious. Reduced afterload could worsen the symptoms.
  • Renal artery stenosis

    • Patients with unstented unilateral/bilateral kidney artery stenosis should be cautious.
    • If unstented unilateral and bilateral renal artery narrowing is suspected or present, it should be avoided.
  • Renal impairment

    • Patients with impaired renal function should be cautious. Dosage adjustment may be necessary.
    • Do not increase the dose too quickly as this could cause further renal impairment.

Ramipril: Drug Interaction

Risk Factor C (Monitor therapy)

Alfuzosin

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Amphetamines

May diminish the antihypertensive effect of Antihypertensive Agents.

Angiotensin II

Angiotensin-Converting Enzyme Inhibitors may enhance the therapeutic effect of Angiotensin II.

Antipsychotic Agents (Second Generation [Atypical])

Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]).

Aprotinin

May diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors.

AzaTHIOprine

Angiotensin-Converting Enzyme Inhibitors may enhance the myelosuppressive effect of AzaTHIOprine.

Barbiturates

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Benperidol

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Brigatinib

May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents.

Brimonidine (Topical)

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Dapoxetine

May enhance the orthostatic hypotensive effect of Angiotensin-Converting Enzyme Inhibitors.

Dexmethylphenidate

May diminish the therapeutic effect of Antihypertensive Agents.

Diazoxide

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Dipeptidyl Peptidase-IV Inhibitors

May enhance the adverse/toxic effect of AngiotensinConverting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased.

Drospirenone

Angiotensin-Converting Enzyme Inhibitors may enhance the hyperkalemic effect of Drospirenone.

DULoxetine

Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine.

Eplerenone

May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors.

Everolimus

May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk of angioedema may be increased.

Ferric Gluconate

Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Ferric Gluconate.

Ferric Hydroxide Polymaltose Complex

Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Ferric Hydroxide Polymaltose Complex. Specifically, the risk for angioedema or allergic reactions may be increased.

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

May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors.

Heparins (Low Molecular Weight)

May enhance the hyperkalemic effect of AngiotensinConverting Enzyme Inhibitors.

Herbs (Hypertensive Properties)

May diminish the antihypertensive effect of Antihypertensive Agents.

Herbs (Hypotensive Properties)

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Hypotension-Associated Agents

Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents.

Icatibant

May diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors.

Levodopa-Containing Products

Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Containing Products.

Loop Diuretics

May enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Loop Diuretics may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors.

Lormetazepam

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Methylphenidate

May diminish the antihypertensive effect of Antihypertensive Agents.

Molsidomine

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Naftopidil

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Nicergoline

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Nicorandil

May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors.

Nicorandil

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Nitroprusside

Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside.

Nonsteroidal Anti-Inflammatory Agents

Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Nonsteroidal Anti-Inflammatory Agents may diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors.

Pentoxifylline

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Pholcodine

Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine.

Phosphodiesterase 5 Inhibitors

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Potassium Salts

May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors.

Potassium-Sparing Diuretics

May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors.

Pregabalin

Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Pregabalin. Specifically, the risk of angioedema may be increased.

Prostacyclin Analogues

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Quinagolide

May enhance the hypotensive effect of Blood Pressure Lowering Agents.

Racecadotril

May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Specifically, the risk for angioedema may be increased with this combination.

Ranolazine

May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors.

Salicylates

May enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Salicylates may diminish the therapeutic effect of Angiotensin-Converting Enzyme Inhibitors.

Sirolimus

May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors.

Tacrolimus (Systemic)

Angiotensin-Converting Enzyme Inhibitors may enhance the hyperkalemic effect of Tacrolimus (Systemic).

Temsirolimus

May enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors.

Thiazide and Thiazide-Like Diuretics

May enhance the hypotensive effect of AngiotensinConverting Enzyme Inhibitors. Thiazide and Thiazide-Like Diuretics may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors.

TiZANidine

May enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors.

Tolvaptan

May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors.

Trimethoprim

May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors.

Yohimbine

May diminish the antihypertensive effect of Antihypertensive Agents.

Risk Factor D (Consider therapy modification)

Aliskiren

May enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Aliskiren may enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Aliskiren may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. Management: Aliskiren use with ACEIs or ARBs in patients with diabetes is contraindicated. Combined use in other patients should be avoided, particularly when CrCl is less than 60 mL/min. If combined, monitor potassium, creatinine, and blood pressure closely.

Allopurinol

Angiotensin-Converting Enzyme Inhibitors may enhance the potential for allergic or hypersensitivity reactions to Allopurinol.

Amifostine

Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered.

Angiotensin II Receptor Blockers

May enhance the adverse/toxic effect of AngiotensinConverting Enzyme Inhibitors. Angiotensin II Receptor Blockers may increase the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Management: In US labeling, use of telmisartan and ramipril is not recommended. It is not clear if any other combination of an ACE inhibitor and an ARB would be any safer. Consider alternatives to the combination when possible.

Grass Pollen Allergen Extract (5 Grass Extract)

Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Grass Pollen Allergen Extract (5 Grass Extract). Specifically, ACE inhibitors may increase the risk of severe allergic reaction to Grass Pollen Allergen Extract (5 Grass Extract).

Iron Dextran Complex

Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Iron Dextran Complex. Specifically, patients receiving an ACE inhibitor may be at an increased risk for anaphylactic-type reactions. Management: Follow iron dextran recommendations closely regarding both having resuscitation equipment and trained personnel on-hand prior to iron dextran administration and the use of a test dose prior to the first therapeutic dose.

Lanthanum

May decrease the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Management: Administer angiotensin-converting enzyme inhibitors at least two hours before or after lanthanum.

Lithium

Angiotensin-Converting Enzyme Inhibitors may increase the serum concentration of Lithium. Management: Lithium dosage reductions will likely be needed following the addition of an ACE inhibitor. Monitor patient response to lithium closely following addition or discontinuation of concurrent ACE inhibitor treatment.

Obinutuzumab

May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion.

Sodium Phosphates

Angiotensin-Converting Enzyme Inhibitors may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Management: Consider avoiding this combination by temporarily suspending treatment with ACEIs, or seeking alternatives to oral sodium phosphate bowel preparation. If the combination cannot be avoided, maintain adequate hydration and monitor renal function closely.

Urapidil

May interact via an unknown mechanism with Angiotensin-Converting Enzyme Inhibitors. Management: Avoid concomitant use of urapidil and angiotensin-converting enzyme (ACE) inhibitors.

Risk Factor X (Avoid combination)

Bromperidol

Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents.

Sacubitril

Angiotensin-Converting Enzyme Inhibitors may enhance the adverse/toxic effect of Sacubitril. Specifically, the risk of angioedema may be increased with this combination.

Telmisartan

May enhance the adverse/toxic effect of Ramipril. Telmisartan may increase the serum concentration of Ramipril. Concentrations of the active metabolite, ramiprilat, may also be increased.

Monitor:

  • Blood pressure
  • BUN, serum creatinine and potassium
  • if the patient has collagen vascular disease and/or renal impairment, periodically monitor CBC with differential.
  • In heart failure post-myocardial infarction patients, monitor for at least 2 hours after the initial dose and for at least an additional hour after blood pressure has been stabilized.

How to administer Ramipril?

  • Swallow capsule as a whole
  • It may be opened and the mix contents with 120 mL of water, apple juice, or applesauce.

Mechanism of action of Ramipril:

  • Ramipril, an ACE inhibitor, prevents angiotensin II formation from angiotensin 1, and has pharmacologic effects similar to captopril.
  • Ramipril is also subject to enzymatic saponification in the liver by esterases to become its biologically active metabolite ramiprilat.
  • The pharmacodynamic effects of ramipril result from the competitive, high-affinity, and reversible binding of ramiprilat to the angiotensin-converting enzyme, thus preventing the formation of the potent vasoconstrictor angiotensin II.
  • This isomerized enzyme inhibitor complex has a slow rate for dissociation which results in high potency, long duration of action and high potency.
  • Angiotensin II, which increases the adrenergic output from the CNS, also has a hypotensive effect through a CNS mechanism
  • Vasoactive kallikreins may be reduced in conversion to activehormones by ACE inhibitors, thereby reducing blood pressure

The onset of action:

  • 1-2 hours

Duration:

  • 24 hours

Absorption:

  • Well absorbed (50% to 60%)

Distribution:

  • Plasma levels decline in a triphasic fashion
  • The rapid decline is a distribution phase to peripheral compartment, plasma protein and tissue ACE (half-life: 2-4 hours)
  • The second phase is an apparent elimination phase showing the clearance of free ramiprilat (half-life: 9-18 hours)
  • The final phase is the terminal elimination phase representing the equilibrium phase between tissue binding and dissociation

Protein binding:

  • Ramipril: 73%; Ramiprilat: 56%

Metabolism:

  • Hepatic to the active form, ramiprilat

Bioavailability:

  • Ramipril: 28%; Ramiprilat: 44%

Half-life elimination:

  • Ramiprilat: Effective: 13-17 hours; Terminal: >50 hours

Time to peak, serum:

  • Ramipril: ~1 hour; Ramiprilat: 2-4 hours

Excretion:

  • Via Urine (60%) and feces (40%) as parent drug and metabolite 

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.

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