Formulary
Ramipril: Indications, Dosing, Side Effects and Interactions
Ramipril clinical drug profile including indications, dosing, side effects, cautions and interactions.
MedNext Academy | 5 min read
Ramipril: Indications, Dosing, Side Effects and Interactions
Ramipril clinical drug profile including indications, dosing, side effects, cautions and interactions.
Indications and dose
**Hypertension**
- **Adult** (By Mouth): Initially 1.25-2.5 mg once daily, increased if necessary up to 10 mg once daily, dose to be increased at intervals of 2-4 weeks.
**Symptomatic heart failure (adjunct) (under close medical supervision)**
- **Adult** (By Mouth): Initially 1.25 mg once daily, increased if tolerated to 10 mg daily in 1-2 divided doses, daily dose preferably taken in 2 divided doses, increase dose gradually at intervals of 1-2 weeks.
**Prophylaxis after myocardial infarction in patients with clinical evidence of heart failure (started at least 48 hours after infarction)**
- **Adult** (By Mouth): Initially 2.5 mg twice daily for 3 days, then increased to 5 mg twice daily.
**Prophylaxis after myocardial infarction in patients with clinical evidence of heart failure (started at least 48 hours after infarction) when initial dose of 2.5 mg not tolerated**
- **Adult** (By Mouth): 1.25 mg twice daily for 2 days, then increased to 2.5 mg twice daily, withdraw treatment if dose cannot be increased to 2.5 mg twice daily, then increased to 5 mg twice daily.
**Prevention of cardiovascular events in patients with atherosclerotic cardiovascular disease or with diabetes mellitus and at least one additional risk factor**
- **Adult** (By Mouth): for cardiovascular disease Initially 2.5 mg once daily for 1-2 weeks, then increased to 5 mg once daily for 2-3 weeks, then increased to 10 mg once daily.
**Nephropathy (consult product literature)**
- **Adult** (By Mouth): Initially 1.25 mg once daily for 2 weeks, then increased to 2.5 mg once daily for 2 weeks, then increased if tolerated to 5 mg once daily.
Cautions
For all angiotensin-converting enzyme inhibitors Concomitant diuretics; diabetes (may lower blood glucose; increased risk of hyperkalaemia); first dose hypotension (especially in patients taking high doses of diuretics, on a low-sodium diet, on dialysis, dehydrated, or with cerebrovascular disease, ischaemic heart disease, or heart failure); patients of black African or African-Caribbean origin (may respond less well to ACE inhibitors); peripheral vascular disease or generalised atherosclerosis (risk of clinically silent renovascular disease); primary aldosteronism (patients may respond less well to ACE inhibitors); the risk of agranulocytosis is possibly increased in collagen vascular disease (blood counts recommended); use with care in patients with aortic or mitral valve stenosis (risk of hypotension); use with care in patients with hypertrophic cardiomyopathy Cautions, further information Anaphylactoid reactions To prevent anaphylactoid reactions, ACE inhibitors should be avoided during dialysis with high-flux membranes (e.g. polyacrylonitrile) and during low-density lipoprotein apheresis with dextran sulfate; they should also be withheld before desensitisation with wasp or bee venom. M Elderly Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria to aid medication reviews (see Prescribing in the elderly for information). Potentially inappropriate: with hyperkalaemia with persistent postural hypotension i.e. recurrent drop in systolic blood pressure 20 mmHg (risk of syncope and falls)
Contraindications
For all angiotensin-converting enzyme inhibitors Hereditary or idiopathic angioedema; history of angioedema associated with prior ACE inhibitor therapy; the combination of an ACE inhibitor with aliskiren is contra-indicated in patients with an eGFR less than 60 mL/minute/1.73 m 2 ; the combination of an ACE inhibitor with aliskiren is contra-indicated in patients with diabetes mellitus
Side effects
For all angiotensin-converting enzyme inhibitors Common or very common Alopecia; angina pectoris; angioedema (can be delayed; more common in black patients); arrhythmias; asthenia; chest pain; constipation; cough; depression; diarrhoea; dizziness; drowsiness; dry mouth; dyspnoea; electrolyte imbalance; gastrointestinal discomfort; headache; hypotension; myalgia; nausea; palpitations; paraesthesia; renal impairment; rhinitis; skin reactions; sleep disorder; syncope; taste altered; tinnitus; vertigo; vomiting Uncommon Arthralgia; confusion; eosinophilia; erectile dysfunction; fever; haemolytic anaemia; hyperhidrosis; myocardial infarction; pancreatitis; peripheral oedema; photosensitivity reaction; respiratory disorders; stroke Rare or very rare Agranulocytosis; hepatitis; leucopenia; neutropenia; pancytopenia; Stevens-Johnson syndrome; thrombocytopenia Side-effects, further information In light of reports of cholestatic jaundice, hepatitis, fulminant hepatic necrosis, and hepatic failure, ACE inhibitors should be discontinued if marked elevation of hepatic enzymes or jaundice occur. Side-effects For ramipril Common or very common Gastrointestinal disorders; increased risk of infection; muscle spasms Uncommon Anxiety; appetite decreased; asthma exacerbated; flushing; libido decreased; myocardial ischaemia; nasal congestion; proteinuria aggravated; vision disorders Rare or very rare Conjunctivitis; hearing impairment; hepatic disorders; hypoperfusion; movement disorders; onycholysis; oral disorders; tremor; vascular stenosis; vasculitis Frequency not known Altered smell sensation; bone marrow failure; cerebrovascular insufficiency; concentration impaired; enanthema; gynaecomastia; hypersensitivity; Raynaud's phenomenon; SIADH; toxic epidermal necrolysis
Interactions
**Other interactions (10):**
- Clinical trial data has shown that dual blockade of the renin-angiotensin-aldosterone-system (RAAS) through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is...
- Precautions for use Potassium salts, heparin, potassium-retaining diuretics and other plasma potassium increasing active substances (including Angiotensin II antagonists, trimethoprim and in fixed...
- Antihypertensive agents (e.g.
- Allopurinol, immunosuppressants, corticosteroids, procainamide, cytostatics and other substances that may change the blood cell count: Increased likelihood of haematological reactions (see section...
- Lithium salts: Excretion of lithium may be reduced by ACE inhibitors and therefore lithium toxicity may be increased.
- Lithium level must be monitored.
Pregnancy
Important safety information For all angiotensin-converting enzyme inhibitors MHRA/CHM advice: ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy (December 2014) See Conception and contraception and Pregnancy . MHRA/CHM advice: ACE inhibitors and angiotensin II receptor antagonists: recommendations on how to use for breastfeeding (December 2014) See Breast feeding .
Breast feeding
For all angiotensin-converting enzyme inhibitors Information on the use of ACE inhibitors in breast-feeding is limited. Breast feeding For ramipril Not recommended; alternative treatment options, with better established safety information during breast-feeding, are available.
Hepatic impairment
Ramipril is a prodrug. Manufacturer advises caution. Dose adjustments Manufacturer advises maximum 2.5 mg daily.
Renal impairment
For all angiotensin-converting enzyme inhibitors Caution (hyperkalaemia and other side-effects of ACE inhibitors are more common in those with impaired renal function). M Dose adjustments Start with low dose and adjust according to response. M Renal impairment For ramipril Dose adjustments Max. daily dose 5 mg if creatinine clearance 30-60 mL/minute; max. initial dose 1.25 mg once daily (do not exceed 5 mg daily) if creatinine clearance less than 30 mL/minute. M See Prescribing in renal impairment .
Medicinal forms
Solution,Tablet,Capsule,Solution
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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