Ramipril has mild interactions with at least 65 different drugs.This document does not contain all possible interactions from the use of this medication. Ramipril, USP is a 2-aza-bicyclo [3.3.0]-octane-3-carboxylic acid derivative. Exchange transfusions or dialysis may be required as a means of reversing hypotension and/or substituting for disordered renal function. Drug class: Angiotensin Converting Enzyme Inhibitors. Renal/heart failure: 1.25 mg PO qDay; may increase to 1.25 mg q12hr and to a maximum dose of 2.5 mg q12hr depending on clinical response and tolerability. The most likely clinical manifestations would be symptoms attributable to hypotension. Ramipril Last updated on Dec 1, 2022. Cleavage of the ester group (primarily in the liver) converts ramipril to its active diacid metabolite, ramiprilat. Patients were then followed for an average of 15 months, with the range of follow-up between 6 and 46 months. Capsules, USP ACE is a peptidyl dipeptidase that catalyzes the conversion of angiotensin I to the vasoconstrictor substance, angiotensin II. In the same study, approximately 2% of patients treated with Ramipril and hydrochlorothiazide for up to 56 weeks had abnormally high potassium values and an increase from baseline of 0.75 mEq/L or greater; and approximately 2% had abnormally low values and decreases from baseline of 0.75 mEq/L or greater [ see Warnings and Precautions (5.8)]. Other (causal relationships unknown): Clinically important changes in standard laboratory tests were rarely associated with Ramipril administration. Peak concentrations of ramiprilat in these patients, however, are not different from those seen in subjects with normal hepatic function, and the effect of a given dose on plasma ACE activity does not vary with hepatic function. Anaphylactoid Reactions During Desensitization. Ramipril Tablets are contraindicated in patients who are hypersensitive to this product or any other angiotensin converting enzyme inhibitor (e.g., a patient who has experienced angioedema during therapy with any other ACE inhibitor). Angiotensin II could presumably serve as a specific antagonist-antidote in the setting of ramipril overdose, but angiotensin II is essentially unavailable outside of scattered research facilities. Because of its potent binding to ACE and slow dissociation from the enzyme, ramiprilat shows two elimination phases. The terminal elimination phase has a prolonged half-life (>50 hours) and probably represents the binding/dissociation kinetics of the Ramiprilat/ACE complex. 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 (including acute renal failure) compared to monotherapy. See what the interactions are and for which people. In addition, ACE inhibitors (for which adequate data are available) cause a higher rate of angioedema in black than in non-black patients (see WARNINGS, Angioedema). A single-dose pharmacokinetic study was conducted in hypertensive patients with varying degrees of renal impairment who received a single 10 mg dose of Ramipril. temsirolimus) therapy or a neprilysin inhibitor may be at increased risk for angioedema. Adjust dose according to blood pressure response. Reduce risk of heart attack (myocardial infarction [MI]), Initial: 2.5 mg orally once/day for 1 week, THEN 5 mg once/day for 3 weeks, Maintenance: Increase as tolerated to 10 mg once/day; for, Reduce risk of MI, stroke, or death from cardiovascular causes in patients 55 years and older at high risk of developing a major cardiovascular event because of a history of, Initial (not on diuretic): 2.5 mg orally once/day, Maintenance: 2.5-20 mg orally once/day; daily dose may be either increased or divided twice daily if, CrCl less than 40 mL/min and concomitant diuretic therapy: Not to exceed 5 mg/day (25% of normal dose), Renal/heart failure: 1.25 mg orally once/day; may increase to 1.25 mg every 12 hours and to a maximum dose of 2.5 mg every 12 hours depending on clinical response and tolerability, Renal failure and hypertension: 1.25 mg orally once/day initially; may titrate upward, not to exceed 5 mg/day, Geriatric patients: At increased risk for renal dysfunction; adjust dose to renal clearance and monitor closely, Requires weeks for full effect; to start, use low dose and titrate every 1-2 weeks, Once/day dosing may result in diminished antihypertensive effect at end of day in some patients; consider increase in dosage or dosing interval (every 12 hours), If blood pressure is not adequately treated, consider adding diuretic, Consider ACE inhibitor in high-risk patients, even if no hypertension or congestive heart failure (CHF), Abrupt discontinuance not associated with rapid increase in blood pressure, Pediatric: Safety and efficacy not established. Coadministration with mTOR inhibitors (e.g., temsirolimus) may increased risk for angioedema. Ramipril Increases in blood urea nitrogen levels occurred in 0.5% of patients receiving Ramipril alone and in 3% of patients receiving Ramipril with a diuretic. The possibility of hypotensive effects with Ramipril can be minimized by either decreasing or discontinuing the diuretic or increasing the salt intake prior to initiation of treatment with Ramipril. The latter decrease may result in a small increase of serum potassium. Since ramipril decreases aldosterone secretion, elevation of serum potassium can occur. The angioedema was diagnosed by procedures including abdominal CT scan or ultrasound, or at surgery, and symptoms resolved after stopping the ACE inhibitor. Ramipril is also used to improve survival after a heart attack. Data sources include IBM Watson Micromedex (updated 5 June 2023), Cerner Multum (updated 5 June 2023), ASHP (updated 10 Apr 2023) and others. Ramipril has been compared with other ACE inhibitors, beta-blockers, and thiazide diuretics as monotherapy for hypertension. If such circumstances are suspected to be present, the initial starting dose should be 1.25 mg once daily. For patients with hypertension and renal impairment, the recommended initial dose is 1.25 mg ramipril once daily. Volume Depletion or Renal Artery Stenosis. Where there is involvement of the tongue, glottis, or larynx, likely to cause airway obstruction, appropriate therapy, e.g., subcutaneous epinephrine solution 1:1,000 (0.3 mL to 0.5 mL) should be promptly administered (see ADVERSE REACTIONS). The ONTARGET trial enrolled 25,620 patients >55 years old with atherosclerotic disease or diabetes with end-organ damage, randomized them to telmisartan only, ramipril only, or the combination, and followed them for a median of 56 months. Most epidemiologic studies examining fetal abnormalities after exposure to antihypertensive use in the first trimester have not distinguished drugs affecting the renin-angiotensin system from other antihypertensive agents. You may report side effects or health problems to FDA at 1-800-FDA-1088. Inform patients that light-headedness can occur, especially during the first days of therapy, and it should be reported. Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal. These effects are usually reversible. In some patients treated once daily, the antihypertensive effect may diminish toward the end of the dosing interval. Angioedema associated with laryngeal edema can be fatal. Cleveland Clinic is a non-profit academic medical center. Drug information provided by: Merative, . The dose may be increased to 1.25 mg twice daily, and up to a maximum dose of 2.5 mg twice daily depending on clinical response and tolerability. Post-Marketing Experience: In addition to adverse events reported from clinical trials, there have been rare reports of hypoglycemia reported during ramipril therapy when given to patients concomitantly taking oral hypoglycemic agents or insulin. Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. How ramipril (Altace) works Ramipril (Altace) is an angiotensin-converting enzyme (ACE) inhibitor. Potential neonatal adverse effects include skull hypoplasia, anuria, hypotension, renal failure, and death. The inactive ingredients present are pregelatinized starch NF, gelatin, and titanium dioxide. Store in a Dry Place. Additionally, coadministration of ramipril with phenprocoumon did not affect minimum phenprocoumon levels or interfere with the subjects state of anti-coagulation. Description and Brand Names. After multiple daily doses of Ramipril capsules 5 mg to 10 mg, the half-life of Ramiprilat concentrations within the therapeutic range was 13 to 17 hours. Ramipril can attenuate potassium loss caused by thiazide diuretics. These drugs should be coadministered with caution, and frequent monitoring of serum lithium levels is recommended. Candesartan Cilexetil Hydrochlorothiazide, High Blood Pressure (Hypertension) Medications, How Crohn's Differs From Ulcerative Colitis. When pregnancy is detected, discontinue Ramipril as soon as possible [ see Use in Specific Populations (8.1)]. Brand name: Altace. Ramipril is converted to ramiprilat by hepatic cleavage of the ester group. Of the total number of patients who received Ramipril in U.S. clinical studies of Ramipril, 11.0% were 65 years of age while 0.2% were 75 years of age. In longer term (4 to 12 weeks) controlled studies, once-daily doses of 2.5 to 10 mg were similar in their effect, lowering supine or standing systolic and diastolic blood pressures 24 hours after dosing by about 6/4 mm Hg more than placebo. Single oral doses in rats and mice of 10 to 11 g/kg resulted in significant lethality. After oral administration of ramipril, about 60% of the parent drug and its metabolites is eliminated in the urine, and about 40% is found in the feces. These effects are usually reversible. Other ACE inhibitors have had less than additive effects with beta adrenergic blockers, presumably, because both drugs lower blood pressure by inhibiting parts of the renin-angiotensin system. Where there is involvement of the tongue, glottis, or larynx likely to cause airway obstruction, administer appropriate therapy (e.g., subcutaneous epinephrine solution 1:1000 [0.3 mL to 0.5 mL]) promptly [see Adverse Reactions (6)]. Because the hypotensive effect of ramipril is achieved through vasodilation and effective hypovolemia, it is reasonable to treat ramipril overdose by infusion of normal saline solution. While the mechanism through which ramipril lowers blood pressure is believed to be primarily suppression of the renin-angiotensin-aldosterone system, ramipril has an antihypertensive effect even in patients with low-renin hypertension. As a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function may be anticipated in susceptible individuals. Safety and effectiveness in pediatric patients have not been established. In patients with heart failure post-myocardial infarction who are currently being treated with a diuretic, symptomatic hypotension occasionally can occur following the initial dose of Ramipril. systemic lupus erythematosus, scleroderma) and renal impairment. During the second and third trimesters of pregnancy, therapy can result in fetal injury (e.g., hypotension. Do not administer Ramipril capsules within 36 hours of switching to or from sacubitril/valsartan, a neprilysin inhibitor [see Warnings and Precautions (5.1)]. It works by blocking a substance in the body that causes blood vessels to tighten. Single doses of Ramipril of 2.5 mg to 20 mg produce approximately 60% to 80% inhibition of ACE activity 4 hours after dosing with approximately 40% to 60% inhibition after 24 hours. Concomitant administration of Ramipril capsules with potassium supplements, potassium salt substitutes, or potassium-sparing diuretics can lead to increases of serum potassium [see Warnings and Precautions (5.8)]. If such circumstances are suspected to be present, initiate dosing at 1.25 mg once daily. The overall incidence of reported adverse events was similar in Ramipril and placebo patients. Always read the label. Ramipril Volume and/or salt depletion should be corrected before initiating therapy with ramipril. Monitor renal function periodically in patients receiving Ramipril and NSAID therapy. Renal: Acute renal failure. The recommended initial dose for patients to be treated for hypertension, not receiving a diuretic is 2.5 mg once a day. Patients receiving the combination of telmisartan and Ramipril did not obtain any benefit in the composite endpoint of cardiovascular death, MI, stroke and heart failure hospitalization compared to monotherapy, but experienced an increased incidence of clinically important renal dysfunction (death, doubling of serum creatinine, or dialysis) compared with groups receiving telmisartan alone or Ramipril alone. The absolute bioavailabilities of Ramipril and Ramiprilat were 28% and 44%, respectively, when 5 mg of oral Ramipril was compared with the same dose of Ramipril given intravenously. Ramipril is an ACE inhibitor and works by relaxing blood vessels so that blood can flow more easily. Subscribe to Drugs.com newsletters for the latest medication news, new drug approvals, alerts and updates. What Are Side Effects Associated with Using Ramipril (Zovirax)? The appearance of hypotension after the initial dose of Ramipril capsules does not preclude subsequent careful dose titration with the drug, following effective management of the hypotension [see Warnings andPrecautions (5.5), Drug Interactions (7.1)]. The antihypertensive effect of Ramipril has been shown to continue during long-term therapy for at least 2 years. Ramipril may also be used to help protect the kidneys from harm due to diabetes. The most common reasons for discontinuation were: cough (1.0%), dizziness (0.5%), and impotence (0.4%). Inform patients that inadequate fluid intake or excessive perspiration, diarrhea, or vomiting while taking Ramipril capsules can lead to an excessive fall in blood pressure, with the same consequences of lightheadedness and possible syncope. Shown to continue during long-term therapy for at least 2 years initiate dosing at 1.25 mg once. 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