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Ramipril

Classification

ACE inhibitor, antihypertensive

Indications

CCP: NSTEMI/STEMI

CCP: HFrEF post MI (heart failure with reduced ejection fraction; EF ≤ 40%)

CCP: Hypertension

Contraindications

Hypersensitivity
Hereditary/idiopathic angioedema
Concomitant use with aliskiren in patients with diabetes mellitus
Concomitant use or within 36 hours of switching to or from a neprilysin inhibitor (eg, sacubitril).
Hemodynamically relevant bilateral renal artery stenosis or unilateral in the single kidney
Hypotensive or hemodynamically unstable states
Hyperkalemia (>5 mmol/L)
Congestive heart failure who are hypotensive.
Concomitant use with angiotensin II receptor blockers (ARBs) in patients with diabetes end organ damage
Moderate to severe renal impairment (GFR <60 mL/minute/1.73 m2)
Pregnancy, breastfeeding.

Cautions

Use with caution in patients with hepatic impairment.
Use with caution in patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction.

Adult dosages

CCP: NSTEMI/STEMI

2.5 mg od PO titrate up slowly based on response up to 20 mg/day

CCP: HFrEF

1.25 to 2.5 mg once daily; as tolerated, may increase every 1 to 2 weeks to a target dose of 10 mg once daily.

CCP: Hypertension

2.5 mg once daily; evaluate response every 2 to 4 weeks and titrate dose as needed up to 20 mg/day in 1 or 2 divided doses.

Pediatric Considerations And Dosing

Dosing is unavailable or not applicable for this medication.

Mechanism Of Action

Ramipril is an ACE (Angiotensin Converting Enzyme) inhibitor which prevents the formation of angiotensin II from angiotensin I. The pharmacodynamic effects of Ramipril result from the high-affinity, competitive, reversible binding of ramiprilat (the active metabolite) to angiotensin-converting enzyme, thus preventing the formation of the potent vasoconstrictor angiotensin II.

Pharmacokinetics

Onset: 1-2 hours

Duration: 24 hours

Time to peak: 1 hour

Half-life: 13-17 hours

Adverse Effects

Cardiovascular:

Hypotension
Angina pectoris, orthostatic hypotension, syncope

Immunologic

Anaphylactoid, angioedema, SJS

Respiratory:

Increased cough

Central nervous system:

Headache, dizziness, fatigue, vertigo, noncardiac chest pain

Endocrine & metabolic:

Hyperkalemia

Gastrointestinal:

Nausea, vomiting

Renal:

Increased blood urea nitrogen (transient increases may occur more frequently), increased serum creatinine (transient increases may occur more frequently), renal insufficiency

Warning And Precautions

Angioedema: At any time during treatment (especially following first dose), angioedema may occur rarely with ACE inhibitors; it may involve the head and neck (potentially compromising airway) or the intestine (presenting with abdominal pain).
A rare toxicity associated with ACE inhibitors includes cholestatic jaundice, which may progress to fulminant hepatic necrosis.
An ACE inhibitor cough is a dry, hacking, nonproductive one that usually occurs within the first few months of treatment and should generally resolve within 1 to 4 weeks after discontinuation of the ACE inhibitor.
Patients with renal impairment are at high risk of developing neutropenia. Patients with both renal impairment and collagen vascular disease (eg, systemic lupus erythematosus) are at an even higher risk of developing neutropenia.
Hyperkalemia may occur with ACE inhibitors. Risk factors include renal impairment, diabetes mellitus, concomitant use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salts.
Deterioration of renal function and/or increases in serum creatinine, particularly in patients with low renal blood flow (eg, renal artery stenosis, heart failure) whose GFR is dependent on efferent arteriolar vasoconstriction by angiotensin II.
Drugs that act on the renin-angiotensin system can cause injury and death to the developing fetus.
The use in patients breastfeeding is not recommended by the manufacturer.

Drug Interactions

Alfuzosin
Aliskiren
Allopurinol
Alteplase
Amifostine
Amphetamines
Angiotensin II
Angiotensin II Receptor Blockers
Antipsychotic Agents (Second Generation [Atypical])
Aprotinin
AzaTHIOprine
Barbiturates
Benperidol
Brigatinib
Brimonidine (Topical)
Bromperidol
Dapoxetine
Dexmethylphenidate
Diazoxide
Dipeptidyl Peptidase-IV Inhibitors
Drospirenone
DULoxetine
Eplerenone
Everolimus
Ferric Gluconate
Ferric Hydroxide Polymaltose Complex
Finerenone
Gelatin (Succinylated)
Gold Sodium Thiomalate
Grass Pollen Allergen Extract (5 Grass Extract)
Heparin
Heparins (Low Molecular Weight)
Herbal Products with Blood Pressure Increasing Effects
Herbal Products with Blood Pressure Lowering Effects
Hypotension-Associated Agents
Icatibant
Iron Dextran Complex
Lanthanum
Levodopa-Containing Products
Lithium
Loop Diuretics
Lormetazepam
Methylphenidate
Molsidomine
Naftopidil
Nicergoline
Nicorandil
Nitroprusside
Nonsteroidal Anti-Inflammatory Agents
Nonsteroidal Anti-Inflammatory Agents (Topical)
Obinutuzumab
Pentoxifylline
Pholcodine
Phosphodiesterase 5 Inhibitors
Potassium Salts
Potassium-Sparing Diuretics
Pregabalin
Prostacyclin Analogues
Quinagolide
Racecadotril
Ranolazine
Sacubitril
Salicylates
Sirolimus
Sodium Phosphates
Tacrolimus (Systemic)
Telmisartan
Temsirolimus
Thiazide and Thiazide-Like Diuretics
TiZANidine
Tolvaptan
Trimethoprim
Urapidil
Urokinase