Ramipril

DEA Class; Rx

Common Brand Names; Altace

• ACE Inhibitors

ACE inhibitor; prodrug metabolized to active ramiprilat; used 1—2 times daily for HTN; also used to reduce proteinuria and slow the progression of renal disease from various nephropathies; given twice daily for CHF, AMI, and post-MI.

Indicated for reduction of cardiovascular mortality, myocardial infarction (myocardial infarction prophylaxis) and stroke (stroke prophylaxis) in adults 55 years or older who are at high risk of developing major cardiovascular events.

Hypersensitivity to drug or other ACE inhibitors

Do not coadminister with aliskiren in patients with diabetes mellitus or with renal impairment (ie, GFR <60 mL/min/1.73 m²)

Coadministration of neprilysin inhibitors (eg, sacubitril) with ACE inhibitors may increase angioedema risk; do not administer ACE inhibitors within 36 hr of switching to or from sacubitril/valsartan

• Cough (7-8%)
• Hypotension (2-11%)
• Headache (1-5%)
• Angina pectoris (3%)
• Dizziness (2-4%)
• Nausea (2%)
• Vomiting (2%)
• Postural hypotension (2%)
• Syncope (2%)
• Vertigo (2%)
• Abnormal kidney function (1%)
• Diarrhea (1%)
• Angioedema (0.3%)

Anaphylactoid and related reactions (head and neck/intestinal angioedema, anaphylaxis during desensitizing treatment with Hymenoptera venom, anaphylaxis during membrane exposure with high-flux membrane dialysis, and low-density lipoprotein apheresis with dextran sulfate absorption)

(Rare) risk of hepatic failure, which starts as cholestatic jaundice and progresses to sometimes fatal fulminant hepatic necrosis; discontinue if patient develops jaundice or marked elevations of hepatic enzymes

Excessive hypotension if on concomitant diuretics, hypovolemia, hyponatremia; increased risk in CHF patients; treat by placing patient in supine position and treating with IV infusion of physiologic saline if necessary

Increased hypotension risk in patients undergoing surgery or during anesthesia with agents that produce hypotension; correct by volume expansion in such situations

Coadministration with mTOR inhibitors (eg, temsirolimus) may increased risk for angioedema

African American patients may have a smaller average reduction in BP than other populations

Changes in renal function due to blockage of renin-angiotensin-aldosterone system; severe CHF patients are at increased risk for oliguria or progressive azotemia and (rarely) for acute renal failure or death; increase in BUN/SCr may occur in patients with unilateral or bilateral renal artery stenosis; monitor closely

Reduction in RBC and hemoglobin content with rare cases of agranulocytosis, pancytopenia and bone marrow depression reported; collagen-vascular disease (SLE, scleroderma) patients with impaired renal function are at increased risk; monitor closely

Dual blockade of the renin angiotensin system with ARBs, ACE inhibitors, or aliskiren associated with increased risk for hypotension, hyperkalemia, and renal function changes (including acute renal failure) compared to monotherapy

Risk of hyperkalemia, especially in patients with renal impairment, DM, concomitant use of K+-elevating drugs

Pregnancy category: D

Discontinue as soon as pregnancy detected; during the second and third trimesters of pregnancy, therapy can result in fetal injury (eg, hypotension, neonatal skull hypoplasia, anuria, reversible and irreversible renal failure) and death

Lactation: Possibly excreted in breast milk; nursing not recommended