Ramipril
ALTACE
What it isACE inhibitor; hypertension, heart failure and cardiovascular risk reduction.
Why this oneCardiovascular event reduction in high-risk patients without heart failure, which is a broader indication than most of the class carries.
What limits itCough, hyperkalemia and the hemodynamic creatinine rise. Contraindicated in pregnancy.
FDA-approved for
- hypertension (1991)
- cardiovascular risk reduction (2000)
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Hypertension | Adults (no diuretic) | 2.5 mg QD | 2.5-20 mg/day QD or divided BID | 20 mg/day |
| Reduce risk of MI/stroke/CV death | Adults | 2.5 mg QD x1 wk, then 5 mg QD x3 wk | 10 mg QD | 10 mg/day |
| Heart failure post-MI | Adults | 2.5 mg BID (1.25 mg BID if hypotensive) | 5 mg BID | 5 mg BID |
Titration HTN: reassess after 2-4 wks; HF post-MI: increase ~3 wks apart
Renal HTN & HF with renal impairment: initial 1.25 mg QD; adjust downward in moderate-severe impairment
Hepatic Impaired liver function may markedly elevate ramipril levels; use caution
Instructions
- May be given once daily or in two divided doses
- Discontinue as soon as possible if pregnancy detected
Contraindications
- History of angioedema with any ACE inhibitor, or hereditary/idiopathic angioedema
- Concomitant neprilysin inhibitor (sacubitril); do not use within 36 h of sacubitril/valsartan
- With aliskiren in patients with diabetes
Cautions
- Angioedema (increased risk with prior history)
- Hypotension and hyperkalemia
- Renal impairment — monitor renal function
- Avoid dual RAS blockade (ACEi + ARB)
- Rare cholestatic jaundice / hepatic failure
- Rare neutropenia / agranulocytosis
Adverse reactions
- Headache
- Dizziness
- Fatigue/asthenia
- Cough
Pregnancy Contraindicated implication — fetal renal toxicity, oligohydramnios, skull hypoplasia, death in 2nd/3rd trimester; discontinue when detected
Lactation Not recommended in nursing mothers
⚠ BOXED WARNING
- Fetal toxicity; discontinue as soon as pregnancy is detected
Principal riskAngioedema and hyperkalemia
Cost, est. cash$5–$150/month
Generic entry2005
Classes and tags
Clinical profile
Legacy pregnancy categoryD
Defining liabilityHyperkalemia, kidney injury, angioedema, fetal toxicity and increased lithium exposure.
Active metabolites
Mechanism of action: Ramipril ballicule
Open Ramipril in the interactive console ↗
Memory aids: mascots and interaction avatars
Easter/April theme → ACE inhibitor = -pril (aPril)
Bananas in bunches → ↑ serum potassium
