ramipril

(ra mi' pril)

Altace

Pregnancy Category C (first trimester)

Pregnancy Category D (second and third trimesters)

Drug classes
Antihypertensive
Angiotensin-converting enzyme (ACE) inhibitor

Therapeutic actions
Ramipril blocks ACE from converting angiotensin I to angiotensin II, a powerful
vasoconstrictor, leading to decreased BP, decreased aldosterone secretion, a small
increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin
synthesis also may be involved in the antihypertensive action.

Indications
• Treatment of hypertension alone or in combination with thiazide-type diuretics
• Treatment of CHF in stable patients in the first few days after MI
• To decrease the risk of CV disease in patients at risk for developing CAD

Contraindications and cautions

• Contraindicated with allergy to ramipril, pregnancy (embryocidal in preclinical
studies).
• Use cautiously with impaired renal function, CHF, salt or volume depletion,
lactation.

Available forms
Capsules—1.25, 2.5, 5, 10 mg

Dosages
ADULTS
• Hypertension: Initial dose, 2.5 mg PO daily. Adjust dose according to BP
response, usually 2.5–20 mg/day as a single dose or in 2 equally divided doses.
Discontinue diuretic 2–3 days before beginning therapy; if not possible,
administer initial dose of 1.25 mg.
• CHF: Initial dose, 2.5 mg PO bid; if patient becomes hypotensive, 1.25 mg PO
bid may be used while adjusting up to target dose of 5 mg PO bid.
• Decrease risk of CAD: Initial dose, 2.5 mg PO once daily for 1 wk, then 5 mg PO
once daily for next 3 wk, maintenance 10 mg PO daily.
PEDIATRIC PATIENTS
Safety and efficacy not established.
GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT
Excretion is reduced in renal failure; use smaller initial dose, 1.25 mg PO daily in
patients with creatinine clearance < 40 mL/min; dosage may be titrated upward until
pressure is controlled or a maximum of 5 mg/day.

Pharmacokinetics
Route Onset Peak Duration
Oral 1–2 hr 1–4 hr 24 hr

Metabolism: Hepatic; T1/2: 13–17 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine and feces

Adverse effects
• CV: Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, hypotension in
salt- or volume-depleted patients, syncope
• Dermatologic: Rash, pruritus, pemphigoid-like reaction, photosensitivity,
erythema multiforme, Stevens-Johnson syndrome
• GI: Gastric irritation, aphthous ulcers, dysgeusia, cholestatic jaundice,
hepatocellular injury, anorexia, constipation, pancreatitis
• GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary
frequency
• Hematologic: Neutropenia, agranulocytosis, thrombocytopenia, hemolytic
anemia, pancytopenia
• Other: Cough, malaise, dry mouth, lymphadenopathy, angioedema

Interactions
Drug-drug
• Exacerbation of cough if taken with capsaicin
• Increased serum levels and increased toxicity with lithium; monitor patient
closely
Drug-food
• Rate of absorption is decreased with food
Drug-lab test
• False-positive test for urine acetone

Nursing considerations
Assessment
• History: Allergy to ramipril, impaired renal function, CHF, salt or volume
depletion, pregnancy, lactation
• Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous
membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function
tests, CBC and differential

Interventions
• Administer 1 hr before or 2 hr after meals.
 • Discontinue diuretic for 2–3 days before beginning therapy, if possible, to avoid
severe hypotensive effect.
• Open capsules and sprinkle contents over a small amount of applesauce or mix in
applesauce or water if patient has difficulty swallowing capsules. Mixture is
stable for 24 hr at room temperature and 48 hr if refrigerated.
• Alert surgeon and mark chart that ramipril is being used; the angiotensin II
formation subsequent to compensatory renin release during surgery will be
blocked; hypotension may be reversed with volume expansion.
• Monitor patient closely for falling BP secondary to reduction in fluid volume
(excessive perspiration and dehydration, vomiting, diarrhea) because excessive
hypotension may occur.
• Reduce dosage in patients with impaired renal function.

Teaching points
• Take drug 1 hr before meals. Do not stop taking without consulting your
prescriber.
• Be careful in any situation that may lead to a drop in BP (diarrhea, sweating,
vomiting, dehydration); if light-headedness or dizziness should occur, consult
your health care provider.
• These side effects may occur: GI upset, loss of appetite, change in taste perception
(transient) mouth sores (use frequent mouth care); rash; fast heart rate; dizziness,
light-headedness (transient; change position slowly, and limit your activities to
those that do not require alertness and precision).
• Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular
heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty breathing.

Adverse effects in Italic are most common; those in Bold are life-threatening.