Generic Name

Ramipril

Mechanism

Ramipril is an *angiotensin‑converting enzyme* (ACE) inhibitor.
• Enzyme blockade: Inhibits the conversion of angiotensin I → angiotensin II, a potent vasoconstrictor.
• Effect on neurohormonal axis: Reduces plasma renin activity, lowers aldosterone secretion, and increases bradykinin levels.
• Hemodynamic impact: Leads to vasodilation, decreased afterload and preload, and improved cardiac output.

Pharmacokinetics

• Absorption: Peak plasma concentration in 1–2 h; oral bioavailability ~30–50 % (dose‑dependent).
• Metabolism: Primarily hepatic to the active metabolite *ramiprilat* (about 10 % of dose).
• Elimination: Renal excretion; half‑life of ramiprilat ≈ 9–15 h (linear over therapeutic range).
• Special populations: Slower clearance in chronic kidney disease; dose adjustment recommended.

Indications

• Hypertension (primary or secondary).
• Heart Failure (NYHA class II–III).
• Post‑myocardial infarction for mortality reduction.
• Renal protection in type 2 diabetes patients with microalbuminuria.
• Pre‑operative preload reduction in elective cardiac surgery (off‑label use).

Contraindications

• Pregnancy: Category X – teratogenic risk to the fetus.
• Renal impairment: CrCl < 30 mL/min → dose reduction or avoidance.
• Hyperkalemia: Monitor serum K⁺; avoid with potassium‑sparing diuretics.
• History of angioedema (especially ACE‑inhibitor related).
• Hypersensitivity to any component.

Dosing

• Administration: Take with food to reduce GI irritation.
• Missed dose: Skip; do not double up.
• Long‑term therapy: Re‑evaluate renal function and electrolytes every 3–6 months.

Adverse Effects

• Common
• Dry cough (≈ 10–20 %)
• Dizziness or orthostatic hypotension (≈ 5–10 %)
• Headache
• Fatigue
• Serious
• Angioedema (≤ 0.1 %; treat with epinephrine, antihistamine, corticosteroid)
• Hyperkalemia (> 5.5 mmol/L) – consider discontinuation.
• Severe renal dysfunction (rise in creatinine > 50 % from baseline).
• Hypersensitivity rash.

Monitoring

• Renal function: Serum creatinine & eGFR at baseline, 1–2 weeks after initiation, then every 3–6 months (or sooner if indicated).
• Electrolytes: Serum K⁺, Na⁺; baseline and periodically.
• Blood pressure & heart rate: Check before dose titration.
• Urine albumin/creatinine ratio: In diabetes‐related kidney indications.
• Signs of angioedema: Patient education upon prescription.

Clinical Pearls

• First‑dose cough: A transient cough that typically resolves within 48–72 h; often considered a class effect.
• Potassium‑sparing diuretics: Combine cautiously; monitor K⁺ levels closely.
• Switching from captopril to ramipril: Ramipril’s longer half‑life allows once‑daily dosing; use a bridging strategy to avoid rebound hypertension.
• Post‑MI ‘starter dose’: 5 mg is usually better tolerated than 10 mg due to cough risk; titrate up after 2–4 weeks if needed.
• Renal protection: In type 2 diabetes with microalbuminuria, 5–10 mg/day reduces progression to end‑stage renal disease; start at the lower end and titrate while monitoring eGFR.
• Pregnancy exclusion: Even a single dose can cause fetal injury; discuss contraception with patients of reproductive age.
• Compliance tip: Take with a meal in a consistent routine; set a daily alarm to reduce missed doses.

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• *This drug card compiles current evidence and guidelines for Ramipril; clinicians should adapt dosing to individual patient factors and institutional protocols.*