Ramipril is a long-acting, non-sulfhydryl angiotensin-converting enzyme (ACE) inhibitor prodrug. It is hydrolyzed in the liver to its active metabolite, ramiprilat. It is a first-line antihypertensive agent and a cornerstone in the management of heart failure, post-myocardial infarction, and diabetic nephropathy in the Indian population. It is widely prescribed due to its favorable efficacy, tolerability, and cost-effectiveness.
Adult: Hypertension: Initial dose 2.5mg once daily. Maintenance: 2.5mg to 10mg once daily. Heart Failure/Post-MI: Initial 1.25mg to 2.5mg twice daily, titrated to a target of 5mg twice daily. CV Risk Reduction: Initial 2.5mg once daily for 1 week, then 5mg once daily for 3 weeks, then 10mg once daily.
Note: Can be taken with or without food, but consistency is advised. Swallow whole with a glass of water. For patients with difficulty swallowing, the capsule can be opened and the contents sprinkled on a small amount (about 120 mL) of apple sauce, apple juice, or water and consumed immediately without chewing.
Ramipril competitively inhibits angiotensin-converting enzyme (ACE or kininase II). This enzyme is responsible for the conversion of angiotensin I to the potent vasoconstrictor angiotensin II. Inhibition leads to decreased plasma angiotensin II levels, resulting in vasodilation, reduced aldosterone secretion, and decreased sodium and water retention. Additionally, by inhibiting the degradation of bradykinin, it potentiates the vasodilatory effects of the kallikrein-kinin system.
Pregnancy: CONTRANDICATED in second and third trimesters (Pregnancy Category D in 2nd/3rd trimester, Category C in 1st trimester). Use can cause fetal injury and death, including oligohydramnios, fetal skull hypoplasia, pulmonary hypoplasia, contractures, and neonatal anuric renal failure. Discontinue immediately if pregnancy is detected.
Driving: May cause dizziness, lightheadedness, or syncope, especially during initiation of therapy. Patients should be cautioned about operating machinery or driving until they know how the medication affects them.
| Diuretics (especially loop and thiazide) | Potentiates hypotensive effect; risk of first-dose hypotension. | Major |
| Potassium-sparing diuretics (Spironolactone, Amiloride) | Increased risk of severe hyperkalemia. | Major |
| Potassium supplements/Salt substitutes | Increased risk of hyperkalemia. | Major |
| Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) e.g., Ibuprofen, Diclofenac | May diminish antihypertensive effect and increase risk of renal impairment. | Moderate |
| Lithium | Decreased lithium excretion leading to lithium toxicity. | Major |
| Aliskiren | Increased risk of hypotension, hyperkalemia, and renal impairment (contraindicated in diabetes/CKD). | Major |
| Angiotensin II Receptor Blockers (ARBs) e.g., Telmisartan | Increased risk of hypotension, hyperkalemia, and renal impairment (dual blockade). | Major |
| Allopurinol, Procainamide, Immunosuppressants | Increased risk of hypersensitivity reactions, including Stevens-Johnson syndrome. | Moderate |
| Antidiabetic agents (Insulin, Sulfonylureas) | May enhance hypoglycemic effect. | Moderate |
| Gold injections (Sodium aurothiomalate) | Nitritoid reactions (flushing, nausea, hypotension). | Moderate |