Antihypertensive Pregnancy: Not recommended during the first trimester and contraindicated during the second and third trimesters (foetotoxicity — decreased renal function, oligohydramnios, skull ossification retardation; neonatal renal failure, hypotension, hyperkalaemia). Stop immediately when pregnancy is diagnosed. Not recommended during breast-feeding (UK SPC §4.6).

Ramipril

Brand names: Tritace, Altace

Used in: Acute Coronary Syndrome & Chest Pain Heart Failure Chronic Kidney Disease Hypertension

Ramipril is an ACE inhibitor used for hypertension, heart failure with reduced ejection fraction, after myocardial infarction, and for cardiovascular and renal protection (e.g. in diabetic nephropathy).

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: 2.5 mg once daily (initial)

Route: Oral

Frequency: Once daily (twice daily for post-MI regimens)

Max: 10 mg daily

Hypertension: start 2.5 mg daily (1.25 mg if strongly activated renin-angiotensin-aldosterone system or if a diuretic is not discontinued); double at 2-4 week intervals to target blood pressure; maximum 10 mg daily. Cardiovascular prevention: start 2.5 mg once daily; up-titrate to target maintenance dose of 10 mg once daily. Diabetes with microalbuminuria or non-diabetic nephropathy (macroproteinuria >=3 g/day): start 1.25 mg once daily, increase to 2.5 mg then 5 mg. Diabetes with at least one cardiovascular risk: start 2.5 mg once daily, increase to 5 mg then 10 mg. Symptomatic heart failure (stabilised on diuretic): start 1.25 mg daily, double every 1-2 weeks to maximum 10 mg daily, preferably in 2 divided doses. Secondary prevention after acute MI with heart failure: start 2.5 mg twice daily for 3 days (1.25 mg twice daily if not tolerated), titrate to maintenance 5 mg twice daily. Hepatic impairment: initiate only under close medical supervision, maximum 2.5 mg daily. Elderly: consider a reduced initial dose of 1.25 mg. Take at the same time each day; swallow whole, do not chew or crush. Paediatric population: safety and efficacy not established (section truncated in source).

Dose adjustments

Renal

Daily dose based on creatinine clearance: CrCl >=60 ml/min — no initial dose adjustment (2.5 mg/day), maximum 10 mg/day; CrCl 30-60 ml/min — no initial adjustment (2.5 mg/day), maximum 5 mg/day; CrCl 10-30 ml/min — initial 1.25 mg/day, maximum 5 mg/day; haemodialysed hypertensive patients — initial 1.25 mg/day, maximum 5 mg/day, given a few hours after haemodialysis.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

US labelling (FDA)

Reference — US labelling, may differ from UK

• Hypertension: Initial dose is 2.5 mg to 20 mg once daily. Adjust dosage according to blood pressure response after 2–4 weeks of treatment. The usual maintenance dose following titration is 2.5 mg to 20 mg daily as a single dose or equally divided doses ( 2.1 ). • Heart failure post-myocardial infarction: Starting dose of 2.5 mg twice daily. If patient becomes hypotensive at this dose, decrease dosage to 1.25 mg twice daily. Increase dose as tolerated toward a target dose of 5 mg twice daily, with dosage increases about 3 weeks apart ( 2.3 ). • Dosage adjustment: See respective sections pertaining to dosage adjustment in special situations ( 2.5 ). 2.1 Hypertension The recommended initial …

Source: US FDA prescribing information (openFDA / DailyMed), label dated 2022-07-01. Accessed 2026-06-12. US dosing and indications can differ from UK practice — use UK sources for prescribing decisions.

Contraindications

Hypersensitivity to the active substance, to any excipient, or to any other ACE inhibitor
History of angioedema (hereditary, idiopathic, or due to previous ACE inhibitor or AIIRA)
Concomitant use with sacubitril/valsartan
Extracorporeal treatments leading to contact of blood with negatively charged surfaces
Significant bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney
Second and third trimesters of pregnancy
Hypotensive or haemodynamically unstable states
Concomitant use with aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR <60 ml/min/1.73m2)

Side effects

Non-productive tickling (persistent dry) cough (common)
Hypotension, orthostatic blood pressure decreased, syncope
Hyperkalaemia (blood potassium increased)
Headache, dizziness (common)
Gastrointestinal disturbances — nausea, vomiting, diarrhoea, dyspepsia, abdominal discomfort; angioedema

Clinical monograph

How it works

It inhibits angiotensin-converting enzyme, lowering angiotensin II and aldosterone to produce vasodilatation, reduced blood pressure and reduced cardiac and renal workload. Reduced bradykinin breakdown contributes to the characteristic dry cough.

Prescribing in practice

Start low and titrate; check renal function and potassium before starting and 1–2 weeks after initiation or each dose increase.
A modest early rise in creatinine can be acceptable; a large rise suggests renovascular disease and should be investigated.
Avoid in pregnancy and in bilateral renal artery stenosis; use caution with potassium-raising drugs and NSAIDs.
A persistent dry cough is common and, if troublesome, is a reason to switch to an ARB.

Monitoring

Check U&E (renal function and potassium) at baseline, after initiation and titration, and periodically; monitor blood pressure for response.

Counselling the patient

The first dose can cause dizziness — take it at bedtime if advised.
Report a persistent dry cough.
Avoid potassium-based salt substitutes, and tell your prescriber if you become pregnant or unwell with vomiting or diarrhoea.

Evidence & guidelines

ACE inhibitors are a cornerstone of HFrEF and post-MI care and a first-line antihypertensive in younger, non–Black-African/Caribbean patients per NICE NG136; cardiovascular/renal protection was shown in trials such as HOPE.

Reference: NICE NG136 Hypertension; AIRE Trial Lancet 1993; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

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