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Antihypertensive Pregnancy: D (second and third trimester) — teratogenic. Stop as soon as pregnancy confirmed.

Ramipril

Brand names: Tritace, Altace

Adult dose

Dose: HTN: 2.5–10mg OD. Post-MI/HFrEF: 2.5mg BD, titrate to 5mg BD. Nephroprotection: 1.25–5mg OD
Route: Oral
Frequency: Once or twice daily
Max: 10mg/day
First dose hypotension risk: take first dose at bedtime. Post-MI (AIRE trial): start 2.5mg BD day 3–10, titrate to 5mg BD over 2–3 weeks. CKD/proteinuria: aim for max tolerated dose.

Dose adjustments

Renal

GFR 30–60: use with monitoring. GFR 10–30: start at 1.25mg OD, max 5mg/day. GFR <10: avoid.

Hepatic

Start at 1.25mg OD in hepatic impairment. Max 2.5mg/day.

Clinical pearls

  • ACE inhibitor cough (class effect): if troublesome, switch to ARB (e.g. losartan, candesartan) — same BP and renal protective benefit without cough.
  • Check U&E and eGFR 1–2 weeks after starting or dose change. Up to 30% rise in creatinine is acceptable — stop if >30% rise or K+ >5.5.
  • 'Triple whammy': ACE inhibitor + diuretic + NSAID = high risk of acute kidney injury. Sick-day rules: withhold ramipril and diuretic during vomiting/diarrhoea.
  • AIRE trial: ramipril 5mg BD post-MI with clinical HF reduced mortality by 27% (NNT = 17 over 15 months).

Contraindications

  • Bilateral renal artery stenosis or unilateral in solitary kidney
  • History of ACE inhibitor-associated angioedema
  • Hyperkalaemia (K+ >5.5 mmol/L)
  • Pregnancy (fetotoxic — avoid from second trimester onwards)
  • Concomitant use with aliskiren in diabetes or CKD (GFR <60)

Side effects

  • Dry persistent cough (10–15% of patients — class effect)
  • First-dose hypotension — especially in volume-depleted patients
  • Hyperkalaemia
  • Worsening renal function (acute — especially in renal artery stenosis)
  • Angioedema (rare but life-threatening — 0.1–0.2%)
  • Teratogenic in pregnancy (second/third trimester)

Interactions

  • NSAIDs: reduced antihypertensive effect and increased renal toxicity (triple whammy with diuretics)
  • Potassium supplements / potassium-sparing diuretics: hyperkalaemia — monitor K+
  • Lithium: increased lithium toxicity
  • Aliskiren: dual blockade — avoid in diabetes and CKD

Monitoring

  • U&E and eGFR at 1–2 weeks after initiation/dose change
  • BP
  • signs of angioedema (face/lips/tongue)

Reference: NICE NG136 Hypertension; AIRE Trial Lancet 1993; NICE BNF 84. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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