Ramipril with felodipine

How it works

Ramipril inhibits angiotensin-converting enzyme to reduce angiotensin-II-mediated vasoconstriction and aldosterone release, while felodipine blocks vascular L-type calcium channels to relax arterial smooth muscle, lowering blood pressure by complementary routes.

Prescribing in practice

• Avoid in pregnancy because the ACE-inhibitor component is foetotoxic; advise effective contraception in women of childbearing potential.
• ACE inhibitors can cause angioedema requiring permanent withdrawal and a persistent dry cough, with risk of hyperkalaemia and renal impairment in volume depletion, renal artery stenosis or with NSAIDs.
• Felodipine commonly causes ankle oedema, flushing and headache and undergoes interaction with grapefruit juice and CYP3A4 inhibitors, which can increase its levels and cause hypotension.

Monitoring

Monitor blood pressure, renal function and serum potassium after initiation and following any dose change.

Counselling the patient

• Avoid grapefruit juice, which can raise levels of the felodipine component.
• Seek urgent help for swelling of the face, lips, tongue or throat.
• Report a persistent dry cough and tell your doctor at once if you become pregnant.

Evidence & guidelines

Pairing a renin-angiotensin blocker with a calcium-channel blocker is supported by NICE hypertension guidance, and fixed-dose combinations improve adherence.