ACE Inhibitor Pregnancy: Contraindicated (all trimesters)

Ramipril

Brand names: Tritace

Adult dose

Dose: 1.25–10 mg

Route: Oral

Frequency: Once daily

Max: 10 mg/day

Start 1.25–2.5 mg; titrate up every 2 weeks. Indications: hypertension, heart failure (post-MI), diabetic nephropathy, CV risk reduction.

Paediatric dose

Route:

Seek specialist opinion

Dose adjustments

Renal

Reduce dose: max 5 mg if eGFR 30–60; avoid if eGFR <30 (risk of hyperkalaemia and deteriorating renal function).

Hepatic

Caution in hepatic impairment — use lowest effective dose.

Clinical pearls

Antidote for ACE inhibitor-induced angioedema: stop drug; icatibant or C1 esterase inhibitor concentrate for severe cases
Check potassium and creatinine 1–2 weeks after initiation and after any dose increase
MHRA: avoid in pregnancy — causes fetal renal dysplasia and death
HOPE trial: ramipril reduced CV events in high-risk patients without heart failure

Contraindications

History of ACE-inhibitor–induced angioedema
Bilateral renal artery stenosis
Pregnancy
Concomitant aliskiren in diabetes/renal impairment
Hypersensitivity

Side effects

Persistent dry cough (10–15%)
Hypotension (especially first dose)
Hyperkalaemia
Acute kidney injury (especially in hypovolaemia or renal artery stenosis)
Angioedema (rare but life-threatening)

Interactions

NSAIDs (reduce efficacy + increase AKI risk)
Potassium-sparing diuretics/spironolactone (hyperkalaemia)
Lithium (increased levels)
Aliskiren (contraindicated in diabetes)
Ciclosporin (hyperkalaemia)

Monitoring

U&E (potassium, creatinine) at baseline, 1–2 weeks post-initiation and after dose changes
Blood pressure

Reference: BNFc; BNF 90; NICE NG136 (Hypertension); HOPE Trial (NEJM 2000); MHRA Safety Update. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

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