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ACE Inhibitor Pregnancy: Contraindicated in pregnancy (fetotoxic)

Ramipril

Brand names: Tritace

Adult dose

Dose: 1.25-10 mg once daily
Route: Oral
Frequency: Once daily
Max: 10 mg/day
Start low in elderly (1.25 mg); titrate up monitoring renal function and blood pressure

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: Oral
Frequency: Seek specialist opinion
Max: Seek specialist opinion
Seek specialist opinion

Dose adjustments

Renal

Reduce dose: eGFR 30-60: start 1.25 mg; eGFR under 30: use with caution under specialist supervision; avoid if eGFR under 10

Hepatic

Use with caution in hepatic impairment

Paediatric weight-based calculator

Seek specialist opinion

Clinical pearls

  • First-dose hypotension is a particular risk in elderly — advise to take first dose at bedtime; check supine and standing BP
  • Check U&E and creatinine at baseline, 1-2 weeks after starting or dose change, and annually
  • A rise in creatinine of up to 30% from baseline after starting ACEi is acceptable and not a reason to stop — beyond this, investigate for renal artery stenosis
  • Cough develops in up to 15% — switch to ARB (e.g. losartan) if intolerable
  • HOPE trial demonstrated cardiovascular mortality benefit in high-risk patients regardless of baseline BP

Contraindications

  • History of ACE inhibitor-associated angioedema
  • Bilateral renal artery stenosis
  • Concurrent sacubitril/valsartan use (36-hour washout required)
  • Pregnancy

Side effects

  • Persistent dry cough (10-15%)
  • Hypotension (first dose — especially in elderly)
  • Hyperkalaemia
  • Acute kidney injury (especially with NSAIDs/diuretics)
  • Angioedema (rare but life-threatening)

Interactions

  • NSAIDs (reduce antihypertensive effect; increase AKI risk)
  • Potassium-sparing diuretics / potassium supplements (hyperkalaemia)
  • Lithium (ACE inhibitors increase lithium toxicity)
  • Aliskiren (avoid combination in diabetes or renal impairment)

Monitoring

  • Blood pressure
  • U&E and creatinine (baseline, 1-2 weeks post-initiation, annually)
  • Potassium
  • eGFR

Reference: BNFc; BNF 90; NICE NG136 (Hypertension); NICE NG106 (Chronic Heart Failure); HOPE Trial. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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