Ramipril

ELDERLY: initial doses should be lower and subsequent titration more gradual because of the greater chance of undesirable effects, especially in very old and frail patients; a reduced initial dose of 1.25 mg ramipril should be considered. Diuretic-treated patients: hypotension is more likely; if possible discontinue the diuretic 2-3 days before starting ramipril, otherwise start at 1.25 mg and monitor renal function and serum potassium. OTHER INDICATIONS: Cardiovascular prevention - 2.5 mg once daily, double after one or two weeks and, after another two to three weeks, increase to the target maintenance dose of 10 mg once daily. Diabetes with microalbuminuria, and non-diabetic nephropathy with macroproteinuria of 3 g/day or more - 1.25 mg once daily, doubled to 2.5 mg after two weeks and then to 5 mg after a further two weeks. Diabetes with at least one cardiovascular risk factor - 2.5 mg once daily, doubled to 5 mg after one or two weeks and then to 10 mg after a further two or three weeks (target 10 mg daily). Symptomatic heart failure (patients stabilised on diuretic therapy) - initial 1.25 mg daily, titrated by doubling every one to two weeks up to a maximum of 10 mg daily, preferably in two administrations per day. Secondary prevention after acute myocardial infarction with heart failure - starting 48 hours after the infarct in a clinically and haemodynamically stable patient, 2.5 mg twice daily for three days (if not tolerated, 1.25 mg twice daily for two days before increasing to 2.5 mg then 5 mg twice daily); thereafter double the dose at intervals of one to three days to the target maintenance dose of 5 mg twice daily; withdraw treatment if the dose cannot be increased to 2.5 mg twice daily. Experience is lacking in severe (NYHA IV) heart failure immediately after myocardial infarction - if treated, start at 1.25 mg once daily with particular caution on any dose increase. Hepatic impairment: initiate only under close medical supervision; maximum daily dose 2.5 mg. NOTE: the fetched eMC bundle did not include §4.5, so the interaction list below is drawn from §4.3, §4.4 and the US label and is not a complete interaction profile.