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ACE Inhibitor

Ramipril 2.5–10mg

Brand names: Tritace, Altace

Adult dose

Dose: Starting dose: 2.5mg once daily. Titrate every 2–4 weeks to 5–10mg once daily as tolerated.
Route: Oral
Frequency: Once daily
Max: 10mg once daily
For CKD with proteinuria (diabetic or non-diabetic nephropathy) — reduces intraglomerular pressure and proteinuria. Titrate to maximum tolerated dose. An initial rise in creatinine (up to 30%) is acceptable on starting — do not stop unless >30% rise or hyperkalaemia develops.

Paediatric dose

Dose: 0.05 mg/kg
Route: Oral
Frequency: Once daily
Max: 5mg OD (paediatric specialist use)
Concentration: 1.25 mg, 2.5 mg, 5 mg, 10 mg capsules mg/ml
Paediatric use in proteinuric nephropathy and hypertension — specialist renal paediatrics. Starting 0.05–0.1 mg/kg OD, titrate to 0.1–0.2 mg/kg OD.

Dose adjustments

Renal

eGFR 30–60: start 1.25–2.5mg OD, titrate cautiously. eGFR <30: use with specialist guidance — risk of hyperkalaemia and acute-on-chronic renal deterioration. Check renal function and K+ within 1–2 weeks of starting or any dose increase.

Hepatic

Reduce dose in severe hepatic impairment — reduced activation (ramipril is a prodrug)

Paediatric weight-based calculator

Paediatric use in proteinuric nephropathy and hypertension — specialist renal paediatrics. Starting 0.05–0.1 mg/kg OD, titrate to 0.1–0.2 mg/kg OD.

Clinical pearls

  • REIN trial and HOPE trial: ramipril reduces progression to ESRD and cardiovascular mortality in CKD with proteinuria — first-line agent for proteinuric CKD
  • Sick day rules: hold ACEi during acute illness, diarrhoea, or before contrast (AKI risk) — 'triple whammy' with NSAIDs + diuretics is a common preventable cause of AKI
  • ACEi cough: dry cough occurs in ~15% — switch to ARB (losartan, candesartan) which has equivalent renoprotective effect without cough
  • Acceptable creatinine rise on starting: up to 30% above baseline is expected due to reduced intraglomerular pressure — only stop if >30% rise or severe hyperkalaemia
  • K+ monitoring is essential in CKD — check within 1–2 weeks of starting; if K+ >5.5 mmol/L, review dose or add potassium binder

Contraindications

  • Bilateral renal artery stenosis (or single functioning kidney with renal artery stenosis)
  • History of ACEi-associated angioedema
  • Pregnancy (all trimesters — teratogenic)
  • Hyperkalaemia (K+ >5.5 mmol/L)
  • Combination with aliskiren in diabetes or CKD (eGFR <60)

Side effects

  • Dry cough (up to 15–20% — class effect; switch to ARB if intolerable)
  • Hyperkalaemia
  • Acute kidney injury (reversible — especially with volume depletion, NSAIDs, contrast)
  • Angioedema (rare but life-threatening — higher risk in Afro-Caribbean patients)
  • First-dose hypotension
  • Dizziness

Interactions

  • Potassium-sparing diuretics/K+ supplements — hyperkalaemia (significant in CKD)
  • NSAIDs — AKI risk (triple whammy with diuretic)
  • Lithium — increased lithium toxicity
  • Aliskiren — dual RAAS blockade contraindicated in CKD/diabetes
  • Ciclosporin — additive hyperkalaemia

Monitoring

  • Renal function and potassium (before starting; 1–2 weeks after starting or dose change; then every 6 months)
  • Blood pressure
  • Urine ACR or PCR (proteinuria response)
  • Signs of angioedema

Reference: BNFc; BNF; REIN Trial (Lancet 1997); KDIGO CKD Guidelines 2024; NICE NG203. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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