Ramipril 2.5–10mg

How it works

It inhibits angiotensin-converting enzyme, reducing angiotensin II and aldosterone; the resulting fall in efferent arteriolar tone lowers intraglomerular pressure and proteinuria in addition to lowering systemic blood pressure.

Prescribing in practice

• It is contraindicated in pregnancy and can cause acute kidney injury and hyperkalaemia, especially with volume depletion, NSAIDs, or in renovascular disease, so check renal function and potassium before and after starting or up-titrating.
• A modest initial rise in creatinine may be acceptable, but a large rise warrants review and exclusion of renal artery stenosis.
• Counsel on dry cough and the small risk of angioedema, and hold the drug during acute intercurrent illness with dehydration (sick-day guidance).

Monitoring

Check renal function and serum potassium before starting, after each dose increase, and periodically thereafter, along with blood pressure.

Counselling the patient

• Stop temporarily and seek advice if you have vomiting, diarrhoea or become dehydrated.
• Report a persistent dry cough or any swelling of the face, lips or tongue.
• Avoid over-the-counter anti-inflammatory painkillers unless advised.

Evidence & guidelines

Major trials demonstrate renoprotection and cardiovascular benefit, and NICE and current prescribing references support ACE inhibitors as first-line in proteinuric CKD.