ACE Inhibitor Pregnancy: Not recommended during the first trimester and contraindicated during the second and third trimesters. Unless continued ACE inhibitor therapy is considered essential, patients planning pregnancy should be changed to alternative antihypertensives with an established safety profile in pregnancy; when pregnancy is diagnosed, stop immediately and start alternative therapy if appropriate. Exposure in the second and third trimesters is known to cause human foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia); if exposure has occurred from the second trimester, ultrasound check of foetal renal function and skull is recommended and newborns should be observed closely for hypotension, oliguria and hyperkalaemia. Breast-feeding: not recommended — insufficient information; alternatives with better established safety are preferable, especially for a newborn or preterm infant.

Ramipril 2.5–10mg

Brand names: Tritace, Altace

Ramipril is an oral ACE inhibitor used in chronic kidney disease for blood pressure control and to slow progression, particularly where there is proteinuria, as well as in hypertension, heart failure and after myocardial infarction.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Treatment of renal disease — diabetes with microalbuminuria, or non-diabetic nephropathy defined by macroproteinuria ≥ 3 g/day: initial 1.25 mg once daily, doubled to 2.5 mg once daily after two weeks and then to 5 mg once daily after a further two weeks, as tolerated. Diabetes with at least one cardiovascular risk factor: initial 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 daily dose 10 mg.

Route: Oral — swallow whole with liquid; must not be chewed or crushed. May be taken before, with or after meals.

Frequency: Once daily, taken at the same time each day (titrated as above)

Max: 10 mg daily is the maximum permitted dose (stated for hypertension). Lower ceilings apply in renal impairment (see renalAdjustment) and in hepatic impairment (maximum 2.5 mg daily).

Source: UK SPC (eMC) for Ramipril 10 mg Tablets, §4.2 (https://www.medicines.org.uk/emc/product/8067/smpc). OTHER INDICATIONS IN THE SAME §4.2 — Hypertension: individualise; start 2.5 mg daily (1.25 mg if the renin-angiotensin-aldosterone system is strongly activated, initiated under medical supervision), doubling at two- to four-week intervals to a maximum of 10 mg daily. Cardiovascular prevention: start 2.5 mg once daily, double after one or two weeks, then after a further two to three weeks increase to the target maintenance dose of 10 mg once daily. Symptomatic heart failure: in patients stabilised on a diuretic start 1.25 mg daily, doubling every one to two weeks up to a maximum of 10 mg daily, preferably in two administrations per day. Secondary prevention after acute MI with heart failure: from 48 hours post-MI 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), then double at intervals of one to three days to a target maintenance of 5 mg twice daily; if the dose cannot be increased to 2.5 mg twice daily, withdraw treatment. In severe (NYHA IV) heart failure immediately after MI experience is lacking — if treated, start at 1.25 mg once daily with particular caution on any increase. DIURETIC-TREATED PATIENTS: hypotension may occur on initiation; if possible stop the diuretic 2 to 3 days before starting ramipril, otherwise start hypertensive patients at 1.25 mg and monitor renal function and serum potassium. ELDERLY: lower initial doses and more gradual titration; a reduced initial dose of 1.25 mg should be considered. PAEDIATRIC: safety and efficacy in children have not yet been established and no specific recommendation on posology can be made — verify any under-18 use against a children's formulary. §4.5 was not retrieved from the eMC in this bundle; the interactions listed below are drawn from eMC §4.3/§4.4 plus, where labelled, the US prescribing information — verify the full §4.5. §4.4 and §4.8 were truncated at the source-fetch limit.

Dose adjustments

Renal

Daily dose must be based on creatinine clearance: CrCl ≥ 60 mL/min — no adjustment of the initial dose (2.5 mg/day), maximum 10 mg daily; CrCl 30-60 mL/min — no adjustment of the initial dose (2.5 mg/day), maximum 5 mg daily; CrCl 10-30 mL/min — initial dose 1.25 mg/day, maximum 5 mg daily; haemodialysed hypertensive patients — ramipril is slightly dialysable, initial dose 1.25 mg/day and maximum 5 mg daily, given a few hours after haemodialysis is performed.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to ramipril, to any excipient or to any other ACE inhibitor
History of angioedema (hereditary, idiopathic, or due to previous angioedema with ACE inhibitors or AIIRAs)
Concomitant use with sacubitril/valsartan
Extracorporeal treatments leading to contact of blood with negatively charged surfaces
Significant bilateral renal artery stenosis, or renal artery stenosis in a single functioning kidney
Second and third trimesters of pregnancy
Hypotensive or haemodynamically unstable states
Concomitant use with aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR < 60 mL/min/1.73 m²)

Side effects

Persistent non-productive tickling cough (common), with bronchitis, sinusitis and dyspnoea
Hypotension, orthostatic blood pressure decrease and syncope (common); headache and dizziness (common)
Blood potassium increased (common); blood sodium decreased (rare); SIADH reported
Renal or hepatic impairment; raised hepatic enzymes/conjugated bilirubin, cholestatic jaundice, hepatocellular damage (uncommon)
Angioedema, including small bowel angioedema, and anaphylactic/anaphylactoid reactions
Neutropenia/agranulocytosis and other blood count decreases (uncommon); eosinophilia (common); pancreatitis (uncommon)

Interactions

Sacubitril/valsartan — concomitant use is contraindicated (§4.3)
Aliskiren-containing products — contraindicated in diabetes mellitus or renal impairment (GFR < 60 mL/min/1.73 m²) (§4.3)
Dual blockade of the renin-angiotensin-aldosterone system with an ACE inhibitor plus an angiotensin II receptor blocker or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function including acute renal failure — not recommended; ACE inhibitors and angiotensin II receptor blockers should not be used concomitantly in patients with diabetic nephropathy (§4.4)
Diuretics — risk of excessive hypotension on initiation; stop the diuretic 2 to 3 days beforehand if possible or start at 1.25 mg with monitoring of renal function and potassium (§4.2/§4.4)
US labelling (cross-check, verify vs UK §4.5): potassium-sparing diuretics (spironolactone, amiloride, triamterene) or potassium supplements increase the risk of hyperkalaemia — monitor serum potassium frequently; lithium — use with caution; gold — nitritoid reactions reported; NSAIDs — increased risk of renal impairment and loss of antihypertensive effect

Clinical monograph

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.

Reference: REIN Trial (Lancet 1997); KDIGO CKD Guidelines 2024; NICE NG203; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

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