Ramipril

How it works

It is a prodrug converted to ramiprilat, which inhibits angiotensin-converting enzyme, reducing angiotensin II formation and aldosterone secretion to cause vasodilatation and to lower blood pressure, with additional reduction of bradykinin breakdown.

Prescribing in practice

• Avoid in pregnancy and stop promptly if a patient becomes pregnant — ACE inhibitors are foetotoxic, causing oligohydramnios and renal and skull defects; it is also contraindicated with a history of angioedema.
• Do not combine with aliskiren or another renin-angiotensin blocker, and use cautiously alongside potassium-sparing diuretics, potassium supplements or NSAIDs because of hyperkalaemia and renal impairment risk.
• Initiate at a low dose with the first dose at bedtime where volume-depleted or on diuretics, as first-dose hypotension can occur, particularly in heart failure and bilateral renal artery stenosis.

Monitoring

Check renal function and serum potassium before starting, shortly after initiation and after each dose increase, and monitor blood pressure throughout.

Counselling the patient

• A dry persistent cough is common; report it as the drug may need changing.
• Seek urgent help for swelling of the face, lips or tongue or difficulty breathing.
• Rise slowly from sitting or lying to limit dizziness.

Evidence & guidelines

Cardiovascular and renal benefits are supported by large outcome trials and endorsed in NICE hypertension, heart failure and cardiovascular risk guidance.