Ramipril Dosing for Hypertension
For patients with hypertension, ramipril should be initiated at 2.5 mg once daily and titrated up to a maintenance dosage range of 2.5-20 mg per day, administered as a single dose or in two equally divided doses. 1
Initial Dosing
- Standard initial dose: 2.5 mg once daily 1
- For patients with renal impairment (creatinine clearance <40 mL/min): 1.25 mg once daily 1
- For patients with volume depletion or renal artery stenosis: 1.25 mg once daily 1
Dose Titration
- Adjust dose according to blood pressure response
- Usual maintenance dosage range: 2.5-20 mg per day 1
- Administration options:
- Single daily dose
- Two equally divided doses (if once-daily dosing shows diminished effect toward end of dosing interval) 1
- Most patients require ≤5 mg once daily (81% of patients in clinical practice) 2
Dosing Considerations
Efficacy
- In clinical trials, ramipril effectively reduced blood pressure with doses in the range of 2.5 to 20 mg 3
- In a large prospective study, 41% of patients required only 2.5 mg and 81% required ≤5 mg once daily for adequate blood pressure control 2
- Morning dosing of 10 mg once daily has been shown to be as effective as 5 mg twice daily in ambulatory blood pressure monitoring studies 4
Combination Therapy
- If blood pressure is not adequately controlled with ramipril alone, a thiazide diuretic can be added 1
- Combination therapy with hydrochlorothiazide has shown good efficacy and safety in long-term studies 5
Special Populations
- Renal impairment: Start with 1.25 mg once daily, with maximum total daily dose of 5 mg 1
- Volume depletion: Start with 1.25 mg once daily and adjust according to blood pressure response 1
Administration
- Ramipril capsules can be:
- Swallowed whole
- Opened and contents sprinkled on applesauce
- Mixed in water or apple juice 1
- When mixed with food or liquid, consume the mixture in its entirety
- Mixtures can be stored for up to 24 hours at room temperature or 48 hours under refrigeration 1
Monitoring
- After initial dose, observe patient under medical supervision for at least two hours and until blood pressure has stabilized for at least an additional hour 1
- Monitor serum potassium when using concomitantly with potassium supplements, potassium salt substitutes, or potassium-sparing diuretics 1
- For patients with renal impairment, monitor renal function and potassium levels 1
Common Pitfalls to Avoid
- Avoid combining ramipril with other ACE inhibitors or ARBs 6
- Avoid excessive diuresis before initiating treatment 6
- Consider reducing or withholding diuretics for 24 hours before starting ramipril to minimize risk of hypotension 6
- Avoid NSAIDs and COX-2 inhibitors when possible, as they may reduce the antihypertensive effect 6
Ramipril has been shown to be effective in reducing cardiovascular events in high-risk patients, as demonstrated in the HOPE study where ramipril 10 mg daily was associated with a 22% reduction in the composite endpoint of cardiovascular death, MI, and stroke 6.