Recommended Ramipril Dosing for Hypertension and Heart Failure
For hypertension, ramipril should be initiated at 2.5 mg once daily and titrated up to 20 mg daily as needed, while for heart failure, ramipril should be started at 2.5 mg twice daily and titrated to a target dose of 5 mg twice daily.
Dosing for Hypertension
Initial Dosing
- Start with 2.5 mg once daily for patients not receiving a diuretic 1
- For patients with renal impairment, start with 1.25 mg once daily 1
- For patients with volume depletion or renal artery stenosis, start with 1.25 mg once daily 1
Maintenance Dosing
- Usual maintenance dose range: 2.5 mg to 20 mg daily (as single dose or divided twice daily) 1
- Titrate according to blood pressure response
- If blood pressure control diminishes toward end of dosing interval, consider twice daily administration 1
- Maximum dose for patients with renal impairment: 5 mg daily 1
Optimization Tips
- If blood pressure not controlled with ramipril alone, add a diuretic 1
- 81% of patients achieve control with ≤5 mg once daily 2
- Morning dosing is effective for 24-hour blood pressure control 3
Dosing for Heart Failure Post-MI
Initial Dosing
- Start with 2.5 mg twice daily (5 mg total daily dose) 1
- For patients with hypotension at this dose, reduce to 1.25 mg twice daily 1
- For patients with heart failure and renal impairment, start with 1.25 mg once daily 1
Titration and Target Dosing
- After one week, increase dose if tolerated
- Target dose: 5 mg twice daily 4, 1
- Allow approximately 3 weeks between dose increases 1
- Maximum dose for patients with renal impairment and heart failure: 2.5 mg twice daily 1
Administration Guidelines
- Generally, swallow ramipril capsules whole
- Can open capsule and sprinkle contents on applesauce or mix in water/apple juice 1
- Consider evening dosing to minimize potential blood pressure effects, though morning dosing is also effective 4, 3
- Monitor blood pressure for at least two hours after initial dose and until stable for at least an additional hour 1
Monitoring
- Check serum potassium and creatinine 5-7 days after initiation and after each dose increase 4
- Recheck every 5-7 days until potassium values are stable 4
- Long-term monitoring at 3 months and then every 6 months 4, 5
Important Precautions
- Avoid concomitant use with potassium supplements, potassium-sparing diuretics, or potassium salt substitutes due to risk of hyperkalemia 1
- Reduce or withhold diuretics 24 hours before starting ramipril if possible 4
- Avoid NSAIDs and COX-2 inhibitors during ramipril therapy 4, 5
- Contraindicated in patients with bilateral renal artery stenosis or history of angioedema with ACE inhibitors 4
Common Side Effects to Monitor
- Cough (consider switching to ARB if intolerable) 4, 5
- Hypotension (especially in volume-depleted patients)
- Renal insufficiency
- Hyperkalemia
- Syncope
- Angioedema (rare but serious)
Ramipril has demonstrated significant benefits in reducing mortality, myocardial infarction, and stroke in high-risk patients 6, making it a valuable medication for both hypertension and heart failure when dosed appropriately.