Ramipril Dosing for Essential Hypertension
The recommended dose range of ramipril for essential hypertension is 2.5 mg to 20 mg daily, with a typical starting dose of 2.5 mg once daily and titration based on blood pressure response. 1
Initial Dosing
- Starting dose: 2.5 mg once daily for patients not currently on diuretics 1
- Lower starting dose: 1.25 mg once daily for patients with:
- Renal impairment (creatinine clearance <40 mL/min) 1
- Volume depletion (e.g., current or past diuretic use)
- Suspected renal artery stenosis
Dose Titration
- Adjust dose according to blood pressure response
- Usual maintenance dose range: 2.5 mg to 20 mg daily 1
- Administration options:
- Single daily dose
- Two equally divided doses (especially if antihypertensive effect diminishes toward end of dosing interval)
- Most patients achieve adequate control with ≤5 mg once daily 2
- In a large study of 591 hypertensive patients, 41% required only 2.5 mg and 81% required ≤5 mg once daily 2
Maximum Dosing
Combination Therapy
- If blood pressure is not controlled with ramipril alone, a diuretic can be added 1
- Studies show that patients who don't respond adequately to ramipril monotherapy usually respond with the addition of a thiazide diuretic such as hydrochlorothiazide 3
Administration Considerations
- Ramipril can be taken with or without food
- Capsules can be swallowed whole or opened and contents sprinkled on applesauce or mixed with water/apple juice 1
- Monitor for hypotension after initial dose, especially in patients:
- Starting on higher doses
- Taking diuretics
- With volume depletion
- With renal impairment
Efficacy
- Ramipril 5-10 mg once daily shows comparable antihypertensive efficacy to therapeutic dosages of captopril, enalapril, and atenolol in patients with mild to moderate essential hypertension 3, 4
- In clinical studies, ramipril reduced mean systolic/diastolic blood pressure by approximately 20/15 mmHg 2
Clinical Pearls
- Ramipril is a prodrug that is hydrolyzed after absorption to form the active metabolite ramiprilat, which has a long elimination half-life allowing once-daily dosing 3
- Avoid concomitant use with potassium supplements, potassium salt substitutes, or potassium-sparing diuretics without careful monitoring, as this can lead to hyperkalemia 1
- Monitor renal function and potassium levels, especially when initiating therapy or increasing doses
This dosing guidance is based on FDA-approved labeling and clinical evidence, prioritizing mortality, morbidity, and quality of life outcomes in patients with essential hypertension.