What is the maximum recommended dose of ramipril (Angiotensin-Converting Enzyme (ACE) inhibitor) for patients with hypertension or heart failure?

Maximum Recommended Dose of Ramipril

The maximum recommended dose of ramipril is 20 mg daily for hypertension and 10 mg daily (5 mg twice daily) for heart failure. 1

Dosing Guidelines by Indication

For Hypertension:

• Initial dose: 2.5 mg once daily for patients not on diuretics 1
• Maintenance dose range: 2.5 mg to 20 mg per day 1
• Administration: Can be given as a single daily dose or divided into two equal doses 1
• Titration: Adjust dose according to blood pressure response 1

For Heart Failure (Post-MI):

• Initial dose: 2.5 mg twice daily (5 mg total daily) 1
• Target dose: 5 mg twice daily (10 mg total daily) 1
• Titration: Increase dose if tolerated after one week, with subsequent increases approximately 3 weeks apart 1
• If hypotension occurs: May reduce to 1.25 mg twice daily 1

Dosing Considerations for Special Populations

Renal Impairment:

• For creatinine clearance >40 mL/min: Standard dosing regimen 1
• For creatinine clearance <40 mL/min: 25% of usual dose (maximum 5 mg daily for hypertension, 2.5 mg twice daily for heart failure) 1
• Initial dose with renal impairment: 1.25 mg once daily 1

Volume Depletion or Renal Artery Stenosis:

• Initial dose: 1.25 mg once daily 1
• Titration: Adjust according to blood pressure response 1

Administration Considerations

• Ramipril can be taken with or without food 1
• Capsules can be swallowed whole or opened and contents sprinkled on applesauce or mixed with water/apple juice 1
• Mixtures can be prepared up to 24 hours in advance at room temperature or 48 hours if refrigerated 1

Monitoring Recommendations

• Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 2
• Monitor at 3 months and subsequently at 6-month intervals 2
• Pay particular attention to potassium levels when used with potassium supplements, potassium-sparing diuretics, or potassium salt substitutes 1

Common Pitfalls to Avoid

• Abrupt discontinuation: Do not stop beta-blockers abruptly as this can cause rebound ischemia and arrhythmias 3
• Excessive diuresis: Avoid excessive diuresis before starting treatment; consider reducing or withholding diuretics for 24 hours 2
• Drug interactions: Avoid NSAIDs and COX-2 inhibitors in heart failure patients 3
• Combination therapy: Do not combine ARBs with ACE inhibitors and mineralocorticoid receptor antagonists due to increased risk of renal dysfunction and hyperkalemia 3

Contraindications

• Bilateral renal artery stenosis 2
• History of angioedema during previous ACE inhibitor therapy 2

Remember that while these are the maximum recommended doses, the goal is to achieve the target doses used in clinical trials that demonstrated mortality benefit, which may be lower than the maximum allowed doses.