What is the maximum daily dose of ramipril (Angiotensin-Converting Enzyme inhibitor) for a typical adult patient with hypertension and normal renal function?

Maximum Daily Dose of Ramipril

The maximum daily dose of ramipril for adults with hypertension and normal renal function is 20 mg per day, administered as a single dose or in two equally divided doses. 1

Standard Dosing for Hypertension

• The FDA-approved dosing for ramipril in hypertension starts at 2.5 mg once daily for patients not receiving a diuretic 1
• The usual maintenance dosage range is 2.5 mg to 20 mg per day, which can be given as a single daily dose or divided into two equal doses 1
• In patients where the antihypertensive effect diminishes toward the end of the dosing interval with once-daily administration, consider either increasing the total daily dose (up to the 20 mg maximum) or switching to twice-daily administration 1

Evidence Supporting Higher Doses

• The landmark HOPE trial demonstrated significant cardiovascular benefits using ramipril 10 mg daily, including a 22% reduction in cardiovascular death, myocardial infarction, and stroke 2, 3
• Clinical studies show that ramipril doses in the range of 2.5 to 20 mg are effective in reducing and maintaining blood pressure control during long-term treatment 4
• Lower doses (1.25 mg daily) have shown inadequate clinical benefit, emphasizing the importance of adequate dosing to achieve therapeutic effects 3

Dose Adjustments for Renal Impairment

• For patients with creatinine clearance >40 mL/min, usual dosing regimens can be followed 1
• In patients with creatinine clearance ≤40 mL/min, the maximum total daily dose should be reduced to 5 mg 1
• For hypertensive patients with renal impairment, start at 1.25 mg once daily and titrate upward to a maximum of 5 mg total daily dose 1

Special Dosing Considerations

• In patients with suspected volume depletion or renal artery stenosis, initiate therapy at 1.25 mg once daily and adjust according to blood pressure response 1
• If blood pressure is not adequately controlled with ramipril monotherapy at maximum doses, a diuretic can be added rather than exceeding the 20 mg maximum 1
• Concomitant use with potassium supplements, potassium salt substitutes, or potassium-sparing diuretics can lead to dangerous increases in serum potassium and should be avoided 1

Clinical Efficacy Across Dose Range

• Ramipril 5 to 10 mg once daily shows comparable antihypertensive efficacy to usual therapeutic dosages of other ACE inhibitors and beta-blockers in mild to moderate essential hypertension 4
• In real-world studies, 41% of patients required only 2.5 mg and 81% required ≤5 mg once daily for adequate blood pressure control 5
• The therapeutic dose range of 2.5-10 mg once daily has been effective and well tolerated during treatment for up to two years 6