Ramipril

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Ramipril quick reference

Ramipril
Ramipril general drug information
 Pronunciation RA mi prill (.wav file)
 Trade Name(s) Altace
 How Supplied Capsule: 1.25mg, 2.5mg, 5mg, 10mg
 Generic Availability No
 Patent Expiry Date October 2008
 Classification Angiotensin Converting Enzyme Inhibitor
 Schedule Rx
 Pregnancy Category C (first trimester) D (second and third trimester)
 Breast-feeding Altace may appear in breast milk and could affect a nursing infant. If this medication is essential to your health, your doctor may advise you to avoid breastfeeding.
Ramipril chemical information
 IUPAC Name (1S,5S,7S)-8-[(2S)-2-(1S)-1-ethoxycarbonyl-3-phenyl-propyl]amino]propanoyl]-8-azabicyclo[3.3.0]octane-7-carboxylic acid
 Empirical Formula C23H32N2O5
 Molecular Weight 416.511 g/mol
pharmacokinetic information  |  pharmacogenomic information
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Description

Ramipril belongs to a class of medications know as the anigotensin converting enzyme inhibitors used to treat and manage high blood pressure. Ramipril may also be used to reduce the risk of heart attack and stroke, and increase survival rates in patients who have heart failure after a heart attack.ACE Inhibitors including ramipril have been proven to provide protection against microvascular disease in diabetic patients.[1]

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Mechanism of Action

Ramipril prevents the angiotensin converting enzyme from converting angiotensin I to angiotensin II. Angiotensin II is a powerful vasoconstrictor. Taking ramipril leads to decreased blood pressure and decreased aldosterone secretion. Ramipril may cause a small increase in serum potassium levels, and some sodium and fluid loss. Increased prostaglandin synthesis may also occur. [2]

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Time Required for Therapeutic Response

  • Following oral administration of ramipril, peak plasma concentrations of ramipril are reached within two to four hours.[3]
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Pharmacokinetics

Absorption
Absorption of ramipril is not altered by food within the gastrointestinal tract, although the time it takes for complete absorption may be delayed. Absorption is at least 50-60%. [4]


Distribution
Ramiprilat is the active metabolite of ramipril, and is slightly less protein bound than the prodrug counter part (56% and 73% respectively). After four doses at once daily-dosing, concentrations within the body are normalized and the drug is at steady-state, with a bioavailability in the range of 44-66%.[5]

Metabolism
Ramipril is converted to its active metabolite, ramiprilat within the liver by the clevage of the side chain ester group. Maximal concentrations are obtained withing the first 4 hours after initial drug intake. Ramipril is almost completely metabolized to ramiprilat, which has about 6 times the ACE inhibitory activity of ramipril. Other inactive metabolites include:diketopiperazine ester, diketopiperazine acid, and the glucuronides of ramipril and ramiprilat.[4]

Excretion
Decreases in the plasma concentrations of the active form ramiprialt occur in a three phase fashion, intitially being rapid, followed by an elimination phase and lastly a terminal elimination. The rapid decline has a life span of 2-4 hours and reflects the distribution of ramiprilat into the peripheral compartments along with tissue binding of ACE and plasma binding of ACE. Two elimination phases of ramiprilat occur because of the tight binding that occurs. The apparent elimination phase corresponds to the clearance of free ramiprilat and has a half-life of 9-18 hours. The terminal elimination phase has a longer half-life (>50 hours) and probably represents the binding/dissociation kinetics of the ramiprilat/ACE complex. After multiple daily doses of ramipril 5-10 mg, the half-life of ramiprilat concentrations within the therapeutic range was 13-17 hours.[6]



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Special Population Pharmacokinetics

  • Renal insufficiency: Patients with compromised renal function will experience a delayed elimination of ramipril and its respective metabolites, due to urinary elimination. Compared to normal subjects, patients with creatinine clearance less than 40 ml/min had higher peak and trough ramiprilat levels and slightly longer times to peak concentrations. Peak levels of ramiprilat are approximately doubled in this patient population, and trough levels may be as much as quintupled. In multiple-dose regimens, the total exposure to ramiprilat (AUC) in these patients is 3-4 times as large as it is in patients with normal renal function who receive similar doses.[7]
  • Hepatic insufficiency: No dosage adjustment is required in hepatically impaired patients, although some conversion of ramipril to ramiprilat may be delayed, this has no effect on dosing guidelines.[8]
  • Hemodialysis: Unavailable
  • Geriatric: Treatment with ramipril in the elderly population is safe and generally well tolerated. It has been shown through expansion trials from HOPE study participants that ramipril reduces the risk of major vascular events occuring in the elderly who currently have vascular disease. No dosage adjustment is required for patients over the age of 55.[9]
  • Pediatric: Although ramipril appears to be safe in pediatric patients with chronic renal failure [10], the use of ramipril in the pediatric population is not reccommended.
  • Gender: No differences observed. [11]
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Indications and Dosages

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FDA Approved Indications [4]

Acute Myocardial Infarction

  • Starting & maintenance dose:
    • Adults: Initially 1.25-2.5mg by mouth twice daily, gradually increase the dose to 5mg by mouth twice daily as tolerated.
    • Elderly: See adult dosage
    • Pediatric: Not recommended

Heart Failure

  • Starting & maintenance dose:
    • Adults: Initially 1.25-2.5mg by mouth twice daily, gradually increase the dose to 5mg by mouth twice daily as tolerated.
    • Elderly: See adult dosage
    • Pediatric: Not recommended

Hypertension

  • Starting & maintenance dose:
    • Adults: Initially 2.5mg by mouth daily, when in combination with a diuretic, reduce the initial dose to 1.25mg by mouth daily. The usual dosage is 2.5-20mg by mouth daily given in 1-2 divided doses.
    • Elderly: See adult dosage
    • Pediatric: Not recommended

Myocardial Infarction Prophylaxis

  • Starting & maintenance dose:
    • Adults: Initially 2.5mg by mouth daily, then titrate up to 5mg orally each day. Gradually titrate up the dose to a target of 10mg per day.
    • Elderly: See adult dosage
    • Pediatric: Not recommended

Post-myocardial Infarction

  • Starting & maintenance dose:
    • Adults: Initially 1.25-2.5mg by mouth twice daily, gradually increase the dose to 5mg by mouth twice daily as tolerated.
    • Elderly: See adult dosage
    • Pediatric: Not recommended

Stroke Prophylaxis

  • Starting & maintenance dose:
    • Adults: Initially 2.5mg by mouth daily, then titrate up to 5mg orally each day. Gradually titrate up the dose to a target of 10mg per day.
    • Elderly: See adult dosage
    • Pediatric: Not recommended
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Non-FDA Approved Indications

  • Diabetic Nephropathy
  • Proteinuria
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Dosage Adjustment

Renal insufficiency: In patients with creatinine clearance <40 ml/min/1.73m2 (serum creatinine approximately >2.5 mg/dl) doses only 25% of those normally used should be expected to induce full therapeutic levels of ramiprilat.[7].
Hepatic insufficiency: There is no known evidence suggesting dosage adjustment is needed in the hepatically impaired patient.[8] Hemodialysis: Current evidence suggests that patients on dialysis who have some remaining renal function could benefit from the use of an ACE inhibitor such as ramipril, however dosing guidelines and clinical outcomes are not defined.[12][13]

Geriatric: No dosage adjustment is needed.[9]
Pediatric: Ramipril is not reccommended in adolescents and children.[4]
Gender: unknown

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Dosage Limits [4]

  • Adults: Adults may take up to 20mg/day orally for hypertension, diabetic nephropathy, or proteinuria; 10mg/day by mouth for heart failure, postmyocardial infarction or acute myocardial infarction.
  • Elderly: Elderly patients may take up to 20mg/day orally for hypertension, diabetic nephropathy, or proteinuria; 10mg/day by mouth for heart failure, postmyocardial infarction or acute myocardial infarction.
  • Adolescents and children: not indicatied for this patient population.


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Administration

  • Route: Oral
  • Method:
    • Ramipril may be taken without regards to meals
    • If patients have difficulty swallowing the capsules, the capsule may be opened and sprinkled over a small amount of applesauce, or may be mixed with 4 oz. of apple juice or water. The mixture is stable at room temperature for 24 hours and 48 hours under refrigerated conditions. Consumption of the entire mixture must be done in order to ensure the whole dose is achieved.[14]
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Monitoring Parameters

  • Creatanine Clearance
  • Serum Potassium
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Contraindications/Precautions

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Contraindications

  • Contraindications to ramipril include those who are hypersensitive to this product,or may have had a hypersensitive reaction to another similar ACE inhibitor.
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Precautions

  • Patients with impaired renal function, or those with severe congestive heart failure, as the heart may depend on the renin based system.
  • Hyperkalemia
  • Impaired Liver Function
  • Surgical Patients or those recieving anesthesia
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Pregnancy indications

Category C (first trimester) Catagory D (second and third trimester)[15]

  • (catagory C data)Animal reproduction studies have shown adverse effects on the fetus, imparticular within the first trimester, including slightly increased offspring mortality and growth retardation. Ramipril may be used during pregnancy in the first trimester if the potential benefits justify the potential risks to the fetus.
  • (catagory D data)There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant the use of the drug in pregnant women despits potential risks.
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Breast-feeding indications

Altace may appear in breast milk and could affect a nursing infant. If this medication is essential to your health, your doctor may advise you to avoid breastfeeding. [4]

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Ramipril Drug Interactions

  • Click the above link to view interactions
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Adverse Reactions/Side Effects

Ramipril Adverse Reactions Chart[4][1]
Incidence Body System Adverse Reactions
>10% CNS cough 12%
1-10% CNS headache 5.4%, dizziness 2.2%, fatigue or asthenia 2.0%
Cardiovascular Hypotension 10%, Angina 3%, postural hypotension 2%, syncope 2%
GI Nausea/Vomiting 1-2%
Renal Renal dysfunction 1%, elevation in serum creatinine 1% to 2%, increased BUN <1% to 3%; transient elevations of creatinine and/or BUN may occur more frequently
Enodocrine/Metabolic Hyperkalemia 1 to 10%
<1% All Agranulocytosis, abdominal pain, amnesia, anaphylactoid reaction, angina, angioedema, anorexia, anxiety, arrhythmia, arthralgia, arthritis, bone marrow depression, cerebrovascular events, constipation, convulsions, decreased hematocrit, decreased hemoglobin, depression, diarrhea, dyspepsia, dysphagia, dyspnea, edema, eosinophilia, epistaxis, erythema multiforme, gastroenteritis, hearing loss, hemolytic anemia, hepatitis, hypersensitivity reactions (fever, rash, urticaria), hyponatremia, impotence, increased diaphoresis, increased salivation, insomnia, malaise, myalgia, MI, nervousness, neuralgia, neuropathy, onycholysis, palpitation, pancreatitis, pancytopenia, paresthesia, pemphigoid, pemphigus, photosensitivity, proteinuria, purpura, somnolence, Stevens-Johnson syndrome, symptomatic hypotension, taste disturbance, thrombocytopenia, tinnitus, toxic epidermal necrolysis, transaminases increased, tremor, vertigo, vision disturbances, weight gain, xerostomia
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Overdosage Measures

Limited data on overdose exists, the most probable clinical manifestation would appear as hypotension.[16]
Treatment:

  • There is no data to suggest that physiological maneuvers such as changing the pH of the urine

might accelerate the elimination of ramipirl and its metaboites.

  • It is unknown if this drug of its metabolites may be removed by hemodialysis.
  • Angiotensin II could work as a theoretical antidote however it is very difficult to obtain outside of a research facility.
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Product Information and Distribution

Note: appearance only available for brand-name product
Dose/form Drug color(s) Drug shape Markings or odor/flavor
1.25 mg capsule yellow gelatin capsule Altace 1.25mg
2.5 mg capsule orange gelatin capsule Altace 2.5mg
5 mg capsule red gelatin capsule Altace 5mg
10 mg capsule blue gelatin capsule Altace 10mg
  • Inactive ingredients for capsules: pregelantinized starch NF, gelatin, titanium dioxide. [4]
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Patient Information

  • Take capsule at the same time each day
  • If a dose is missed, skip the dose for the day and do not double the dose the following day.
  • Store Ramipril at room temperature in a tightly closed container.


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References

  1. ↑ 1.0 1.1 The HOPE (Heart Outcomes Prevention Evaluation) Study: the design of a large, simple randomized trial of an angiotensin-converting enzyme inhibitor (ramipril) and vitamin E in patients at high risk of cardiovascular events. The HOPE study investigators. Can J Cardiol. 1996 Feb;12(2):127-37.
  2. ↑ Soehnlein O, Schmeisser A, Cicha I, Reiss C, Ulbrich H, Lindbom L, Daniel WG, Garlichs CD. ACE inhibition lowers angiotensin-II-induced monocyte adhesion to HUVEC by reduction of p65 translocation and AT 1 expression. J Vasc Res. 2005 Sep-Oct;42(5):399-407.
  3. ↑ Heintz B, Verho M, Brockmeier D, Lückel G, Maigatter S, Sieberth HG, Rangoonwala B, Bender N. Multiple-dose pharmacokinetics of ramipril in patients with chronic congestive heart failure. J Cardiovasc Pharmacol. 1993;22 Suppl 9:S36-42.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Altace [package insert]. Bristol, TN: Monarch Pharmaceuticals; September 2005.
  5. ↑ van Griensven JM, Schoemaker RC, Cohen AF, Luus HG, Seibert-Grafe M, Röthig HJ.Pharmacokinetics, pharmacodynamics and bioavailability of the ACE inhibitor ramipril. Eur J Clin Pharmacol. 1995;47(6):513-8.
  6. ↑ Verho M, Luck C, Stelter WJ, Rangoonwala B, Bender N.Pharmacokinetics, metabolism and biliary and urinary excretion of oral ramipril in man.Curr Med Res Opin. 1995;13(5):264-73.
  7. ↑ 7.0 7.1 Esposito R, Giammarino A, De Blasio A, Martinelli V, Cirillo F, Scopacasa F, Federico S, Russo D. Ramipril in post-renal transplant erythrocytosis. J Nephrol. 2007 Jan-Feb;20(1):57-62.
  8. ↑ 8.0 8.1 Pidlich J, Cichini GM, Reinisch W, Peck-Radosavljevic M, Renner F.Angiotensin-converting enzyme inhibition in cirrhotic patients--pharmacokinetics of ramipril. Acta Med Austriaca. 1997;24(1):15-8.
  9. ↑ 9.0 9.1 Gianni M, Bosch J, Pogue J, Probstfield J, Dagenais G, Yusuf S, Lonn E. Effect of long-term ACE-inhibitor therapy in elderly vascular disease patients. European Heart Journal.2007;28(11):1382-8.
  10. ↑ Wühl E, Mehls O, Schaefer F; ESCAPE Trial Group. Antihypertensive and antiproteinuric efficacy of ramipril in children with chronic renal failure. Kidney International. 2004;66(2):768-76.
  11. ↑ Vree TB, Dammers E, Ulc I, Horkovics-Kovats S, Ryska M, Merkx , Ijsbrand. Lack of male-female differences in disposition and esterase hydrolysis of ramipril to ramiprilat in healthy volunteers after a single oral dose. ScientificWorldJournal. 2003 Dec 11;3:1332-43.
  12. ↑ Kam-Tao Li P, Chow K,Yuk-Hwa Wong T,Leung C, Szeto C.Effects of an Angiotensin-Converting Enzyme Inhibitor on Residual Renal Function in Patients Receiving Peritoneal Dialysis: A Randomized, Controlled Study. Annals 2003 139: 105-112.
  13. ↑ Fillastre JP, Baguet JC, Dubois D, Vauquier J, Godin M, Legallicier B, Luus HG, de la Rey N, Carcone N, Genthon R.Kinetics, safety, and efficacy of ramipril after long-term administration in hemodialyzed patients. J Cardiovasc Pharmacol. 1996 Feb;27(2):269-74.
  14. ↑ Lee ID, Hunt TL, Bradley CR, Copp C, Griffiths L, Brobst-Kromer J. Effects on the pharmacokinetics and pharmacodynamics in the elderly of coadministering ramipril with water, apple juice, and applesauce. Pharm Res. 1996 Apr;13(4):639-42.
  15. ↑ Kalyoncu NI, Yaris F, Kadioglu M, Kesim M, Ulku C, Yaris E, Unsal M, Dikici M.Pregnancy outcome following exposure to orlistat, ramipril, glimepiride in a woman with metabolic syndrome. Saudi Med J. 2005 Mar;26(3):497-9.
  16. ↑ Lucas C, Christie GA, Waring WS. Rapid onset of haemodynamic effects after angiotensin converting enzyme-inhibitor overdose: implications for initial patient triage. Emerg Med J. 2006 Nov;23(11):854-7.
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PUBMED References

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Efficacy Trial Articles

  1. Walter U, Forthofer R, Witte PU.Dose-response relation of the angiotensin converting enzyme inhibitor ramipril in mild to moderate essential hypertension. Am J Cardiol. 1987 Apr 24;59(10):125D-132D.
  2. McFarlane SI, Provilus A, Shin JJ.Diabetes prevention between RAAS inhibition and PPAR-gamma stimulation: the diabetes reduction assessment with ramipril and rosiglitazone medication (DREAM) trial. J Cardiometab Syndr. 2007 Spring;2(2):149-50.
  3. Kindler J, Schunkert H, Gassmann M, Lahn W, Irmisch R, Debusmann ER, Ocón-Pujadas J, Ritz E, Sieberth HG. Therapeutic efficacy and tolerance of ramipril in hypertensive patients with renal failure.J Cardiovasc Pharmacol. 1989;13 Suppl 3:S55-8.
  4. Böhm RO, van Baak MA, Rahn KH. Studies on the antihypertensive effect of single doses of the angiotensin converting enzyme inhibitor ramipril (HOE 498) in man. Eur J Clin Pharmacol. 1986;30(5):541-7.
  5. Stumpe KO, Overlack A, Kolloch R, Schatz J, Witte PU, Pahnke K. Effects of the new angiotensin-converting enzyme inhibitor, ramipril, in patients with essential hypertension. Klin Wochenschr. 1986 Jun 16;64(12):558-62.
  6. Karlberg BE, Lindström T, Rosenqvist U, Ohman KP. Efficacy, tolerance and hormonal effects of a new oral angiotensin converting enzyme inhibitor, ramipril (HOE 498), in mild to moderate primary hypertension. Am J Cardiol. 1987 Apr 24;59(10):104D-109D.
  7. Heber ME, Brigden GS, Caruana MP, Lahiri A, Raftery EB. First dose response and 24-hour antihypertensive efficacy of the new once-daily angiotensin converting enzyme inhibitor, ramipril. Am J Cardiol. 1988 Aug 1;62(4):239-45.
  8. Predel HG, Düsing R, Bäcker A, Kipnowski J, Kramer HJ. Combined treatment of severe essential hypertension with the new angiotensin converting enzyme inhibitor ramipril. Am J Cardiol. 1987 Apr 24;59(10):143D-148D.
  9. Kaneko Y, Omae T, Yoshinaga K, Iimura O, Inagaki Y, Ishii M, Saruta T, Yamada K, Kumahara Y, Ito K, et al. Effect of ramipril, a new angiotensin converting enzyme inhibitor, on diurnal variations of blood pressure in essential hypertension. Am J Cardiol. 1987 Apr 24;59(10):86D-91D.
  10. Tochikubo O, Asahina S, Kaneko Y. Effect of ramipril on 24-hour variability of blood pressure and heart rate in essential hypertension. Am J Cardiol. 1987 Apr 24;59(10):83D-85D.
  11. Wenting GJ, Blankestijn PJ, Poldermans D, van Geelen J, Derkx FH, Man in't Veld AJ, Schalekamp MA. Blood pressure response of nephrectomized subjects and patients with essential hypertension to ramipril: indirect evidence that inhibition of tissue angiotensin converting enzyme is important. Am J Cardiol. 1987 Apr 24;59(10):92D-97D.


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Therapeutic Class Comparison Articles

  1. Witte PU, Walter U. Comparative double-blind study of ramipril and captopril in mild to moderate essential hypertension. Am J Cardiol. 1987 Apr 24;59(10):115D-120D.
  2. Comini L, Bachetti T, Cargnoni A, Bastianon D, Gitti GL, Ceconi C, Ferrari R. Therapeutic modulation of the nitric oxide: all ace inhibitors are not equivalent. Pharmacol Res. 2007 Jul;56(1):42-8. Epub 2007 Mar 27.
  3. Song JC, White CM. Clinical pharmacokinetics and selective pharmacodynamics of new angiotensin converting enzyme inhibitors: an update. Clin Pharmacokinet. 2002;41(3):207-24.
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Pharmacokinetics Articles

  1. Schunkert H, Kindler J, Gassmann M, Lahn W, Irmisch R, Ritz E, Debusmann ER, Pujadas JO, Koch KM, Sieberth HG.Pharmacokinetics of ramipril in hypertensive patients with renal insufficiency. Eur J Clin Pharmacol. 1989;37(3):249-56.
  2. Gerckens U, Grube E, Mengden T, Sigel H, Wagner WL, Lahn T, Irmisch R, Metzger H. Pharmacokinetic and pharmacodynamic properties of ramipril in patients with congestive heart failure (NYHA III-IV). J Cardiovasc Pharmacol. 1989;13 Suppl 3:S49-51.
  3. Aurell M, Delin K, Herlitz H, Ljungman S, Witte PU, Irmisch R. Pharmacokinetics and pharmacodynamics of ramipril in renal failure. Am J Cardiol. 1987 Apr 24;59(10):65D-69D.
  4. Schunkert H, Kindler J, Gassmann M, Lahn W, Irmisch R, Debusmann ER, Ocón-Pujadas J, Sieberth HG. Steady-state kinetics of ramipril in renal failure. J Cardiovasc Pharmacol. 1989;13 Suppl 3:S52-4.
  5. Meyer BH, Müller FO, Badian M, Eckert HG, Hajdú P, Irmisch R, Schmidt D. Pharmacokinetics of ramipril in the elderly. Am J Cardiol. 1987 Apr 24;59(10):33D-37D.
  6. Gilchrist WJ, Beard K, Manhem P, Thomas EM, Robertson JI, Ball SG. Pharmacokinetics and effects on the renin-angiotensin system of ramipril in elderly patients. Am J Cardiol. 1987 Apr 24;59(10):28D-32D.




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Drug Interaction Articles

  1. Imbs JL, Barthelmebs M, Danion JM, Singer L. Mechanisms of drug interactions with renal elimination of lithium. Bull Acad Natl Med. 1997 Apr;181(4):685-95; discussion 695-7.
  2. Barthelmebs M, Grima M, Imbs JL. Ramipril-induced decrease in renal lithium excretion in the rat. Br J Pharmacol. 1995 Oct;116(4):2161-5.
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Adverse Effects Articles

  1. Coleman CI, Makanji S, Kluger J, White CM. Effect of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers on the frequency of post-cardiothoracic surgery atrial fibrillation. Ann Pharmacother. 2007 Mar;41(3):433-7.
  2. McAreavey D, Robertson JI. Angiotensin converting enzyme inhibitors and moderate hypertension. Drugs. 1990 Sep;40(3):326-45.
  3. Hecker M, Blaukat A, Bara AT, Müller-Esterl W, Busse R. ACE inhibitor potentiation of bradykinin-induced venoconstriction. Br J Pharmacol. 1997 Aug;121(7):1475-81.


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Compliance Articles

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Pharmacoeconomic Articles

  1. Costa-Scharplatz M, van Asselt AD, Bachmann LM, Kessels AG, Severens JL.Cost-effectiveness of pharmacogenetic testing to predict treatment response to angiotensin-converting enzyme inhibitor. Pharmacogenet Genomics. 2007 May;17(5):359-68.
  2. Golan L, Birkmeyer JD, Welch HG. The cost-effectiveness of treating all patients with type 2 diabetes with angiotensin-converting enzyme inhibitors. Ann Intern Med. 1999 Nov 2;131(9):660-7.
  3. Dong FB, Sorensen SW, Manninen DL, Thompson TJ, Narayan V, Orians CE, Gregg EW, Eastman RC, Dasbach EJ, Herman WH, Newman JM, Narva AS, Ballard DJ, Engelgau MM. Cost effectiveness of ACE inhibitor treatment for patients with type 1 diabetes mellitus. Pharmacoeconomics. 2004;22(15):1015-27.


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External Links

Clinical treatment guidelines


Patient information pages

Other resources


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