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Vostally
ramipril
Black Box Warnings .
Fetal Toxicity
fetal/neonatal morbidity/mortality may occur when drugs that act directly on the renin-angiotensin system are used in pregnancy; D/C drug ASAP once pregnancy detected
Adult Dosing .
Dosage forms: SOL: 1 mg per mL
HTN
- [2.5-20 mg/day PO divided qd-bid]
- Start: 2.5 mg PO qd; Info: start 1.25 mg PO qd if hypovolemia or renal artery stenosis
cardiovascular event risk reduction
- [10 mg PO qd]
- Start: 2.5 mg PO qd x1wk, then 5 mg PO qd x3wk, then 10 mg PO qd; Info: for pts 55 yo and older w/ CAD, stroke, PVD, or DM hx plus 1 other risk factor; start 1.25 mg PO qd if hypovolemia or renal artery stenosis; may divide dose bid if MI or HTN
heart failure, post-MI
- [5 mg PO bid]
- Start: 2.5 mg PO bid, may incr. dose q3wk; Info: start 1.25 mg PO qd if hypovolemia or renal artery stenosis
heart failure w/ reduced ejection fraction (off-label)
- [10 mg PO qd]
- Start: 1.25-2.5 mg PO qd, may incr. dose q1-2wk
renal dosing
- [HTN]
- CrCl <40: start 1.25 mg qd, max 5 mg/day
- HD: 1.25-5 mg qd; no supplement after dialysis; PD: 1.25-5 mg qd; supplement not defined
- [heart failure, post-MI]
- CrCl <40: start 1.25 mg qd, then may incr. to 1.25 mg bid, max 2.5 mg bid
- HD: 1.25-5 mg/day divided qd-bid; no supplement after dialysis; PD: 1.25-5 mg/day divided qd-bid; supplement not defined
- [all other indications]
- CrCl <40: decr. usual dose by 75%
- HD: 1.25-5 mg qd; no supplement after dialysis; PD: 1.25-5 mg qd; supplement not defined
hepatic dosing
- [see below]
- hepatic impairment: not defined, caution advised
Peds Dosing .
Peds dosing is currently unavailable or not applicable for this drug.
Contraindications / Cautions .
- hypersensitivity to drug or ingredient
- angioedema hx, ACE inhibitor-associated
- angioedema, hereditary
- angioedema, idiopathic
- pregnancy
- caution: hypersensitivity to tartrazine (generic form)
- caution: elderly patients
- caution: Black patients (incr. risk of angioedema)
- caution: hepatic impairment
- caution: renal impairment
- caution: renal artery stenosis
- caution: volume depletion
- caution: hyponatremia
- caution: hyperkalemia risk
- caution: hypotension
- caution: CHF, severe
- caution: aortic stenosis
- caution: cardiomyopathy, hypertrophic
- caution: CAD
- caution: cerebrovascular dz
- caution: collagen vascular dz
- caution: dialysis w/ high-flux membrane
- caution: LDL apheresis w/ dextran
- caution: antigen desensitization tx
Drug Interactions .
Overview
ramipril
ACE inhibitor
- angioedema
- antihypertensive agent
- decreases renal perfusion/fxn
- hyperkalemia
- hyponatremia
Contraindicated
- aliskiren
Avoid/Use Alternative
- amikacin
- benazepril
- irbesartan
- lisinopril
- potassium chloride
- trimethoprim
Monitor/Modify Tx
- abiraterone acetate
- acyclovir
- adefovir dipivoxil
- albuterol
- albuterol inhaled
- alfentanil
- alfuzosin
- almotriptan
- amantadine
- amifostine
- amikacin inhaled
- amiloride
- amitriptyline
- amoxapine
- amphetamine
- amphotericin
- anthrax immune globulin
- apomorphine
- apraclonidine ophthalmic
- arformoterol inhaled
- aripiprazole bimonthly injection
- aripiprazole monthly injection
- aripiprazole oral
- armodafinil
- articaine
- asciminib
- asenapine
- aspirin
- atogepant
- atomoxetine
- atropine ophthalmic
- auranofin
- avanafil
- axitinib
- balsalazide
- benzphetamine
- berberine
- betamethasone
- betaxolol ophthalmic
- bethanechol
- bevacizumab
- bexagliflozin
- bismuth subsalicylate
- bortezomib
- botulism immune globulin
- brexpiprazole
- brexucabtagene autoleucel
- brigatinib
- brimonidine ophthalmic
- brimonidine topical
- bromocriptine
- budesonide
- bumetanide
- bupivacaine
- bupivacaine liposomal
- buprenorphine
- bupropion
- butorphanol
- cabergoline
- cabozantinib
- caffeine
- canagliflozin
- cannabis
- capecitabine
- carboplatin
- carfilzomib
- cariprazine
- carteolol ophthalmic
- celecoxib
- chloroprocaine
- chlorothiazide
- chlorpromazine
- chlorthalidone
- cidofovir
- cilostazol
- cisplatin
- clindamycin
- clomipramine
- clonidine
- clozapine
- cocaine
- codeine
- coenzyme Q-10
- colistimethate
- copanlisib
- creatine
- cyclophosphamide
- cyclosporine
- cytomegalovirus immune globulin
- danazol
- dapagliflozin
- darbepoetin alfa
- decitabine
- deferasirox
- deferoxamine
- deflazacort
- denileukin diftitox
- desflurane
- desipramine
- desmopressin
- desvenlafaxine
- dexamethasone
- dexmedetomidine
- dexmedetomidine injection
- dexmethylphenidate
- dextroamphetamine
- diazoxide
- diclofenac
- diclofenac topical
- diethylpropion
- diflunisal
- dihydrocodeine
- dihydroergotamine
- dinutuximab
- dipyridamole
- doxapram
- doxazosin
- doxepin
- dronabinol
- drospirenone (contraceptive)
- drospirenone (hormone replacement)
- droxidopa
- duloxetine
- eletriptan
- empagliflozin
- entacapone
- entecavir
- entrectinib
- enzalutamide
- ephedra
- ephedrine injection
- ephedrine oral
- epinephrine
- eplerenone
- epoetin alfa
- epoprostenol
- eptinezumab
- erenumab
- ergotamine
- ertugliflozin
- esketamine
- estetrol (contraceptive)
- estradiol (contraceptive)
- ethacrynic acid
- ethanol
- ethinyl estradiol (contraceptive)
- etodolac
- etrasimod
- fenfluramine
- fenoprofen
- fentanyl
- ferumoxytol
- finerenone
- fingolimod
- flaxseed
- flibanserin
- flucytosine
- fludrocortisone
- fluphenazine
- flurbiprofen
- formoterol inhaled
- foscarnet
- foslevodopa
- fostamatinib
- fremanezumab
- frovatriptan
- fruquintinib
- furosemide
- galcanezumab
- ganciclovir
- garlic
- gentamicin
- gilteritinib
- guanfacine
- haloperidol
- heparin
- hoodia
- hydralazine
- hydrochlorothiazide
- hydrocodone
- hydrocortisone
- hydromorphone
- ibrutinib
- ibuprofen
- ibuprofen lysine
- ifosfamide
- iloperidone
- iloprost
- imipramine
- immune globulin
- indapamide
- indomethacin
- iohexol
- iomeprol
- iopamidol
- iron sucrose
- isoflurane
- ketamine
- ketoprofen
- ketorolac
- landiolol
- leflunomide
- lenvatinib
- levalbuterol inhaled
- levobunolol ophthalmic
- levodopa
- levomilnacipran
- levorphanol
- levothyroxine
- licorice
- lidocaine
- liothyronine
- lisdexamfetamine
- lithium
- lorlatinib
- loxapine
- lubiprostone
- lumacaftor/ivacaftor
- lumateperone
- lurasidone
- luspatercept
- lutetium Lu 177 vipivotide tetraxetan
- magnesium citrate
- magnesium salicylate
- mannitol
- maraviroc
- meclofenamate
- mefenamic acid
- meloxicam
- meperidine
- mepivacaine
- mesalamine
- mesalamine rectal
- methadone
- methamphetamine
- methotrexate
- methoxy polyethylene glycol-epoetin beta
- methylene blue injection
- methylergonovine
- methylphenidate
- methylprednisolone
- methyltestosterone
- metoclopramide
- metolazone
- midazolam
- midodrine
- milnacipran
- milrinone
- mirabegron
- mirtazapine
- mitomycin
- modafinil
- molindone
- morphine
- nabumetone
- nalbuphine
- naphazoline ophthalmic
- naproxen
- naratriptan
- nattokinase
- naxitamab
- neomycin
- nilotinib
- niraparib
- nitric oxide
- nitrite
- nitroglycerin
- nitroprusside
- nortriptyline
- nusinersen
- obinutuzumab
- olanzapine
- oliceridine
- olodaterol inhaled
- olsalazine
- opicapone
- opium
- osilodrostat
- oxaliplatin
- oxaprozin
- oxazepam
- oxycodone
- oxymetazoline nasal
- oxymetazoline ophthalmic
- oxymetazoline topical
- oxymorphone
- oxytocin
- ozanimod
- paliperidone
- palopegteriparatide
- pamidronate
- paromomycin
- pazopanib
- peginterferon alfa 2a
- pemetrexed
- penicillamine
- pentamidine
- pentazocine
- pentobarbital
- perphenazine
- pexidartinib
- phendimetrazine
- phenelzine
- phenobarbital
- phentermine
- phenylephrine
- phenylephrine injection
- phenylephrine nasal
- phenylephrine ophthalmic
- phenylephrine rectal
- piroxicam
- plazomicin
- polyethylene glycol
- polyethylene glycol/electrolytes
- ponatinib
- ponesimod
- potassium acid phosphate
- potassium bicarbonate
- potassium citrate
- potassium iodide
- potassium phosphate
- pralsetinib
- pramipexole
- pramlintide
- prazosin
- prednisolone
- prednisone
- procarbazine
- prochlorperazine
- promethazine
- propafenone
- propofol
- protriptyline
- pseudoephedrine
- quetiapine
- ramucirumab
- rasagiline
- regorafenib
- remifentanil
- remimazolam
- Rho(D) immune globulin
- rimegepant
- riociguat
- ripretinib
- risperidone
- rituximab
- rizatriptan
- ropeginterferon alfa-2b
- ropinirole
- ropivacaine
- safinamide
- salmeterol inhaled
- salsalate
- selegiline
- selegiline transdermal
- selpercatinib
- sevoflurane
- sildenafil
- silodosin
- siponimod
- sirolimus
- sitagliptin
- sodium ferric gluconate complex
- solriamfetol
- sorafenib
- sotagliflozin
- sotalol
- spironolactone
- streptomycin
- streptozocin
- sufentanil
- sulfate bowel prep
- sulindac
- sumatriptan
- sunitinib
- tadalafil
- tagraxofusp
- tamsulosin
- tapentadol
- taurine
- telavancin
- temsirolimus
- tenofovir alafenamide
- tenofovir disoproxil
- terazosin
- terbutaline
- teriflunomide
- testosterone
- tetrahydrozoline ophthalmic
- thalidomide
- thioridazine
- thiothixene
- thyroid
- timolol ophthalmic
- tiopronin
- tivozanib
- tizanidine
- tobramycin
- tobramycin inhaled
- tolcapone
- tolmetin
- tolvaptan
- torsemide
- tramadol
- trametinib
- tranylcypromine
- trazodone
- treprostinil
- triamcinolone
- triamterene
- trifluoperazine
- trimipramine
- ubrogepant
- vaccinia immune globulin
- vadadustat
- valacyclovir
- valganciclovir
- vamorolone
- vancomycin
- vandetanib
- vardenafil
- vasopressin
- venlafaxine
- vilanterol inhaled
- viloxazine
- voclosporin
- vosoritide
- willow bark
- yohimbe
- zavegepant
- ziprasidone
- ziv-aflibercept
- zoledronic acid
- zolmitriptan
Caution Advised
- everolimus
- icatibant
- iloprost inhaled
- iron dextran
- pregabalin
- sirolimus albumin-bound
- sirolimus topical
Adverse Reactions .
Serious Reactions
- anaphylactoid rxn
- angioedema, head or neck
- angioedema, intestinal
- hypotension, severe
- hyperkalemia
- renal impairment
- renal failure
- hepatotoxicity
- pancytopenia
- agranulocytosis
- pancreatitis
- Stevens-Johnson syndrome
Common Reactions
- cough
- hypotension
- dizziness
- fatigue
- hyperkalemia
- angina
- nausea
- vomiting
- syncope
- vertigo
- BUN or Cr elevated
- photosensitivity
- hyperuricemia
Safety/Monitoring .
Monitoring Parameters
BUN/Cr at baseline, then periodically, or more frequently if heart failure, renal artery stenosis; electrolytes; BP; WBC if collagen vascular dz, especially if renal impairment
Look/Sound-Alike Drug Names
ramipril confused with: Accupril; donepezil; enalapril; quinapril; rifAMPin; trihexyphenidyl
Pregnancy/Lactation .
Pregnancy
Clinical Summary
avoid use during pregnancy; if must use, monitor amniotic fluid and fetus closely; risk of fetal and neonatal harm, incl. intrauterine growth restriction, oligohydramnios, renal failure, and death, in 2nd and 3rd trimesters based on human data and drug's mechanism of action
Lactation
Clinical Summary
weigh risk/benefit while breastfeeding; inadequate human data available to assess risk of infant harm; no human data available to assess effects on milk production
Pharmacology .
Metabolism: liver; CYP450: unknown; Info: prodrug converted to ramiprilat
Excretion: urine 60% (<2% unchanged); feces 40%; Half-life: >50h
Subclass: Angiotensin-Converting Enzyme (ACE) Inhibitors
Mechanism of Action
inhibits angiotensin converting enzyme, interfering w/ conversion of angiotensin I to angiotensin II
Formulary .
No Formulary Selected
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