Clinical beta

FMBM is currently in clinical beta. Content is for professional review/testing and must not replace local protocols, senior clinical judgment, or official prescribing references.

Drug Monograph

Ramipril

Ramipril

ACE inhibitor (prodrug)

AdultACEiHFHTNPost-MI

Indication

Post-MI risk reduction β€’ HFrEF β€’ HTN β€’ CKD proteinuria

At a glance

INDICATIONS (CORE USE)

HFrEF and post-MI remodeling risk reduction; also HTN and CKD proteinuria contexts.

ADULT DOSE (STANDARD)

PO START low (e.g. 1.25–2.5 mg daily) and titrate with BP/labs.

MAX DOSE

Common max 10 mg/day (indication-specific).

Route

PO (prodrug)

PEDIATRIC DOSE

Not routine.

Do not miss

Must-not-miss safety points

Major warning

- Angioedema can be delayed and fatal β†’ DO NOT re-challenge any ACE inhibitor - Pregnancy is contraindicated β†’ DO NOT use

Indications

Strong post-MI/HFrEF evidence context; same ACEi class hard-stops apply.

Primary

  • HFrEF
  • Post-MI LV dysfunction risk reduction
  • Hypertension

Secondary

  • CKD with proteinuria where ACEi appropriate

Dosing

STANDARD (ADULT PO)

START low and titrate with lab checks.

ADULT DOSE

Common START 1.25–2.5 mg daily; titrate by BP and safety labs.

PEDIATRIC DOSE

N/A

MAX DOSE

Common max 10 mg/day.

Practical Note

Up-titrate only after creatinine/potassium review.

Warnings

Clinical warnings

  • Angioedema can be delayed and fatal β€” DO NOT re-challenge. First-dose hypotension risk is higher with volume depletion / HF / high-renin states; correct volume before starting.

Adverse effects

  • Cough
  • hyperkalemia
  • hypotension
  • AKI trend
  • angioedema

Contraindications

  • Pregnancy
  • Prior ACE inhibitor-induced angioedema
  • Bilateral renal artery stenosis (known/suspected)
  • Baseline K+ β‰₯5.5 mmol/L

Drug interactions

  • ARB / aliskiren combination: avoid routine dual RAAS blockade (AKI, hyperkalemia, hypotension risk)
  • Potassium-sparing agents / supplements: hyperkalemia risk
  • NSAIDs β†’ ↑ AKI risk + ↓ ACEi effect β€” avoid or monitor closely
  • Loop/thiazide preload depletion can amplify first-dose hypotension.

Special populations

Pediatrics

Not routine.

Pregnancy

Pregnancy: contraindicated.

Lactation

specialist guidance.

Renal impairment

Dose conservatively in CKD and monitor trend after each increase.

Hepatic impairment

Prodrug conversion context: titrate clinically and by labs.

Elderly

Lower initial doses reduce hypotension/fall risk.

Administration

PO, consistent daily use with interval lab checks.

Monitoring

  • Recheck: - Check creatinine + potassium within 1–2 weeks after initiation - Recheck creatinine + potassium within 1–2 weeks after dose increase - Check earlier if CKD, elderly, volume depletion, or interacting drugs
  • Hold if:
    - HOLD if:
    - SBP <90–100
    - K+ β‰₯5.5 mmol/L
    - creatinine rise >30% from baseline
    - symptomatic hypotension
    - STOP permanently if angioedema
  • If targets not met after reassessment of dose, organ function, and interactions β†’ escalate per protocol (DO NOT continue blindly)

Overdose / toxicity

Clinical Picture

A) Mild β†’ dizziness, hypotension, fatigue B) Moderate β†’ persistent hypotension, AKI trend, hyperkalemia C) Severe β†’ refractory shock, severe hyperkalemia, respiratory compromise (e.g. angioedema context)

Immediate Actions

β€’ Airway + continuous monitoring (ABC, BP, telemetry) β€’ Hypotension β†’ IV fluids first-line β€’ Refractory hypotension β†’ early vasopressors (norepinephrine) β€’ Check potassium immediately β†’ treat per hyperkalemia protocol if elevated β€’ Stop ACE inhibitor

Antidote

- No specific antidote - Supportive care + hemodynamic stabilization - Hyperkalemia treatment β†’ calcium + insulin/dextrose + potassium-shifting protocol - Airway intervention β†’ if angioedema compromises respiration

Decontamination

β€’ Recent oral ingestion β†’ activated charcoal if protected airway and early presentation (toxicology-guided)

Escalation

- Refractory hypotension or airway compromise β†’ ICU + early vasopressors / airway team - Severe hyperkalemia / AKI β†’ nephrology + renal replacement planning if indicated

Clinical pearls

Common mistakes, resistance logic, and bedside traps

High-Yield Summary

Post-MI/HFrEF signal is strong, but lab safety rules are unchanged.

Clinical pearls

Never continue blindly through potassium/creatinine drift.

ACE inhibitor safety

  • Recheck labs after initiation and each up-titration

Pharmacokinetics

Prodrug profile; once-daily dosing common.

Mechanism of action

ACE inhibition with afterload reduction and renal hemodynamic effect.

Common brand names

Saudi Arabia

Tritace, Altace, Ramipril

Global

(placeholder β€” verify local formulation)

Common trade names are curated examples only β€” formulations and availability vary. Verify the exact product name with your local pharmacy and national regulator before prescribing or dispensing.

Country practice notes

Global data (no country-specific data available)

  • Follow local antimicrobial stewardship policy, hospital formulary, and national resistance guidance.
  • Confirm dosing, stock, and restrictions with institutional pharmacy and current product labeling.

References

Saudi Arabia

  • SFDA (Saudi Food & Drug Authority)
  • Saudi National Formulary / MOH (where available)

International

  • WHO Model List of Essential Medicines (verify current edition)
  • US FDA or EU EMA product information (when national SmPC is unavailable)
  • ACC / AHA HF, post-MI, and HTN guidance
  • KDIGO CKD and proteinuria guidance
  • FDA / SFDA product labeling

Do not miss

  • Angioedema can be delayed and fatal β†’ DO NOT re-challenge
  • Pregnancy contraindicated β†’ DO NOT use
  • First-dose hypotension risk (especially HF / volume depletion) β†’ correct volume before starting
  • Hyperkalemia risk β†’ monitor potassium early
  • Recheck labs after initiation and each up-titration