Ramipril

Ramipril is an ACE inhibitor (angiotensin-converting enzyme inhibitor). It is used to treat high blood pressure (hypertension) and heart failure and to protect the kidneys in people with diabetes.

The active ingredient lowers blood pressure while also protecting the heart, blood vessels and kidneys from the long-term damage caused by high blood pressure. Ramipril is taken once daily and is available as a generic from numerous manufacturers, including Ramipril-1 A Pharma®, Ramipril HEXAL® and Ramipril-ratiopharm®.

Ramipril is also available in combination products with amlodipine or hydrochlorothiazide (HCT).

Ramipril acts on the renin-angiotensin-aldosterone system (RAAS):

Mechanism of action:

• Inhibits the angiotensin-converting enzyme (ACE)
• As a result, less angiotensin II is formed
• Angiotensin II is a potent vasoconstrictor
• Less angiotensin II means: blood vessels widen, blood pressure falls

Additional effects:

• Reduces the release of aldosterone (less water and salt retention)
• Inhibits the breakdown of bradykinin (vasodilating)
• Protects the heart and kidneys from structural changes (remodeling)
• Improves the function of the inner lining of the blood vessels (endothelium)

Onset of action: The blood pressure-lowering effect begins after 1-2 hours. The maximum effect is reached after 3-6 hours. A stable reduction in blood pressure is achieved after 3-4 weeks of taking it regularly.

Ramipril is suitable for:

• Adults with high blood pressure (arterial hypertension)
• Patients with heart failure
• Follow-up treatment after a heart attack
• Patients with diabetic nephropathy (kidney protection)
• Cardiovascular prevention in high-risk patients

Especially recommended for:

• Diabetes with high blood pressure
• Heart failure
• After a heart attack
• Protein in the urine (proteinuria)

Not suitable in cases of:

• Pregnancy and breastfeeding
• Bilateral renal artery stenosis
• History of angioedema
• Concomitant use with aliskiren in diabetes

High blood pressure:

• Starting dose: 2.5 mg once daily
• Usual maintenance dose: 5-10 mg once daily
• Maximum dose: 10 mg daily

Heart failure:

• Starting dose: 1.25 mg once daily
• Slow increase over weeks
• Target dose: 10 mg daily

Available strengths:

• 1.25 mg, 2.5 mg, 5 mg, 10 mg tablets

Combination products:

• Ramipril + amlodipine (e.g., Ramipril HEXAL® plus Amlodipin)
• Ramipril + hydrochlorothiazide (e.g., Ramipril-1 A Pharma® plus)

How to take:

• Once daily, always at the same time of day
• Regardless of meals
• Swallow with sufficient water
• Do not chew the tablet

Dose adjustment:

• Start with a low dose
• Increase slowly every 2-4 weeks
• Check blood pressure and kidney values regularly

Important notes:

• Do not stop on your own, only after talking to your doctor
• If you miss a dose: take it if less than 12 hours have passed
• Regular blood pressure checks are recommended
• Avoid potassium-containing salt substitutes

Ramipril must not be taken in cases of:

• Hypersensitivity to ramipril or other ACE inhibitors
• History of angioedema (including hereditary)
• Bilateral renal artery stenosis
• Pregnancy in the second and third trimesters
• Concomitant use with aliskiren in people with diabetes
• Extracorporeal treatments in which the blood comes into contact with negatively charged surfaces (e.g. haemodialysis or haemofiltration with certain high-flux membranes, LDL apheresis with dextran sulfate)

Use with caution in cases of:

• Impaired kidney function (dose adjustment)
• Aortic stenosis or mitral stenosis
• Elevated potassium levels
• Concurrent dialysis
• Collagen diseases (e.g., lupus)
• Liver function disorders

Pregnancy and breastfeeding: Ramipril is not recommended in the first trimester of pregnancy and is contraindicated in the second and third trimesters. During this time it can harm the unborn child, for example by reducing kidney function. Treatment should not be started during pregnancy. If pregnancy is confirmed, treatment must be stopped immediately and, if necessary, switched to another therapy. If you are planning to have a child, treatment should be switched in good time. Ramipril is not recommended during breastfeeding.

Common (1-10%):

• Dry, irritating cough (up to 10% of patients)
• Dizziness, especially at the start
• Headache
• Fatigue
• Elevated potassium levels

Uncommon (0.1-1%):

• Drop in blood pressure (especially with the first dose)
• Kidney function disorders
• Skin rash
• Gastrointestinal complaints
• Taste disturbances

Rare but serious:

• Angioedema (swelling of the face, lips, tongue) – call emergency services immediately!
• Severe drop in blood pressure
• Severe kidney dysfunction

Irritating cough: The dry cough is the most common reason for switching medication. It occurs in about 5-10% of patients and goes away after the medication is stopped. Alternative: switching to an AT1 blocker (sartan).

Contraindicated with:

• Aliskiren in diabetes or renal insufficiency
• Sacubitril/valsartan (36-hour interval)

Caution when taken at the same time as:

• Potassium-sparing diuretics (spironolactone, triamterene) – hyperkalemia
• NSAIDs (ibuprofen, diclofenac) – reduced effect, kidney damage
• Lithium – increased lithium levels
• Other blood pressure-lowering medications – enhanced lowering of blood pressure
• Antidiabetic medications – enhanced lowering of blood sugar

Important: Avoid potassium-containing dietary supplements and salt substitutes. Regular monitoring of kidney values and potassium is recommended.