Adults

The usual initial dose for hypertension is 2.5 mg once daily, adjusted based on response up to 10 mg daily. For heart failure, initial dose is typically 1.25-2.5 mg once daily, titrated up to 10 mg daily. For cardiovascular risk reduction, initial dose is 2.5 mg once daily, titrated to 10 mg daily. A 25 mg dose is exceptionally high for Ramipril and would only be considered in very specific, severe cases under strict medical supervision, exceeding typical maximum recommended doses (usually 10-20 mg).

Elderly

Similar to adults, but may require lower initial doses (e.g., 1.25 mg) and careful titration due to potential renal impairment and increased sensitivity.

Renal_impairment

Dosage adjustment is required. If creatinine clearance is < 30 mL/min, the initial dose should be 1.25 mg once daily, and the maximum dose is usually limited to 5 mg daily. Close monitoring of renal function and potassium levels is essential.

Onset

Antihypertensive effect typically begins 1-2 hours after administration.

Excretion

Primarily excreted renally (60%) as metabolites and unchanged drug, with some biliary/fecal excretion (40%).

Half life

The active metabolite, ramiprilat, has an effective half-life of 13-17 hours, allowing for once-daily dosing.

Absorption

Well absorbed from the gastrointestinal tract; approximately 50-60% bioavailability of the active metabolite, ramiprilat.

Metabolism

Prodrug, ramipril, is extensively hydrolyzed in the liver to its active metabolite, ramiprilat, and other inactive metabolites.

Lithium

Increased serum lithium concentrations and lithium toxicity.

Aliskiren

Increased risk of hypotension, hyperkalemia, and renal impairment (contraindicated in diabetic patients or those with moderate to severe renal impairment).

Diuretics

Increased risk of symptomatic hypotension (low blood pressure), especially after initiating Primace.

Other antihypertensives

Additive hypotensive effects.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

May reduce the antihypertensive effect and increase the risk of renal impairment, especially in elderly or dehydrated patients.

mTOR inhibitors (e.g., everolimus, sirolimus, temsirolimus)

Increased risk of angioedema.

Hypoglycemic agents (e.g., insulin, oral hypoglycemic drugs)

Enhanced blood-glucose-lowering effect, potentially leading to hypoglycemia.

Potassium-sparing diuretics/Potassium supplements/Salt substitutes containing potassium

Increased risk of hyperkalemia (high potassium levels).