Ramipril is an ACE-i (Angiotensin Converting Enzyme inhibitor) medication which is used medically for following different disease processes.
There may be a few other unlicensed uses in other countries. Please refer to local guidelines for more details.
Angiotensin II: Angiotensin II has various effects which help in improving blood pressure.
Angiotensin-converting enzyme inhibitor medications such as ramipril suppress the mechanisms as mentioned above. As a result, sympathetic activity goes down, sodium and water reabsorption from the kidneys reduces, smooth muscles in the arterioles also relax. As a result, blood pressure decreases.
Only oral administration is licensed. In the United States, capsule form is available. Capsules can be opened to mix the contents with 120 ml of water, applesauce, or juice for the patient not able to swallow capsules.
Doses can range between 1.25mg per day to 10mg per day.
Ramipril is often started at the lowest dose and titrated according to blood pressure response.
Dry cough: In the lung tissues, Angiotensin converting enzymes inhibitors also inhibits the degradation of bradykinin. Higher levels of Bradykinin causes a dry cough. This side effect is more prevalent in patients from Afro-Caribbean descent than other cohorts.
Postural hypotension: Some patients may develop postural hypotension and may also have fallen as a result, which can lead to a higher risk of head injuries and bone fractures in elderly patients. Dizziness and lightheadedness are related to postural hypotension when patients suddenly stand up from sitting or lying positions. Patients should receive counsel regarding signs of postural hypotension on initiating the treatment.
Elevated serum creatinine: Ramipril may cause a transient increase in serum creatinine in 1% to 2% of the patients.
Hyperkalemia: In 1% to 10% of patients, hyperkalemia has been present.
Ramipril can also cause anxiety-like symptoms including shakiness in some patient. Patients who are known to have anxiety or tremors should be watched for these symptoms for few weeks minimum when initiating ramipril.
Angioedema, nausea, dry mouth, fatigue, erectile dysfunction have appeared in other patients.
Few other rare side effects include hypoperfusion, movement disorders, onycholysis, and oral disorders. [British National Formulary]
The HOPE (Heart Outcome Prevention Study) study conducted in 2008 demonstrated that after administering ramipril 10mg for 12 weeks, clinically there is no significant change in renal function of patients who had renal artery stenosis. Therefore according to the HOPE study, ramipril can be safely used in patients with renal artery stenosis.
Ramipril overdose can result in severe hypotension.
A study conducted in 2006 to investigate the effects of ramipril overdose on blood pressure concluded that in most cases, drop in blood pressure occurs within first 4-4.5 hours after ingestion. Monitoring the patient for a minimum of 6 hours after taking the overdose is essential. If the blood pressure remains normal at in the first 6 hours after exposure, then the patient can be considered for discharge. 
Health care professionals including family physicians, specialists, nurses, and pharmacists are valuable sources of information for patients. Increasing patient's knowledge about the medication and providing them information about possible side effects to look for, would make patients more compliant with their medications and subsequently improve their blood pressure control.
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