Names and pronunciation
(ra-mi′pril) Altace
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Drug reference
(ra-mi′pril) Altace
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Func. class.: Antihypertensive
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Chem. class.: Angiotensin-converting enzyme inhibitor (ACE)
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Do not confuse: ramipril/enalapril Altace/alteplase
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ACTION: Selectively suppresses renin- angiotensin-aldosterone system; inhibits ACE, prevents conversion of angiotensin I to angiotensin II; results in dilation of arterial, venous vessels
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USES: Hypertension, alone or in combination with thiazide diuretics; HF (post-MI), reduction in risk for MI, stroke, death from CV disorders
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CONTRAINDICATIONS: Breast feeding, children, hypersensitivity to ACE inhibitors, history of ACE inhibitor– induced angioedema
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Black Box Warning: Pregnancy second/ third trimesters Precautions: Geriatric patients, impaired renal/hepatic function, dialysis patients, hypovolemia, blood dyscrasias, HF, renal artery stenosis, cough, African descent, aortic stenosis Black Box Warning: Pregnancy: identify if pregnant or if pregnancy is planned or suspected; if pregnant, discontinue prod- uct; do not use in pregnancy/breastfeed- ing; can cause injury or death to develop- ing fetus • For dry cough; notify prescriber as product may need to be discontinued Black Box Warning: To inform prescriber if pregnancy is planned or suspected; not to breastfeed
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SIDE EFFECTS CNS: Headache, dizziness, anxiety, insomnia, paresthesia, fatigue, depres- sion, malaise, vertigo, syncope CV: Hypotension, chest pain, palpita- tions, angina, syncope, dysrhythmia, heart failure, MI GI: Nausea, constipation, vomiting, anorexia, diarrhea, abdominal pain GU: Proteinuria, increased BUN, creati- nine, impotence INTEG: Rash, sweating, photosensitivity, pruritus META: Hyperkalemia MS: Arthralgia, arthritis, myalgia RESP: Dry cough, dyspnea
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INTERACTIONS • Do not use with aliskiren in moderate- severe renal disease Increase: hyperkalemia—potassium- sparing diuretics, potassium supplement, angiotensin II receptor agonists Increase: hypotension—diuretics, other antihypertensives, ganglionic blockers, adrenergic blockers, nitrates, acute alco- hol ingestion Increase: toxicity—vasodilators, hydrAL- AZINE, prazosin, potassium-sparing diuretics, sympathomimetics, potassium supplements Increase: serum levels of lithium Decrease: absorption—antacids Decrease: antihypertensive effect—indo- methacin, NSAIDs, salicylates Drug/Herb Increase: antihypertensive effect—garlic hawthorn Decrease: antihypertensive effect—black licorice, ephedra Drug/Food Increase: hyperkalemia—potassium salt substitutes; avoid use Drug/Lab Test Increase: LFTs, BUN, creatinine, glucose, potassium Decrease: RBC, HB, platelets
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TREATMENT OF OVERDOSE: 0.9% NaCl IV infusion, hemodialysis
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DOSAGE AND ROUTES Hypertension • Adult: PO 2.5 mg/day initially, then 2.5-20 mg/day divided bid or daily HF post-MI • Adult: PO 1.25-2.5 mg bid; may in- crease to 5 mg bid Reduction in risk for MI, stroke, death • Adult: PO 2.5 mg/day × 7 days, then 5 mg/day × 21 days, then may increase to 10 mg/day Renal dose • Adult: PO CCr <40 mL/min, reduce by 25%, titrate upward to max 5 mg/day
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Available forms: Caps 1.25, 2.5, 5, 10 mg
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Administer: • Without regard to meals • Swallow cap or tablet whole • Caps can be opened, added to food; mixture is stable for 24 hr at room tem- perature, 48 hr refrigerated • Store in tight container at ≤86°F (30°C)
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Assess: • Hypertension: monitor B/P baseline and regularly, orthostatic hypotension, syncope • Heart failure: edema in feet, legs daily; weight daily • Collagen-vascular disease (SLE, scle roderma): neutrophils, decreased plate- lets; WBC with differential at baseline, periodically; if neutrophils <1 × 109/L, discontinue treatment • Renal disease: protein, BUN, creati- R nine, potassium, sodium at baseline, pe- riodically; increased levels may indicate nephrotic syndrome; renal symptoms: polyuria, oliguria, urinary frequency, dysuria • Serious allergic reactions: angio edema, Stevens-Johnson syndrome, rash, fever, pruritus, urticaria; product should be discontinued if antihistamines fail to help • Monitor electrolytes baseline and peri- odically; potassium may be increased
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Evaluate: • Therapeutic response: decrease in B/P; HF
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • Not to discontinue product abruptly; to comply with dosage schedule, even if feeling better • Not to use OTC products (cough, cold, allergy), herbals, supplements unless di- rected by prescriber; not to use salt sub- stitutes containing potassium without consulting prescriber • To rise slowly to sitting or standing position to minimize orthostatic hypoten- sion • To notify prescriber of mouth sores, sore throat, fever, swelling of hands or feet, irregular heartbeat, chest pain • To report excessive perspiration, de- hydration, vomiting, diarrhea; may lead to fall in B/P; to maintain hydration • That product may cause dizziness, fainting, light-headedness; that these may occur during first few days of therapy; to avoid hazardous activities until response is known • That product may cause skin rash, impaired perspiration • How to take B/P, normal readings for age group • To report dry cough to provider
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PHARMACOKINETICS Bioavailability >50%-60%, onset 1-2 hr, peak 1-3 hr, duration 24 hr, protein bind- ing 73%, half-life 13-17 hr, metabolized by liver (metabolites excreted in urine, feces)
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• Adult: PO 2.5 mg/day initially, then 2.5-20 mg/day divided bid or daily HF post-MI
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• Adult: PO 1.25-2.5 mg bid; may in- crease to 5 mg bid Reduction in risk for MI, stroke, death
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• Adult: PO 2.5 mg/day × 7 days, then 5 mg/day × 21 days, then may increase to 10 mg/day Renal dose
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• Adult: PO CCr <40 mL/min, reduce by 25%, titrate upward to max 5 mg/day
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