It is recommended to double the dose after one or two weeks of treatment and – after another two to three weeks – to increase it up to the target maintenance dose of 10mg of Ramipril once daily.See also posology of diuretic treated patient aboveThe recommended initial dose is 1.25 mg of Ramipril once daily.Depending on the patient's tolerability to the active substance, the dose is subsequently increased. Characteristically, the cough is non-productive, persistent and resolves after discontinuation of therapy. Monitoring of serum potassium is recommended.Potentiation of the risk of hypotension is to be anticipated (see section 4.2 for diuretics).Increased likelihood of haematological reactions (see section 4.4).Hypoglycemic reactions may occur.
Given their similar pharmacodynamic properties, these results are also relevant for other ACE-inhibitors and angiotensin II receptor blockers.ACE-inhibitors and angiotensin II receptor blockers should therefore not be used concomitantly in patients with diabetic nephropathy.ALTITUDE (Aliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints) was a study designed to test the benefit of adding aliskiren to a standard therapy of an ACE-inhibitor or an angiotensin II receptor blocker in patients with type 2 diabetes mellitus and chronic kidney disease, cardiovascular disease, or both. If the dose cannot be increased to 2.5 mg twice a day treatment should be withdrawn.
Maintenance dose: 10 mg once daily after further 3 wk. The intergroup difference was thus 0.34 [0.03-0.65] per month, and around 4 ml/min/year; 23.1 % of the patients in the Ramipril group reached the combined secondary endpoint of doubling of baseline serum creatinine concentration and/or end-stage renal disease (ESRD) (need for dialysis or renal transplantation) vs. 45.5 % in the placebo group (p = 0.02).Two large randomised, controlled trials (ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and VA NEPHRON-D (The Veterans Affairs Nephropathy in Diabetes)) have examined the use of the combination of an ACE-inhibitor with an angiotensin II receptor blocker.ONTARGET was a study conducted in patients with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes mellitus accompanied by evidence of end-organ damage. Call your doctor right away if you have severe stomach pain (with or without nausea or vomiting). Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard Or search for MHRA Yellow card in the Google Play or Apple App Store.Symptoms associated with overdose of ACE inhibitors may include excessive peripheral vasodilatation (with marked hypotension, shock), bradycardia, electrolyte disturbances, and renal failure. The maintenance dose is divided in 2 administrations per day where possible. If tolerated, increase to 5 mg once daily after 1 wk. Maintenance: 2.5-5 mg bid. Make sure you know how you react to this medicine before you drive, use machines, or do other things that could be dangerous if you are dizzy or not alert. Ask your doctor before you use any medicine, supplement, or salt substitute that contains potassium. You may need to stop using this medicine several days before having surgery or medical tests. Doubling the once daily dose to 2.5 mg after two weeks and then to 5 mg after a further two weeks is recommended.In patients stabilized on diuretic therapy, the recommended initial dose is 1.25 mg daily.Ramipril should be titrated by doubling the dose every one to two weeks up to a maximum daily dose of 10 mg. Two administrations per day are preferable.After 48 hours, following myocardial infarction in a clinically and haemodynamically stable patient, the starting dose is 2.5 mg twice daily for three days. In plasma and tissue this enzyme catalyses the conversion of angiotensin I to the active vasoconstrictor substance angiotensin II, as well as the breakdown of the active vasodilator bradykinin. Ramipril capsules can be taken before, with or after meals, because food intake does not modify its bioavailability (see section 5.2).Ramipril capsules have to be swallowed with liquid. sirolimus, everolimus, temsirolimus) and vildagliptin may lead to an increased risk for angioedema (see section 4.4).Ramipril is not recommended during the first trimester of pregnancy (see section 4.4) and contraindicated during the second and third trimesters of pregnancy (see section 4.3).Epidemiological evidence regarding the risk of teratogenicity following exposure to ACE inhibitors during the first trimester of pregnancy has not been conclusive; however a small increase in risk cannot be excluded. The effect is usually not significant in patients with normal renal function.
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