Ramipril drug interactions

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, M.D. [2], Amr Marawan, M.D. [3]

For patient information about Ramipril, click here.

Ramipril

Overview

Ramipril tablet is an angiontensin converting enzyme inhibitor drug that is FDA approved for the treatment of hypertension, heart failure, left ventricular dysfunction after myocardial infarction, diabetic nephropathy. Adverse reactions include hypotension, rash, hyperkalemia, disorder of taste, cough. hypotension, rash, hyperkalemia, disorder of taste, cough.

Category

Antihypertensive Agents, Angiotensin Converting Enzyme Inhibitors. Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4]; Associate Editor(s)-in-Chief: Amr Marawan, M.D. [5]

Drug Interactions

Diuretics

Patients on diuretics, especially those in whom diuretic therapy was recently instituted, may occasionally experience an excessive reduction of blood pressure after initiation of therapy with ALTACE. The possibility of hypotensive effects with ALTACE can be minimized by either decreasing or discontinuing the diuretic or increasing the salt intake prior to initiation of treatment with ALTACE. If this is not possible, reduce the starting dose.

ALTACE can attenuate potassium loss caused by thiazide diuretics. Potassium-sparing diuretics (spironolactone, amiloride, triamterene, and others) or potassium supplements can increase the risk of hyperkalemia. Therefore, if concomitant use of such agents is indicated, monitor the patient's serum potassium frequently.


Other Antihypertensive Agents

Limited experience in controlled and uncontrolled trials combining ALTACE with a calcium channel blocker, a loop diuretic, or triple therapy (beta-blocker, vasodilator, and a diuretic) indicate no unusual drug-drug interactions. Other ACE inhibitors have had less than additive effects with beta adrenergic blockers, presumably because both drug classes lower blood pressure by inhibiting parts of the renin-angiotensin-aldosterone system.

The combination of ramipril and propranolol showed no adverse effects on dynamic parameters (blood pressure and heart rate).

In a large-scale, long-term clinical efficacy study, the combination of telmisartan and ramipril resulted in an increased incidence of clinically important renal dysfunction (death, doubling of serum creatinine, dialysis) compared with groups receiving either drug alone. Therefore, concomitant use of telmisartan and ramipril is not recommended.


Lithium

Increased serum lithium levels and symptoms of lithium toxicity have been reported in patients receiving ACE inhibitors during therapy with lithium; therefore, frequent monitoring of serum lithium levels is recommended. If a diuretic is also used, the risk of lithium toxicity may be increased.


Gold

Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients on therapy with injectable gold (sodium aurothiomalate) and concomitant ACE inhibitor therapy including ALTACE.


Non-Steroidal Anti-Inflammatory Agents including Selective Cyclooxygenase-2 Inhibitors (COX-2 Inhibitors)

In patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function, co-administration of NSAIDs, including selective COX-2 inhibitors, with ACE inhibitors, including ramipril, may result in deterioration of renal function, including possible acute renal failure. These effects are usually reversible. Monitor renal function periodically in patients receiving ramipril and NSAID therapy.

The antihypertensive effect of ACE inhibitors, including ramipril, may be attenuated by NSAIDs.


Aliskiren

Do not co-administer aliskiren with ALTACE in patients with diabetes. Avoid concomitant use of aliskiren with ALTACE in patients with renal impairment (GFR <60 mL/min/1.73 m2).


mTOR Inhibitors

Patients taking concomitant mTOR inhibitor (e.g. temsirolimus) therapy may be at increased risk for angioedema.

Other

Neither ramipril nor its metabolites have been found to interact with food, digoxin, antacid, furosemide, cimetidine, indomethacin, and simvastatin. The co-administration of ramipril and warfarin did not adversely affect the anticoagulation effects of the latter drug. Additionally, co-administration of ramipril with phenprocoumon did not affect minimum phenprocoumon levels or interfere with the patients' state of anticoagulation.[1]


References

  1. ↑ "ALTACE (RAMIPRIL) CAPSULE [PFIZER LABORATORIES DIV PFIZER INC]".

Adapted from the FDA Package Insert.


Drug interactions


Antacids

Capsaicin

Digoxin

Diuretics

Indomethacin, salicylates (e.g, aspirin)

Lithium

Loop diuretics

Phenothiazines

Potassium supplements, potassium-sparing diuretics

Laboratory Test Interactions



Antacids

Ramipril bioavailability may be decreased. Separate administration times by 1 to 2 h.

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Capsaicin

May exacerbate cough.

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Digoxin

Increased or decreased digoxin levels.

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Diuretics

Increased risk of hypotension.

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Indomethacin, salicylates (e.g, aspirin)

May reduce hypotensive effects, especially in low-renin or volume-dependent hypertensive patients.

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Lithium

May cause increased lithium levels and symptoms of lithium toxicity.

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Loop diuretics

Effects of loop diuretics may be decreased.

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Phenothiazines

Enhanced hypotensive effects.

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Potassium supplements, potassium-sparing diuretics

May cause increased potassium (serum) levels.

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Laboratory Test Interactions

False elevation of liver enzymes, serum bilirubin, uric acid, and blood glucose may occur.

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Complete list of drug interactions

Major Interactions

Moderate Interactions

Minor Interactions




Adapted from the FDA Package Insert.

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