Ramipril

ALTACE

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Pronunciation: ra-MI-pril

Ramipril ballicule: receptor binding, kinetics and half-life diagram — Mechanism of action: Ramipril ballicule

Ramipril ALTACE mascot mnemonic cartoon — Visual mnemonic: Ramipril mascot
**“Rammin’ the Altar of ACE”**
Easter/April theme → ACE inhibitor = -pril (aPril)
Bananas in bunches → ↑ serum potassium

What it isACE inhibitor; hypertension, heart failure and cardiovascular risk reduction.

Why this oneCardiovascular event reduction in high-risk patients without heart failure, which is a broader indication than most of the class carries.

What limits itCough, hyperkalemia and the hemodynamic creatinine rise. Contraindicated in pregnancy.

Ramipril molecular structure (skeletal formula) — Molecular structure: Ramipril

FDA-approved for

hypertension (1991)
cardiovascular risk reduction (2000)

FDA label

Read the full label on DailyMed ↗

BOXED WARNING Fetal toxicity — discontinue as soon as pregnancy detected; RAS-acting drugs can injure/kill the developing fetus

FDA dosing	Population	Start	Target	Max
Hypertension	Adults (no diuretic)	2.5 mg QD	2.5-20 mg/day QD or divided BID	20 mg/day
Reduce risk of MI/stroke/CV death	Adults	2.5 mg QD x1 wk, then 5 mg QD x3 wk	10 mg QD	10 mg/day
Heart failure post-MI	Adults	2.5 mg BID (1.25 mg BID if hypotensive)	5 mg BID	5 mg BID

Titration HTN: reassess after 2-4 wks; HF post-MI: increase ~3 wks apart

Renal HTN & HF with renal impairment: initial 1.25 mg QD; adjust downward in moderate-severe impairment

Hepatic Impaired liver function may markedly elevate ramipril levels; use caution

Instructions

May be given once daily or in two divided doses
Discontinue as soon as possible if pregnancy detected

Available strengths

cap 1.25, 2.5, 5, 10 mg

Contraindications

History of angioedema with any ACE inhibitor, or hereditary/idiopathic angioedema
Concomitant neprilysin inhibitor (sacubitril); do not use within 36 h of sacubitril/valsartan
With aliskiren in patients with diabetes

Cautions

Angioedema (increased risk with prior history)
Hypotension and hyperkalemia
Renal impairment — monitor renal function
Avoid dual RAS blockade (ACEi + ARB)
Rare cholestatic jaundice / hepatic failure
Rare neutropenia / agranulocytosis

Adverse reactions

Headache
Dizziness
Fatigue/asthenia
Cough

Pregnancy Contraindicated implication — fetal renal toxicity, oligohydramnios, skull hypoplasia, death in 2nd/3rd trimester; discontinue when detected

Lactation Not recommended in nursing mothers

Cost

Ramipril (ALTACE)

What pharmacies pay · NADAC 9/30/26

Strength		#/mo	generic $/mo	CostPlus
1.25 mg	cap	30 qd	$2.41	offered
2.5 mg	cap	30 qd	$1.42	offered
5 mg	cap	30 qd	$1.54	offered
10 mg	cap	30 qd	$2.12	offered

Generic entry2005

⚠ BOXED WARNING

Fetal toxicity; discontinue as soon as pregnancy is detected

Principal riskAngioedema and hyperkalemia

Classes and tags

Clinical profile

Therapeutic safety burden2 / 4

Overdose danger2 / 4

Weight-gain liability0 / 4

Sedation liability0 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk4 / 4

Legacy pregnancy categoryD

Defining liabilityHyperkalemia, kidney injury, angioedema, fetal toxicity and increased lithium exposure.

Active metabolites

Ramiprilat

Open Ramipril in the interactive console ↗

Memory aids: interaction avatars

Box: minimal PK interactions

Open Ramipril in the interactive console ↗