Ramoril Plus

Ramipril is an angiotensin converting enzyme (ACE) inhibitor. Once it is hydrolysed to ramiprilat, it blocks the conversion of angiotensin I to angiotensin II, which is a vasoconstrictor. So when ramipril inhibits ACE, plasma angiotensin II falls, and this lowers vasopressor activity and aldosterone secretion. That is how ramipril brings blood pressure down. It is also effective in managing heart failure and in reducing the risk of stroke, myocardial infarction and death from cardiovascular events. Ramipril is long acting and well tolerated, so it can be used in long term therapy.

Hydrochlorothiazide is a thiazide diuretic. Thiazides act on the renal tubular mechanisms of electrolyte reabsorption and directly increase the excretion of sodium and chloride in approximately equivalent amounts. The indirect effect comes from the diuretic action of hydrochlorothiazide, which reduces plasma volume. As a result, plasma renin activity goes up, aldosterone secretion goes up, urinary potassium loss increases and serum potassium decreases. The link between renin and aldosterone is mediated by angiotensin II, so giving an ACE inhibitor together with the diuretic tends to reverse the potassium loss that these diuretics cause.

Pregnancy should be ruled out before treatment with ramipril starts, and it should be avoided while the treatment goes on. When a mother is exposed to ACE inhibitors in mid or late pregnancy, it has been linked with oligohydramnios, and with neonatal hypotension with anuria or renal failure. Animal experiments show that ramipril may decrease utero-placental perfusion. There is also a possible risk of effects on the fetus or after birth, because ACE inhibitors also act on the local renin-angiotensin system. In peri-post natal studies, increased renal pelvic dilatation was seen in the first generation offspring. Ramipril itself was not fetotoxic in studies, although ACE inhibitors have shown fetotoxicity in some species. Ramipril should not be used during lactation.

Dosage in renal impairment

If a patient's creatinine clearance is between 60 and 30 ml/min, start treatment with Ramipril 1.25 mg alone. If blood pressure isn't controlled well enough, the Ramipril dose may be raised to 2.5 mg. If blood pressure is still not controlled, the patient may be switched to one tablet of Ramipril BP 2.5 mg and Hydrochlorothiazide BP 12.5 mg once daily. The dose can then be increased step by step up to Ramipril BP 5 mg and Hydrochlorothiazide BP 25 mg, until blood pressure is controlled.

Ramipril: Only limited data on overdose in humans are available. The most likely effects are symptoms of hypotension (low blood pressure). Ramipril lowers blood pressure through vasodilation and effective hypovolemia, so it is reasonable to treat an overdose with an infusion of normal saline solution.

Hydrochlorothiazide: The signs and symptoms seen most often are caused by electrolyte depletion (hypokalemia and hypochloremia) and by dehydration from excessive diuresis. If digitalis has also been given, hypokalemia may make cardiac arrhythmias worse. How much Hydrochlorothiazide is removed by hemodialysis has not been established.

Keep Ramipril + Hydrochlorothiazide in a cool, dry place, away from light.