Ramipril and hydrochlorothiazide combination Tablets - Dose, Side effects

Ramipril hydrochlorothiazide is available as a combination product. It is a combination of an ACE inhibitor and a thiazide diuretic.

  • It is used for the treatment of hypertension

Ramipril hydrochlorothiazide Dose in Adults

Ramipril hydrochlorothiazide Dose in the treatment of Hypertension:

  • Ramipril 2.5 mg/hydrochlorothiazide 12.5 mg is given once daily
  • Titration is done to maximum ramipril 10 mg/hydrochlorothiazide 50 mg once daily.
  • Patients using diuretics prior to initiating ramipril/hydrochlorothiazide should attempt to discontinue diuretic therapy at least 2 to 3 days before initiation, or at least reduce the diuretic dose
  • if unable to stop the diuretic, start ramipril at the lowest possible dose (eg, 1.25 mg daily).
  • As clinically indicated may change to ramipril/hydrochlorothiazide at an initial dose of ramipril ≤2.5 mg/hydrochlorothiazide 12.5 mg once daily.

Ramipril hydrochlorothiazide Dose in Children:

The usual initial dose is 2.5 mg/5 ml of oral solution daily.

Pregnancy Risk Factor: D

  • Drugs that affect the renin-angiotensin system have the potential to harm or even kill a developing foetus.
  • As soon as pregnancy is discovered, stop immediately.
  • Use is contraindicated in pregnant women.

Ramipril and hydrochlorothiazide use during breastfeeding:

  • Ramipril and thiazide diuretics are usually found in breast milk.
  • The use in breastfeeding women is contraindicated.

Ramipril Hydrochlorothiazide dose in kidney disease:

  • CrCl >60 mL/minute/1.73 m² :

    • No dosage adjustment required.

  • CrCl 30 to 60 mL/minute/1.73 m² :

    • Initial dose is  Ramipril 2.5 mg/hydrochlorothiazide 12.5 mg once daily
    • Maximum dose is Ramipril 5 mg/hydrochlorothiazide 25 mg once daily

  • CrCl <30 mL/minute/1.73 m² :

    • Use is contraindicated.

  • Dialysis:

    • Use is contraindicated.

Ramipril hydrochlorothiazide Dose in Liver disease:

  • Mild-to-moderate impairment:

    • Maximum dose is 2.5 mg of ramipril/12.5 mg hydrochlorothiazide once daily.
    • Start treatment under close medical supervision.

  • Severe impairment:

    • Use is contraindicated.

Side Effects of Ramipril hydrochlorothiazide:

  • Neuromuscular & skeletal:

    • Back pain

  • Respiratory:

    • Bronchitis
    • Cough increased

Contraindications to Ramipril hydrochlorothiazide:

  •  
  • Anuria
  • hemodynamically relevant bilateral or unilateral (in patients with a single kidney) renal artery stenosis
  • hypotensive states
  • hemodynamically unstable states
  • Hypersensitivity to any component of the formulation, including ramipril, hydrochlorothiazide, other ACE inhibitors or thiazides, sulfonamide-derived medications, or any other component
  • patients with or without a history of treatment for angioedema
  • use within 36 hours of switching to or from sacubitril/valsartan concomitant use of aliskiren-containing medications in patients with diabetes mellitus (type 1 or type 2)
  • heart failure who are hypotensive, moderate to severe renal impairment (GFR 60 mL/minute/1.73 m), hyperkalemia (>5 mMol/L), and concomitant use of angiotensin II receptor antagonists (ARBs) 
  • clinically relevant electrolyte disturbances (eg, hypokalemia, hyponatremia, or hypercalcemia)
  • pregnancy
  • breastfeeding

Warnings and Precautions

  • Angioedema:

    • Angioedema may occur during treatment
    • It might affect the intestine or head and neck, which could compromise the breathing (presenting with abdominal pain).
    • Patients of colour could be at higher risk.
    • Concomitant usage of a mTOR inhibitor, such as everolimus, may also raise the risk.
    • When the tongue, glottis, or larynx are affected, frequent and sustained monitoring is necessary since these structures are linked to airway obstruction.
    • Patients who have had airway surgery in the past are more likely to experience airway blockage.
    • It is necessary to control aggressively and appropriately early.
    • Use is not advised in people who have experienced angioedema in the past.

  • Cholestatic jaundice:

    • Cholestatic jaundice is a rare complication associated with ACE inhibitors that can proceed to fulminant hepatic necrosis.
    • If this happens, stop taking the medication immediately.
    • Consider stopping therapy if symptoms of hepatic dysfunction (eg, fever, malaise, muscle pain, rash) present within the first weeks to months of therapy.

  • Cough:

    • A dry, hacking, nonproductive cough caused by ACE inhibitors usually appears during the first few months of treatment and should go away within 1 to 4 weeks of stopping the medication.
    • Before quitting the medication, other possible reasons of cough should be ruled out, such as lung congestion in patients with heart failure.

  • Dermatologic malignancy:

    • Hydrochlorothiazide use has been linked to non-melanoma skin and lip cancer (basal cell carcinoma and squamous cell carcinoma)
    • The risk may rise with continued use.
    • Use cautiously in patients at high risk for non-melanoma skin cancer including personal or family history of skin cancer, immunosuppressive therapy or light-colored skin.
    • Evaluate skin for new or changing lesions.
    • Limit sunlight exposure and avoid usage of sunlamps/tanning equipment.
    • Daily sunscreen (SPF ≥30) use, sun protective clothing and hats, and other protective measures are advised.

  • Electrolyte disturbances:

    • ACE inhibitors may cause hyperkalemia.
    • Renal impairment, diabetes mellitus, and concurrent use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salts are risk factors for hyperkalemia.
    • When using these medications, use caution and keep an eye on your potassium levels.
    • Hypokalemia, hypochloremic alkalosis, hypomagnesemia, and hyponatremia are possible side effects of thiazide diuretics.
    • Use is contraindicated with clinically relevant electrolyte abnormalities (eg, hypokalemia, hyponatremia, or hypercalcemia).

  • Gout:

    • Hydrochlorothiazide has the potential to exacerbate gout in some people having a history of the condition, a family history of the condition, or chronic renal failure.
    • Higher doses above 25 mg may result in an increase in this risk.

  • Hypersensitivity reactions:

    • With ACE inhibitors, anaphylactic/anaphylactoid responses could happen.
    • In rare cases, severe allergic reactions have been seen during low-density lipoprotein apheresis using dextran sulphate cellulose and hemodialysis (e.g., CVVHD) with high-flux dialysis membranes (e.g., AN69).
    • Rare incidences of allergic reactions have been seen in people receiving ACE inhibitor therapy while getting venom from
    • Hymenoptera (bee, wasp). These reactions have been averted by briefly stopping the ACE inhibitor therapy (24 hours), but they have returned following rechallenge.
    • Patients with a history of allergies or bronchial asthma are at a higher risk of developing hypersensitivity reactions to hydrochlorothiazide.

  • Hypotension/syncope:

    • Syncope or symptomatic hypotension may happen (usually with the first several doses)
    • Effects are most frequently seen in volume-depleted patients
    • therefore, it is important to prevent volume depletion before therapy begins.
    • After a dose increase, blood pressure must be decreased at a rate appropriate to the patient's clinical condition.
    • Advise patients to use caution when driving or operating machinery during therapy initiation or with dose increases;
    • hypotensive effects may impair the ability to perform these tasks.
    • Hypotension is not a reason to stop using ACE inhibitors in the future, even though dose reduction may be required. This is especially true for patients with heart failure, when a decrease in systolic blood pressure is a desired finding.

  • Neutropenia/ agranulocytosis:

    • In rare instances of agranulocytosis, neutropenia, or leukopenia with myeloid hyperplasia, it has been linked to bone marrow suppression.
    • Patients with renal disease and/or collagen vascular disease (such systemic lupus erythematosus) may be more likely to experience bone marrow suppression.
    • In these patients, keep an eye on the CBC with a differential.

  • Ocular effects:

    • Acute transitory myopia and acute angle-closure glaucoma can also be brought on by hydrochlorothiazide, usually within hours to weeks of treatment beginning. Patients experiencing sudden declines in visual acuity or eye pain should stop taking their medication right once.
    • If the intraocular pressure cannot be managed, other therapies can be required.
    • Patients who have previously experienced penicillin or sulfonamide allergies are more vulnerable.

  • Photosensitivity:

    • Photosensitization might occur
    • Stop use if photosensitivity reactions occur.

  • Renal function deterioration:

    • In individuals with limited renal blood flow, such as those with renal artery stenosis and heart failure, it may be linked to worsening renal function and/or increases in serum creatinine. In these patients, angiotensin II-induced efferent arteriolar vasoconstriction determines the glomerular filtration rate (GFR).
    • Oliguria, abrupt renal failure, and increasing azotemia are all symptoms of deterioration.
    • Following start-up, slight elevations in serum creatinine could happen.
    • Treatment may be discontinued if significant or progressive renal function deterioration occurs.

  • Sulfonamide (“sulfa”) allergy:

    • Cross-reactivity between individuals in a given class is possible (eg, two antibiotic sulfonamides).
    • Crossreactivity worries, however, have previously applied to all substances with the sulfonamide structure (SO NH ).
    • Sulfonamides that are not antibiotics are unlikely to cause mechanisms of cross-reaction brought on by the formation of antibodies (anaphylaxis).
    • Some medical professionals decide not to expose patients to these medications in situations where earlier reactions were severe (Stevens-Johnson syndrome/TEN).

  • Aortic stenosis:

    • In patients with severe aortic stenosis, use with caution.
    • It might lower coronary perfusion, which would cause ischemia.

  • Bariatric surgery:

    • When using diuretics right after bariatric surgery, electrolyte imbalances and dehydration are possible.
    • Once oral fluid consumption objectives are achieved, diuretics may be resumed if necessary.

  • Cardiovascular disease:

    • Due to the potential repercussions of lowering blood pressure, the start of medication in patients with ischemic heart disease or cerebrovascular disease necessitates thorough monitoring (eg, MI, stroke).
    • If additional fluid is required, blood pressure may be restored; therapy may then resume.
    • Patients whose hypotension recurs should stop their therapy.

  • Collagen vascular disease:

    • Patients with collagen vascular disease should use ACE inhibitors with caution, especially if there is concurrent renal impairment.
    • They might be more susceptible to hematopoietic toxicity.
    • Systemic lupus erythematosus (SLE) aggravation or activation may result after using hydrochlorothiazide.

  • Diabetes:

    • In patients with prediabetes or diabetes mellitus, use hydrochlorothiazide with caution; it may alter glucose regulation.

  • Hepatic impairment:

    • In cases of severe hepatic dysregulation, use is not advised.
    • Avoid electrolyte and acid/base imbalances in patients with progressing liver disease since they may cause hepatic encephalopathy or coma.

  • Hypercalcemia:

    • Thiazide diuretics should not be used in patients with hypercalcemia because they may reduce renal calcium excretion.

  • Hypercholesterolemia:

    • Use with caution in patients with moderate or high cholesterol levels because thiazides have been linked to elevated levels of cholesterol and triglycerides.

  • Hypertrophic cardiomyopathy (HCM) with outflow tract obstruction:

    • Use with caution in individuals who have HCM and an obstruction of the outflow tract, as a reduction in afterload could make the symptoms of this illness worse.

  • Parathyroid disease:

    • Thiazide diuretics can lower calcium excretion, and extended use has been associated with pathologic alterations in the parathyroid glands, including hypercalcemia and hypophosphatemia, which should be halted before parathyroid function tests.

  • Renal artery stenosis:

    • Use is not advised in people with unilateral or bilateral (in those with just one kidney) renal artery stenosis that is hemodynamically significant.
    • Oliguria, progressive azotemia, and in rare cases, acute renal failure and/or death, may be related to it.

  • Renal impairment:

    • Use ACE inhibitors with caution if you already have renal insufficiency; your dosage may need to be adjusted.
    • Avoid abrupt dose increases, which might exacerbate renal impairment.
    • Patients who have impaired renal function may be more susceptible to hematologic toxicity.
    • In patients with reduced renal function, hydrochlorothiazide's cumulative side effects, including azotemia, may manifest.
    • In cases of severe renal illness, avoid using hydrochlorothiazide (ineffective).
    • Patients with severe renal impairment (CrCl 30 mL/minute/1.73 m) or anuria should not use this medication.

Drug Interaction

Risk Factor C (Monitor therapy)

Ajmaline

Sulfonamides might make ajmaline more harmful or poisonous. In particular, there may be an elevated risk for cholestasis.

Alcohol (Ethyl)

Increases the effectiveness of thiazide and thiazide-like diuretics in lowering orthostatic blood pressure.

Alfuzosin

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Aminolevulinic Acid (Topical)

Aminolevulinic Acid's photosensitizing impact may be enhanced by photosensitizing agents (Topical).

Amphetamines

May lessen the effectiveness of antihypertensive agents.

Angiotensin II

The therapeutic efficacy of angiotensin II may be enhanced by angiotensin-converting enzyme inhibitors.

Angiotensin-Converting Enzyme Inhibitors

Angiotensin-Converting Enzyme Inhibitors' hypotensive effects may be enhanced by thiazide and thiazide-like diuretics. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by thiazide and thiazide-like diuretics.

Anticholinergic Agents

May raise the levels of thiazide and thiazide-like diuretics in the blood.

Antidiabetic Agents

The therapeutic value of anti-diabetic agents may be diminished by thiazide and thiazide-like diuretics.

Antidiabetic Agents

The therapeutic benefit of anti-diabetic agents may be reduced by hyperglycemia-associated agents.

Antipsychotic Agents (Second Generation [Atypical])

Antipsychotic drugs' hypotensive effects may be enhanced by blood pressure-lowering medications (Second Generation [Atypical]).

Aprotinin

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

AzaTHIOprine

AzaTHIOprine's myelosuppressive effects may be enhanced by angiotensin-converting enzyme inhibitors.

Barbiturates

The hyponatremic effects of thiazide and thiazide-like diuretics may be enhanced.

Barbiturates

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Benazepril

Benazepril's hypotensive impact may be strengthened by hydrochlorothiazide. Benazepril may have a more nephrotoxic effect when combined with hydrochlorothiazide. Benazepril may lower the level of HydroCHLOROthiazide in the blood.

Benperidol

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Beta2-Agonists

The hyponatremic effects of thiazide and thiazide-like diuretics may be enhanced.

Brigatinib

May lessen the effectiveness of antihypertensive agents. Antihypertensive Agents' bradycardic action may be strengthened by brutinib.

Brimonidine (Topical)

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Calcium Salts

The excretion of calcium salts may be decreased by thiazide and thiazide-like diuretics. Metabolic alkalosis can also be brought on by continued concurrent usage.

CarBAMazepine

Thiazide and Thiazide-Like Diuretics may intensify CarBAMazepine's negative/toxic effects. Particularly, there could be a higher risk of hyponatremia.

Cardiac Glycosides

Cardiac Glycosides may have an increased negative or toxic effect when used with thiazide and thiazide-Like Diuretics. Particularly, the hypokalemic and hypomagnesemic impact of thiazide diuretics may worsen cardiac glycoside toxicity.

Corticosteroids (Orally Inhaled)

The hyponatremic effects of thiazide and thiazide-like diuretics may be enhanced.

Corticosteroids (Systemic)

The hyponatremic effects of thiazide and thiazide-like diuretics may be enhanced.

Cyclophosphamide

Thiazide and Thiazide-Like Diuretics may intensify Cyclophosphamide's harmful or hazardous effects. Particularly, granulocytopenia could be worsened.

Dapoxetine

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Dexketoprofen

Sulfonamides' harmful or poisonous effects could be amplified.

Dexmethylphenidate

May lessen the effectiveness of antihypertensive agents.

Diacerein

Could make diuretics' therapeutic effects stronger. Particularly, there may be a higher chance of hypokalemia or dehydration.

Diazoxide

Thiazide and Thiazide-Like Diuretics may intensify Diazoxide's harmful or toxic effects.

Diazoxide

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Dipeptidyl Peptidase-IV Inhibitors

May worsen angiotensin-converting enzyme inhibitors' toxic or severe effects. Particularly, there may be a higher incidence of angioedema.

Drospirenone

Drospirenone's hyperkalemic impact may be enhanced by angiotensin-converting enzyme inhibitors.

DULoxetine

The hypotensive impact of DULoxetine may be enhanced by blood pressure lowering medications.

Eplerenone

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Everolimus

May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. Particularly, there may be a higher incidence of angioedema.

Ferric Gluconate

Angiotensin-Converting Enzyme Inhibitors might make ferric gluconate more harmful or poisonous.

Ferric Hydroxide Polymaltose Complex

Ferric Hydroxide Polymaltose Complex may have a more negative or toxic effect when taken with angiotensin-converting enzyme inhibitors. In particular, there may be an elevated risk for angioedema or allergic responses.

Gelatin (Succinylated)

Gelatin's harmful or toxic effects may be increased by angiotensin-converting enzyme inhibitors (Succinylated). Particularly, there may be a higher chance of a paradoxical hypotensive reaction.

Gold Sodium Thiomalate

Gold Sodium Thiomalate may have a more negative or toxic effect when used with angiotensin-converting enzyme inhibitors. Nitritoid responses are more likely now, it has been noted.

Heparin

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Heparins (Low Molecular Weight)

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Herbs (Hypertensive Properties)

May lessen the effectiveness of antihypertensive agents.

Herbs (Hypotensive Properties)

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Hypotension-Associated Agents

The hypotensive action of hypotension-associated agents may be strengthened by blood pressure lowering medications.

Icatibant

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Ipragliflozin

The toxic and harmful effects of thiazide and thiazide-like diuretics may be increased. In particular, there may be an elevated risk for intravascular volume depletion.

Ivabradine

The arrhythmogenic impact of ivabradine may be enhanced by thiazide and thiazide-like diuretics.

Levodopa-Containing Products

Levodopa-Containing Products' hypotensive effects may be strengthened by blood pressure-lowering medications.

Licorice

The hyponatremic effects of thiazide and thiazide-like diuretics may be enhanced.

Loop Diuretics

May strengthen angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by loop diuretics.

Lormetazepam

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Methylphenidate

May lessen the effectiveness of antihypertensive agents.

Molsidomine

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Multivitamins/Fluoride (with ADE)

The hyponatremic effects of thiazide and thiazide-like diuretics may be enhanced.

Multivitamins/Minerals (with ADEK, Folate, Iron)

The effect of multivitamins and minerals on hypercalcemia may be enhanced by thiazide and thiazide-like diuretics (with ADEK, Folate, Iron).

Multivitamins/Minerals (with AE, No Iron)

The serum concentration of multiple vitamins and minerals may rise after taking thiazide and thiazide-like diuretics (with AE, No Iron). Particularly, thiazide diuretics may reduce calcium excretion, and long-term concurrent usage may result in metabolic alkalosis.

Naftopidil

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Neuromuscular-Blocking Agents (Nondepolarizing)

The neuromuscular-blocking action of neuromuscular-blocking agents may be enhanced by thiazide and thiazide-like diuretics (Nondepolarizing).

Nicergoline

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Nicorandil

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Nicorandil

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Nitroprusside

Nitroprusside's hypotensive impact may be strengthened by blood pressure-lowering medications.

Nonsteroidal Anti-Inflammatory Agents

Nonsteroidal Anti-Inflammatory Agents' negative/toxic effects may be increased by angiotensin-converting enzyme inhibitors. In particular, the combination may cause a marked decline in renal function. Angiotensin-Converting Enzyme Inhibitors' antihypertensive effects may be lessened by nonsteroidal anti-inflammatory drugs.

Nonsteroidal Anti-Inflammatory Agents

Nonsteroidal Anti-Inflammatory Agents' nephrotoxic effects may be intensified by thiazide and thiazide-like diuretics. Thiazide and Thiazide-Like Diuretics may have less of a therapeutic impact when used with nonsteroidal anti-inflammatory drugs.

Opioid Agonists

Could make diuretics' harmful or toxic effects worse. Opioid antagonists may reduce diuretics' therapeutic benefit.

Oxcarbazepine

Thiazide and Thiazide-Like Diuretics may intensify OXcarbazepine's negative/toxic effects. Particularly, there could be a higher risk of hyponatremia.

Pentoxifylline

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Pholcodine

Pholcodine's hypotensive impact may be strengthened by blood pressure lowering medications.

Phosphodiesterase 5 Inhibitors

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Porfimer

The photosensitizing effect of Porfimer may be strengthened by photosensitizing agents.

Potassium Salts

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Potassium-Sparing Diuretics

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Pregabalin

Angiotensin-Converting Enzyme Inhibitors may intensify Pregabalin's negative/toxic effects. Particularly, there may be a higher incidence of angioedema.

Prostacyclin Analogues

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Quinagolide

The hypotensive effects of blood pressure-lowering medications may be strengthened.

Racecadotril

May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. In particular, this combination may make angioedema more likely.

Ranolazine

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Reboxetine

The hyponatremic effects of thiazide and thiazide-like diuretics may be enhanced.

Salicylates

May intensify angiotensin-converting enzyme inhibitors' nephrotoxic effects. The therapeutic benefit of angiotensin-converting enzyme inhibitors may be reduced by salicylates.

Selective Serotonin Reuptake Inhibitors

The hyponatremic effects of thiazide and thiazide-like diuretics may be enhanced.

Sirolimus

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Tacrolimus (Systemic)

Tacrolimus's effect of making you more hyperkalemic may be enhanced by angiotensin-converting enzyme inhibitors (Systemic).

Temsirolimus

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Thiazide and Thiazide-Like Diuretics

May increase the angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by thiazide and thiazide-like diuretics.

TiZANidine

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Tolvaptan

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Toremifene

Toremifene's hypercalcemic impact may be enhanced by thiazide and thiazide-like diuretics.

Trimethoprim

May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.

Verteporfin

Verteporfin's photosensitizing effect may be strengthened by photosensitizing agents.

Vitamin D Analogs

The hypercalcemic impact of vitamin D analogues may be enhanced by thiazides and thiazide-like diuretics.

Yohimbine

May lessen the effectiveness of antihypertensive agents.

Risk Factor D (Consider therapy modification)

Aliskiren

Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects. Angiotensin-Converting Enzyme Inhibitors' hypotensive effects may be strengthened by aliskiren. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be made worse by aliskiren. Treatment: It is not advised for diabetic patients to take aliskiren along with ACEIs or ARBs. Combination therapy should be avoided in other patients, especially when CrCl is less than 60 mL/min. If combined, keep a close eye on your blood pressure, potassium, and creatinine levels.

Allopurinol

Angiotensin-Converting Enzyme Inhibitors might make Allopurinol more likely to cause allergic or hypersensitive reactions.

Amifostine

Amifostine's hypotensive impact may be strengthened by blood pressure lowering medications. Treatment: Blood pressure-lowering drugs need to be avoided for 24 hours before amifostine is administered when used at chemotherapeutic doses. Amifostine should not be given if blood pressure lowering treatment cannot be stopped.

Angiotensin II Receptor Blockers

May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. Angiotensin-Converting Enzyme Inhibitors' serum levels may rise in response to angiotensin II receptor blockers. Management: According to US labelling, it is not advisable to take telmisartan and ramipril. It is unclear whether another ACE inhibitor and ARB combo would be any safer. When feasible, think about alternatives to the mix.

Bile Acid Sequestrants

The absorption of thiazide and thiazide-like diuretics may be reduced. Also reduced is the diuretic reaction.

Grass Pollen Allergen Extract (5 Grass Extract)

Grass pollen allergen extract may have a more negative or toxic effect if angiotensin-converting enzyme inhibitors are used (5 Grass Extract). With regard to grass pollen allergen extract, ACE inhibitors may specifically enhance the likelihood of a severe allergic reaction (5 Grass Extract).

Iron Dextran Complex

Angiotensin-Converting Enzyme Inhibitors might make Iron Dextran Complex more harmful or poisonous. Patients taking an ACE inhibitor may be more susceptible to events of the anaphylactic variety. Management: Adhere strictly to the instructions for iron dextran administration, including the use of a test dose before the initial therapeutic dose and the availability of resuscitation tools and qualified people.

Lanthanum

May lower angiotensin-converting enzyme inhibitors' serum concentration. Angiotensin-converting enzyme inhibitors should be given at least two hours before or after lanthanum.

Lithium

The excretion of lithium may be reduced by thiazide and thiazide-like diuretics.

Lithium

The serum concentration of lithium may rise in response to angiotensin-converting enzyme inhibitors. Management: After adding an ACE inhibitor, lithium dosage decreases will probably be required. Following the addition or discontinuation of concurrent ACE inhibitor therapy, carefully monitor the patient's response to lithium.

Obinutuzumab

The hypotensive effects of blood pressure-lowering medications may be strengthened. Management: Take into account temporarily stopping blood pressure-lowering drugs 12 hours before the start of the obinutuzumab infusion and keeping them off until 1 hour after the infusion is finished.

Sodium Phosphates

The nephrotoxic impact of sodium phosphates may be enhanced by angiotensin-converting enzyme inhibitors. In particular, there may be an increased risk of acute phosphate nephropathy. Treatment: You might want to temporarily stop taking ACEIs or look into alternatives to the oral sodium phosphate bowel preparation in order to prevent this combo. Maintaining appropriate hydration and properly monitoring renal function should be done if the combination cannot be avoided.

Sodium Phosphates

The nephrotoxic effects of sodium phosphates may be increased by diuretics. In particular, there may be an increased risk of acute phosphate nephropathy. Treatment: You might want to temporarily stop taking diuretics or look for an alternative to the oral sodium phosphate bowel preparation in order to prevent this combo. If the combination cannot be avoided, drink well and keep an eye on your kidney and fluid levels.

Topiramate

Thiazide and Thiazide-Like Diuretics may exacerbate the hypokalemic impact of Topiramate. Thiazide and Thiazide-Like Diuretics may raise the serum levels of Topiramate. When using a thiazide diuretic, monitor for elevated topiramate levels and any negative consequences (such as hypokalemia). Serum potassium levels should be closely watched when receiving concurrent treatment. There may be a need to lower topiramate dosage.

Urapidil

Angiotensin-Converting Enzyme Inhibitors may interact with them through an unidentified method. Avoid taking urapidil and ACE inhibitors simultaneously as a management strategy.

Risk Factor X (Avoid combination)

Aminolevulinic Acid (Systemic)

Aminolevulinic Acid's photosensitizing impact may be enhanced by photosensitizing agents (Systemic).

Bromperidol

The hypotensive impact of bromperidol may be enhanced by blood pressure lowering medications. Blood Pressure Lowering Agents' hypotensive effects may be lessened by bromperidol.

Dofetilide

The QTc-prolonging action of dofetilide may be strengthened by hydrochlorothiazide. The serum levels of Dofetilide may rise in response to HydroCHLOROthiazide.

Levosulpiride

Thiazide and Thiazide-Like Diuretics may intensify Levosulpiride's negative/toxic effects.

Mecamylamine

Sulfonamides may intensify Mecamylamine's harmful or hazardous effects.

Promazine

Promazine's ability to prolong QTc may be enhanced by thiazide and thiazide-like diuretics.

Sacubitril

The negative or hazardous effects of sacubitril may be increased by angiotensin-converting enzyme inhibitors. In particular, this combination may raise the risk of angioedema.

Telmisartan

Could make Ramipril's harmful or hazardous effects worse. Ramipril's serum levels may be raised by telmisartan. Ramiprilat, the active metabolite, may also have higher concentrations.

Monitor:

  • Blood pressure
  • BUN, serum creatinine, and electrolytes
  • CBC

How to administer Ramipril and hydrochlorothiazide?

  • Give in the morning with one-half glass of water and without regard to meals.
  • Do not chew or crush tablets

Mechanism of action of Ramipril

  • Ramipril is an ACE inhibitor that works similarly to captopril in terms of pharmacology and blocks the production of angiotensin II from angiotensin I.
  • In the liver, esterases also enzymatically saponify ramipril to create ramiprilat, which is ramipril's physiologically active metabolite.
  • The competitive, high-affinity, and reversible binding of ramiprilat to the angiotensin-converting enzyme causes ramipril to have pharmacological effects by inhibiting the production of the potent vasoconstrictor angiotensin II.

Mechanism of action of Hydrochlorothiazide:

  • Hydrochlorothiazide is a thiazide diuretic that exerts its effects by inhibiting the reabsorption of sodium and chloride in the distal tubules resulting in their excretion along with water.
  • Potassium, hydrogen ions, magnesium, phosphate, and bicarbonate may also be lost.

International Brands of Ramipril and hydrochlorothiazide:

  • Altace HCT
  • PMS-Ramipril/HCTZ
  • RAN-Ramipril HCTZ
  • TEVA-Ramipril/HCTZ
  • Altace Plus
  • Ampril HD
  • Ampril HL
  • Cardace-H
  • Co-ramipril
  • Co-Tritace
  • Cotriatec
  • Hartil HCT
  • Mypril Plus
  • Prilen Plus
  • Ramace H
  • Ramicar 2.5 Plus
  • Ramicar 5 Plus
  • Ramicard
  • Ramimed HCT
  • Ramipril Comp
  • Ramipril Plus
  • Ramiro N
  • Ramitas-HT
  • Ramizid
  • Triatec Comp
  • Triatec HCT
  • Triatec Plus
  • Triltec Plus
  • Tritace Comp
  • Tritace Max
  • Tritace Plus
  • Tritace-HCT
  • Tritazide

Ramipril hydrochlorothiazide Brand Names in Pakistan:

Ramipril and hydrochlorothiazide Tablets 5/12.5 mg
Ramipace D Pharmevo (Pvt) Ltd.
Ramy Plus Getz Pharma Pakistan (Pvt) Ltd.
Ramy Plus Getz Pharma Pakistan (Pvt) Ltd.
Triatec Hct Sanofi Aventis (Pakistan) Ltd.

 

Ramipril and hydrochlorothiazide Tablets 10/12.5 mg
Ramipace D Pharmevo (Pvt) Ltd.

 

Ramipril and hydrochlorothiazide Tablets 5/25 mg
Co-Tritace Sanofi Aventis (Pakistan) Ltd.

 

Ramipril and hydrochlorothiazide Tablets 2.5/12.5 mg
Adytum-H Macter International (Pvt) Ltd.
Co-Tritace Sanofi Aventis (Pakistan) Ltd.
Ramy Plus Getz Pharma Pakistan (Pvt) Ltd.
Triatec Hct Sanofi Aventis (Pakistan) Ltd.
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