page141
. Nephropathy,
initially 1.25 mg once daily,
increased
after 2 weeks to 2.5 mg once daily,
then increased
after a further 2 weeks to 5 mg once daily if tolerated
Ramipril
(Non-proprietary) A
Capsules
,
ramipril 1.25 mg,
net price 28-cap pack =
£1.10; 2.5 mg, 28-cap pack = £1.18; 5 mg, 28-cap pack
= £1.25;
10 mg,
28-cap pack = £1.41
Tablets
,
ramipril 1.25 mg,
net price 28-tab pack =
£1.71; 2.5 mg, 28-tab pack = £1.42; 5 mg, 28-tab pack
= £1.66;
10 mg,
28-tab pack = £1.89
Tritace
c
(Sanofi-Aventis) A
Tablets
, scored, ramipril 1.25 mg (white), net price 28-
tab pack = £5.09; 2.5 mg (yellow), 28-tab pack = £7.22;
5 mg (red),
28-tab pack = £10.05;
10 mg (white),
28-
tab pack = £13.68
Titration pack, tablets
,
35-day starter pack of rami-
pril 7 2.5 mg with 21 5 mg and 7 10 mg,
net
price = £13.00
With calcium-channel blocker
Note
For hypertension in patients stabilised on the individual
components in the same proportions.
For prescribing infor-
mation on felodipine,
see section 2.6.2
Triapin
c
(Sanofi-Aventis) A
Triapin
c
tablets
, f/c, brown, ramipril 5 mg, felodipine
5 mg (m/r), net price 28-tab pack = £16.13. Label: 25
Triapin mite
c
tablets
,
f/c,
orange,
ramipril 2.5 mg,
felodipine 2.5 mg (m/r),
net price 28-tab pack =
£24.55.
Label:
25
TRANDOLAPRIL
Indications
mild to moderate hypertension; following
myocardial infarction in patients with left ventricular
dysfunction
Cautions
see notes above
Contra-indications
see notes above
Hepatic impairment
see notes above
Renal impairment
see notes above; max. 2 mg daily if
eGFR less than 10 mL/minute/1.73 m
2
Pregnancy
see notes above
Breast-feeding
see notes above
Side-effects
see notes above;
also ileus,
dry mouth;
tachycardia, palpitation,
arrhythmias,
angina,
transi-
ent ischaemic attacks,
cerebral haemorrhage,
myo-
cardial infarction,
syncope;
dyspnoea,
bronchitis;
asthenia,
nervousness,
sleep disturbances;
hot
flushes;
alopecia,
sweating,
skin reactions including
Stevens-Johnson syndrome,
toxic epidermal necro-
lysis,
and psoriasis-like efflorescence
Dose
. Hypertension,
initially 500 micrograms once daily,
increased at intervals of 2–4 weeks; usual range 1–
2 mg once daily; max. 4 mg daily; if used in addition to
diuretic see notes above
. Prophylaxis after myocardial infarction (starting as
early as 3 days after infarction),
initially 500 micr-
ograms once daily,
gradually increased to max.
4 mg
once daily
Note
If symptomatic hypotension develops during titration,
do not increase dose further; if possible, reduce dose of any
adjunctive treatment and if this is not effective or feasible,
reduce dose of trandolapril
Trandolapril
(Non-proprietary) A
Capsules
,
trandolapril 500 micrograms, net price 14-
cap pack = £1.49; 1 mg, 28-cap pack = £7.23; 2 mg, 28-
cap pack = £3.75;
4 mg,
28-cap pack = £12.31
Gopten
c
(Abbott) A
Capsules
,
trandolapril 500 micrograms (red/yellow),
net price 14-cap pack = £1.19; 1 mg (red/orange), 28-
cap pack = £5.81;
2 mg (red/red), 28-cap pack =
£5.81;
4 mg (red/maroon),
28-cap pack = £9.86
With calcium-channel blocker
Note
For hypertension in patients stabilised on the individual
components in the same proportions.
For prescribing infor-
mation on verapamil, see section 2.6.2
Tarka
c
(Abbott) T A U
Capsules
,
pink,
trandolapril 2 mg,
verapamil hydro-
chloride 180 mg (m/r),
net price 28 cap-pack =
£10.29.
Label:
25
2.5.5.2
Angiotensin-II receptor
antagonists
Candesartan, eprosartan, irbesartan, losartan, olme-
sartan,
telmisartan,
and valsartan are angiotensin-II
receptor
antagonists with many properties similar
to
those of the ACE inhibitors.
However,
unlike ACE inhi-
bitors,
they do not inhibit the breakdown of bradykinin
and other kinins,
and thus are less likely to cause the
persistent dry cough which can complicate ACE inhibi-
tor therapy.
They are therefore a useful
alternative for
patients
who have to discontinue an ACE inhibitor
because of persistent cough.
An angiotensin-II receptor antagonist may be used as an
alternative to an ACE inhibitor in the management of
heart
failure (section 2.5.5)
or
diabetic nephropathy
(section 6.1.5).
Cautions
Angiotensin-II receptor antagonists should
be used with caution in renal
artery stenosis (see also
Renal
Effects under
ACE Inhibitors,
section 2.5.5.1).
Monitoring
of
plasma-potassium concentration
is
advised,
particularly in the elderly and in patients with
renal
impairment;
lower initial
doses may be appropri-
ate in these patients.
Angiotensin-II
receptor
antago-
nists should be used with caution in aortic or
mitral
valve stenosis
and in hypertrophic cardiomyopathy.
Those with primary aldosteronism, and Afro-Caribbean
patients (particularly those with left ventricular hyper-
trophy), may not benefit from an angiotensin-II receptor
antagonist.
Interactions:
Appendix 1 (angiotensin-II
receptor antagonists).
Pregnancy
Angiotensin-II receptor antagonists should
be avoided in pregnancy unless essential.
They may
adversely affect fetal and neonatal blood pressure con-
trol
and renal
function;
skull
defects and oligohydram-
nios have also been reported.
Breast-feeding
Information on the use of
angio-
tensin-II receptor antagonists in breast-feeding is lim-
ited.
They are not recommended in breast-feeding and
alternative treatment
options,
with better
established
safety information during breast-feeding,
are available.
Side-effects
Side-effects are usually mild.
Sympto-
matic hypotension including dizziness may occur, parti-
cularly in patients with intravascular volume depletion
BNF 61
2.5.5 Drugs affecting the renin-angiotensin system
121
2
Cardiovascular system