A patient has just been counseled on the appropriate use of her new prescription for Altace (ramipril). The pharmacist says, "Swallow the capsule whole. Alternatively, you may open the capsule and sprinkle the contents on a small amount (about 4 oz) of applesauce or mix them with 4 oz (120 mL) of water or apple juice. These mixtures may be prepared in advance." Which statement about storing a prepared mixture is TRUE?
Explanation
Altace (Ramipril) is an angiotensin-converting enzyme (ACE) inhibitor used primarily to treat hypertension. It is supplied as hard-shell capsules containing 1.25 mg, 2.5 mg, 5 mg, or 10 mg of ramipril.
For hypertension, the recommended initial dose in a patient not receiving a diuretic is 2.5 mg once daily. The usual maintenance dosage is 2.5–20 mg/day, administered as a single dose or in two equally divided doses.
The capsule is usually swallowed whole. Alternatively, it may be opened and the contents sprinkled on approximately 4 oz of applesauce or mixed with 4 oz (120 mL) of water or apple juice. The entire mixture should be consumed to ensure delivery of the complete dose.
A prepared mixture may be stored for up to 24 hours at room temperature or up to 48 hours under refrigeration. Therefore, option D is correct.Options A and E are unnecessarily restrictive because immediate consumption is not required. Option B exceeds the permitted room-temperature storage period, and option C exceeds the permitted refrigerated storage period.
Ramipril carries a boxed warning for fetal toxicity and should be discontinued as soon as pregnancy is detected. Important adverse effects include dry cough, hyperkalemia, hypotension, increased serum creatinine, and angioedema.
Key Points:
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Monitor blood pressure, serum creatinine, and potassium after initiation and dosage increases.
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If a diuretic cannot be withheld before starting therapy, consider an initial ramipril dose of 1.25 mg to reduce the risk of excessive hypotension.
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Concomitant use with aliskiren is contraindicated in patients with diabetes.
Exam Pearl: ACE inhibitor–associated angioedema can occur at any time during therapy and requires immediate discontinuation.
