The Side effects of ACE inhibitors and monitoring：

The Side effects of ACE inhibitors mainly are hyperkalaemia，renal impairment and cough (the most frequent side effect and characteristically dry and troublesome).

As monitoring, We should check effect on blood pressure at the same time as monitoring blood tests. For low risk patients we usually check creatinine and potassium at about one week, and for moderate and high patients we often check at 7 ro10 days and one month. Checks should also be sent after dose increases, and if diuretic doses are increased.

For creatinine, a rise of over 20% is generally considered to be significant, but NICE/SIGN guidelines allow up to 30% rise . Smaller rises are common and are to be expected in many patients. For potassium, when K+>5.5mmol/L we suggest ACE inhibitor should be stopped and check recheck.

Well with regards to the Ramipril which is one of the ACE inhibitors and its is also used for the treatment of hypertension, either used alone or in combination with thiazide diuretics.

In using ramipril, consideration should be given to the fact that another angiotensin converting enzyme inhibitor, captopril, has caused agranulocytosis, particularly in patients with renal impairment or collagen-vascular disease. Available data are insufficient to show that ramipril does not have a similar risk.

Blood pressure decreases associated with any dose of ramipril depend, in part, on the presence or absence of volume depletion (e.g., past and current diuretic use) or the presence or absence of renal artery stenosis. If such circumstances are suspected to be present, the initial starting dose should be 1.25 mg once daily.

The recommended initial dose for patients not receiving a diuretic is 2.5 mg once a day. Dosage should be adjusted according to the blood pressure response. The usual maintenance dosage range is 2.5 to 20 mg per day administered as a single dose or in two equally divided doses. In some patients treated once daily, the antihypertensive effect may diminish toward the end of the dosing interval. In such patients, an increase in dosage or twice daily administration should be considered. If blood pressure is not controlled with ramipril alone, a diuretic can be added.

After the initial dose of ramipril, the patient should be observed under medical supervision for at least two hours and until blood pressure has stabilized for at least an additional hour. If possible, the dose of any concomitant diuretic should be reduced which may diminish the likelihood of hypotension. The appearance of hypotension after the initial dose of ramipril does not preclude subsequent careful dose titration with the drug, following effective management of the hypotension. If the diuretic cannot be discontinued, an initial dose of 1.25 mg ramipril should be used to avoid excess hypotension.

In patients with creatinine clearance 2.5 mg/dL) doses only 25% of those normally used should be expected to induce full therapeutic levels of ramiprilat.

Another potencial adverse effect in renal patients treated with ACE inhibitors is hyperkalemia. Avoid dual blockade of the RAAS, NSAIDs, potassium sparing diuretics and salt substitutes containing potassium .

The majority of the side effects of captopril in the past were due to the excessive dose of it: I remember very well

that we at the very begining were authorized to use high doses of captopril. Our laboratory was the first to recognize

side effects of cough, hematologic troubles and angioedema. We discover if the dose of captopril were not higher that 150 or 200 mg per day you will not see severe side effects. Concerning ramipril we also were the first to investigate the antihypertensive properties of it and at that time I speaking 1980 we establish that ramipril was

a potent and effective antihypertensive agent with good tolerance. we also investigate other ACE inhibitors such

as cilazapril, perindopril, etc

The Side effects of ACE inhibitors and monitoring：

The Side effects of ACE inhibitors mainly are hyperkalaemia，renal impairment and cough (the most frequent side effect and characteristically dry and troublesome).

As monitoring, We should check effect on blood pressure at the same time as monitoring blood tests. For low risk patients we usually check creatinine and potassium at about one week, and for moderate and high patients we often check at 7 ro10 days and one month. Checks should also be sent after dose increases, and if diuretic doses are increased.

For creatinine, a rise of over 20% is generally considered to be significant, but NICE/SIGN guidelines allow up to 30% rise . Smaller rises are common and are to be expected in many patients. For potassium, when K+>5.5mmol/L we suggest ACE inhibitor should be stopped and check recheck.

I agree with the previous comments, specially those related to the simultaneous use of loop diuretics. In this case care should be taken for drug interactions and diminished diuretic effect.

monitering side effects to ACE inhi that are not clinically evident will include Drug history to find any drug that may cause hyperK eg K sparing diuretics...:24-h BP to detect hypotension kidney function tests: urea, creatinine, and electrolytes, specially potassium. If angioedema occured, one may screen the patient for genetic markers, though this rarely required.Uurinalysis and blood counts may be also needed.Imaging for renal artery stenosis may be rewuired if acute renal failure developed.

I agree with the comment for adverse effect of ACE inhibitors.

Certainly among the less-invasive system to evaluate the effects of ACE inhibitors on renal I emphasize the role of the Gamma camera renography and glomerular function using tracers (99mTc-DTPA) and tubular (99mTc-MAG3). In addition to imaging, and then to the estimation of the separate function, as is known renography with radionuclides allows a very precise absolute estimate of renal function.

Another side effect is angioedema. This can often develop after many years of being on the drug. It is related to C1 esterase inhibitor deficiency which can be measured

Kidneys have a very strong compensatory function. Even the removal of a kidney, serum creatinine will not be increased. When the creatinine is increased beyond the normal level, the renal function has been severely compromised(damaged). ACEI can not directly damage renal function. Patients can also check the serum lipids level and Hs-CRP, Because Dyslipidemia indicates that renal function will be undermined.

ramipril is an ace inhibitor, so it has the same side effect with another ace inhibitor. the usual side effect is dry cough which can be easily monitored. according to the research made in my university, ACE inhibitor and Angiotensin receptor blocker can induce acute renal failure, and it can be detected in creatinine. if the creatinine raised 3 times higher than the normal creatinine for that patient then, you can suspect ACE inhibitor.

if the reatinine raised 3 times higher than the normal creatinine for that patient, you decide what to for the patients then, it may be too late to protect patient. Hyperlipidemia patients should reduce ACEI dose, the patients of renal insufficiency should be very careful to use ACEI.

ACE inhibitors supress platelet function. Patients that bruise easily, have a history of bleeding, or otherwise are at risk, should have platelet function checked.