A randomised controlled study of ramipril dose-escalation packs in clinical practice

The benefits of angiotensin-converting enzyme (ACE) inhibitors occur early in the treatment period and may be dose-dependent. The utilisation of ACE inhibitors in cardiovascular patients is often suboptimal. This current study evaluates the clinical use of a specific ACE inhibitor dose-escalation pack.
Fifty hospital in-patients with a definite indication for ACE inhibitor therapy were randomised to receive either a dose-escalation pack or ‘usual’ initiation and escalation of ramipril. Patients and general practitioners received an information sheet outlining the benefits and risks of ACE inhibitors and the need for monitoring of serum urea and electrolytes. The groups were matched for age, gender, deprivation score and blood pressure. One patient died in each group and one patient withdrew from the control group. More patients in the dose-escalation group reached target dose by six weeks (72% vs. 33%; p< 0.01) and three months (67% vs. 35%; p<0.05). At three months, there were no differences in serum creatinine, urea or potassium (all p>0.05). Cough was the most commonly reported side effect although there was no difference in its incidence between the dose-escalation and control groups (8% vs. 6%, p>0.05). This study demonstrates that the use of a specific dose-escalation pack for the ACE inhibitor ramipril is a simple, reliable and safe mechanism for reaching a target dose. This approach could find utility with other drug therapies.