Patient Group Direction for the supply of Ramipril starting dose 1.25mg
or 2.5mg daily up to 5mg twice daily or 10 mg daily to Patients with
documented LVSD attending Heart failure clinics or on home visits
This document authorises the supply of Ramipril 1.25mg daily up to
10 mg daily by cardiac/heart failure specialist nurses to patients with
documented LVSD who meet the criteria for inclusion under the terms
of the document
The cardiac/heart failure specialist nurses seeking to supply or
administer Ramipril 1.25mg daily up to 10 mg daily must ensure that all
patients have been screened and meet the criteria before supply takes
place
The purpose of this Patient Group Direction is to ensure optimum doses
of ACE used as per SIGN guidelines, allow better continuity of care, and
reduce GP visits.
This direction was authorised on: October 2011
The direction will be reviewed by: October 2013
Clinician Responsible for Training and Review: Gillian Donaldson
PGD reviewed by: Claire Stein, Helen Oxenham, Gillian Donaldson
Cardiology PGD no 5: Ramipril
Page 1
Patient Group Direction for the supply of Ramipril 1.25mg once daily up
to 5mg twice daily or 10 mg once daily without a prescription for a
named individual by Cardiac/Heart failure specialist nurses employed
by NHS Borders in Borders General Hospital/Community
1. This Patient Group Direction relates to the following specific
preparation:
Name of medicine,
Ramipril 1.25mg, 2.5mg, 5mg, 10mg capsules
Strength,Formulation
Legal status
Prescription only medicine (POM)
Storage
Store in a dry place below 25 degrees C and
protect from light.
Dose
Start dose 1.25mg then double dose at no less
than two weekly intervals to maximum 10 mg
daily/ or 5mg in twice daily dose.
Route/method
Oral
Frequency
Once a day or split into twice daily when daily
dose higher than 1.25mg
Total dose Quantity
Supply as per requirements of titration.
(Maximum/Minimum)
Advice to Patients
Explain that treatment given as much to prevent
worsening of heart failure and increase survival as
to improve symptoms and reduce admissions to
hospital
Symptoms may take from a few weeks to few
months to improve
Advise to report dizziness/symptomatic
hypotension rash or cough
Advise to avoid NSAIDS and salt substitutes high in
K+
Cardiology PGD no 5: Ramipril
Page 2
Follow up
Arrangements
Contact G.P or heart failure nurse if any increased
dizziness/ heart failure symptoms.
Do not stop taking without consulting doctor or
heart failure nurse unless severe side effects
Encourage patients to weigh themselves daily and
to consult doctor or heart failure nurse if they have
persistent weight gain of 1kg for > 2days.
Heart failure nurse will follow up patient within two
weeks of commencement/up-titration to check
electrolytes. If baseline Creatinine increased by
more than 50% or 200micromol/l consider stopping
other vasodilators, NSAIDS or reducing diuretics if
no fluid retention. If renal impairment persistsreduce dose of ramipril and recheck blood
chemistry within 1 week. See HFN Specialist
Guidelines.
Relevant Warnings
If potassium rises to 5.5mmol/l or greater reduce
dose of ramipril
If potassium remains above 5.5mmol/l despite
reducing ramipril dose stop ramipril
If Creatinine increases by 100% or above
310micromol/l stop ramipril
If symptomatic hypotension (systolic BP90mmHg)
stop calcium channel antagonists, consider
reducing diuretic if no fluid retention, reduce dose
or stop ramipril
Cardiology PGD no 5: Ramipril
Page 3
2. Clinical condition
Clinical Condition
Patients with heart failure due to left ventricular
to be treated
systolic dysfunction.
Criteria for inclusion
 Documented LVSD
 K+ level 5.5mmol/l or less.
 Systolic BP > 90mmHg
 Creatinine less than 221 micromol/l
 Urea less than 15mmol/l
Criteria for
 Systolic BP < 90mmHg
exclusion
 Significant renovascular disease
 Pregnancy/breastfeeding
 Hypersensitivity to Ramipril or other ACEI
 Severe aortic stenosis
 K+ greater than 5.5mmol/l
 History of angioedema
 hepatic impairment (as ramipril pro-drug,
lisinopril not pro-drug)
Action if excluded
1. Record reason for exclusion clearly in
notes/heart failure database
2. Consider alternative treatment eg ARB
3. Optimise other heart failure
medications
4. Inform consultant
cardiologist/physician
Action if declines
As for action if excluded
Interactions with
 Enhanced hypotensive effects with other
other medicaments
medications including nitrates, beta
and other forms of
blockers/calcium channel-blockers,
anxiolytics/hypnotics, antipsychotics, interaction
blockers (e.g. tamsulosin), MAOIs, nitrates,
angiotensien-ll receptor antagonists,
vasodilators (e.g. hydralazine), clonidine,
corticosteroids, diuretics, levodopa,
moxonidine, methyldopa, levodopa Alcohol
(See B.N.F)
 Enhanced hypoglycaemic effect with insulin,
metformin, and sulphonylureas
 Increased risk of renal impairment along with
NSAID.
 Increased risk of hyperkalaemia with
potassium sparing diuretics
e.g.spironolactone, eplerenone
 Lithium - reduced excretion (increased
plasma lithium concentrations)
Cardiology PGD no 5: Ramipril
Page 4
3. Records- Cardiac nurse specialists office, dictated letter in patient
records in main stores and copy to G.P records. Heart Failure Database
when available.
1. The following records should be kept (either paper or computer based)
The GP practice, clinic, hospital, and ward or department.
The patient name and CHI number.
The medicine name, dose, route, time of dose(s), and where
appropriate, start date, number of doses and or period of time, for
which the medicine is to be supplied or administered.
Drug batch number and expiry.
The signature and printed name of the approved healthcare
professional who supplied or administered the medicine.
The patient group direction title and/or number.
Whether patient met the inclusion criteria and whether the exclusion
criteria were assessed.
Reason for exclusion.
Quantity supplied / received and current stock balance
2.
Preparation, audit trail, data collection and reconciliationStock balances should be reconcilable with Receipts,
Administration,
Records and Disposals on a patient-by-patient basis.
3. Storage- Store in a dry place below 25 degrees C and protect from
light.
4. Professional Responsibility  All Health Professionals will ensure he/she has the relevant
training and is competent in all aspects of medication, including
contra-indications and the recognition and treatment of adverse
effects. He/she will attend training updates as appropriate. For
those involved in immunization, regular anaphylaxis updates are
mandatory.
 Nurses will have due regard for the NMC Code of Professional
Conduct, standards for conduct, performance and ethics (2010)
and NMC Standards for Medicines Management (2010)
 Sources of Evidence used for the PGD creation:
British National Formulary – Latest edition
Summary of Product Characteristics - Zestril, Carace –
www.medicines.org
NICE Heart Failure Guidelines
Cardiology PGD no 5: Ramipril
Page 5