Ramipril

What is Ramipril?

Ramipril is a type of medicine known as an Angiotensin Converting Enzyme (ACE) Inhibitor and is used to treat high blood pressure (hypertension) and heart failure. Treating high blood pressure is essential for preventing heart attacks, strokes and kidney problems.

How does Ramipril work?

High blood pressure results in the heart and arteries working too hard to pump blood around the body and, if left untreated, can lead to damaged vessels in the brain, heart and kidneys, heart failure, stroke or kidney failure. Ramipril, an ACE inhibitor, works by blocking the mechanism of a substance in the body which causes blood vessels to constrict. When blood vessels are relaxed, blood pressure is lowered and the supply of oxygen to the heart is increased.

How long does Ramipril take to work?

Ramipril will begin to lower blood pressure within just a few hours, but will not take full effect for a few weeks at least. 

Active ingredients

The active ingredient in Ramipril is ramipril.

Inactive ingredients

The inactive ingredients in Ramipril are hypromellose, pregelatinised maize starch, microcrystalline cellulose, and sodium stearyl fumarate. The 2.5 mg tablets also contain yellow ferric oxide (E172), and the 5 mg tablets also contain red ferric oxide (E172).

Please Note: Different manufacturers of generic Ramipril may use different inactive ingredients in their drugs that those listed here.

How to start taking Ramipril

Never start taking Ramipril without the instruction of a doctor. To begin with, a doctor will start you on a low dose to reduce the risk of side effects. You can then build up to the dose recommended for your condition. Take Ramipril once a day at the same time each day. Tablets should be swallowed whole with water and should not be crushed or split.

Ramipril dosage

Always take Ramipril as instructed by a doctor. The usual starting dose of Ramipril is 1.25 - 2.5 mg taken once daily and can be increased gradually over time until your blood pressure is controlled. For the treatment of high blood pressure, heart failure, for reducing the risk of heart attack or stroke or for treatment following a heart attack, the maximum daily dosage is 10mg. For reducing or delaying the worsening of kidney problems, the usual daily dose is between 5 and 10 mg per day.

Why do I take Ramipril in the evening?

It is sometimes advised to take Ramipril before bed, particularly the first dose, as it can make you feel dizzy. 

Ramipril side effects

Like all medications, Ramipril can cause side effects in some people. Stop taking Ramipril and see a doctor immediately if you experience either the following serious side effects:

• A severe allergic reaction to Ramipril, including swelling of the face, lips or throat, difficulty breathing, itching or rashes.
• A severe skin reaction, including rash, ulcers in your mouth, worsening of pre-existing skin disease, reddening, blistering or detachment of skin.

If you experience any of the following, tell your doctor right away:

• Faster, uneven or forceful heart rate, chest pain or tightness
• Shortness of breath or a persistent cough
• Bruising easily, bleeding for longer than is usual, unexplained bleeding or bruising, purple spots, getting infections more easily, sore throat and fever, fatigue, feeling faint or dizzy or having pale skin.
• Severe stomach pain which may reach through to your back
• Fever, chills, tiredness, loss of appetite, stomach pain, nause, jaundice (yellowing of the skin or whites of the eyes).

Speak to a doctor if any of the following less serious side effects persist for longer than a few days. Common side effects (affecting up to 1 in 10 people) include:

• Headache and fatigue
• Feeling dizzy
• Fainting, hypotension (abnormally low blood pressure)
• Dry, tickly cough, sinusitis or bronchitis
• Stomach or gut pain, diarrhoea, indigestion, nausea or vomiting
• Skin rash with or without raised area
• Chest pain
• Muscle pain or cramps
• Blood tests showing more potassium than usual in the blood

Uncommon side effects can affect up to 1 in 100 people and include:

• Vertigo
• Itching and unusual sensations such as numbness, tinging, pricking or burning.
• Loss or change of taste
• Sleep problems
• Feeling depressed, anxious, nervous or restless
• Blocked nose, worsening of asthma
• Intestinal angioedema (abdominal pain, vomiting diarrhoea)
• Heartburn, constipation or dry mouth
• Urinating more than usual
• Sweating more than usual
• Loss or decrease of appetite
• Increased or irregular heartbeat
• Swollen arms of legs
• Flushing
• Blurred vision
• Joint pain
• Fever
• Reduced sexual desire
• Increased number of white blood cells
• Blood test showing changes to liver, kidney or pancreas function

The following rare side effects can affect up to 1 in 1,000 people:

• Feeling shaky or confused
• Red and swollen tongue
• Severe flaking or peeling of the skin, itchy or lumpy rash
• Loosening of separation of the nail from the nail bed
• Skin rash or bruising
• Blotches on the skin and cold extremities
• Red, itchy, swollen or watery eyes
• Disturbed hearing or ringing in the ears
• Feeling weak
• Blood tests showing a decrease in red blood cells, white blood cells, platelets or haemoglobin

Very rarely (1 in 10,000), patients may experience increased sensitivity to sunlight.

The following side effects have been reported, although their frequency is unknown:

• Difficulty concentrating
• Swollen mouth
• Blood tests showing too few blood cells
• Blood tests showing less sodium in the blood
• Concentrated urine, nausea or vomiting, muscle cramps, confusion, fits
• Fingers and toes changing colour when cold, tingling or pain when warming up
• Breast enlargement in men
• Impaired reactions
• Burning sensation
• Change in sense of smell
• Hair loss  

Contraindications

Do NOT take Ramipril if:

• You are allergic to any of the ingredients in this medication
• You have ever had angioedema, a severe allergic reaction that includes itching, hives, red marks on the hands, feet and throat, swelling around the eyes or lips,difficulty breathing and swallowing.
• You have kidney problems where the blood supply to your kidneys is reduced
• You are in the last 6 months of pregnancy
• You are breastfeeding
• Your blood pressure is abnormally low or unstable
• You have diabetes or impaired kidney function 
• You are having dialysis

Before taking Ramipril, tell your doctor if any of the following applies to you:

• You have heart, liver or kidney problems
• You have lost a lot of salts or fluids through vomiting, diarrhoea, sweating more than usual, being on a low-salt diet, taking diuretics or having dialysis
• You are having desensitization treatment for wasp stings
• You are going to receive an anaesthetic
• You have a high amount of potassium in your blood 
• You have a decreased amount of sodium in your blood
• You have a collagen vascular disease such as scleroderma or systemic lupus erythematosus
• You are or might become pregnant

Drug interactions

Before taking Ramipril, tell your doctor if you are taking any other medicines, including those purchased over the counter without a prescription. In particular, tell your doctor if you are taking any of the following:

• Painkillers and anti-inflammatory medicines
• Medicines used for the treatment of low blood pressure, shock, cardiac failure, asthma or allergies such as ephedrine, noradrenaline or adrenaline
• Sacubitril/valsartan for treatment of long-term chronic heart failure
• Chemotherapy medicines
• Medicines to stop the rejection of organs after surgery such as ciclosporin
• Diuretics
• Medicines that can increase the amount of potassium in your blood such as spironolactone, triamterene, amiloride, potassium salts, trimethoprim, sulfamethoxazole and heparin.
• Medicines that may increase the risk of angioedema, such as mTOR inhibitors, vildagliptin, neprilysin inhibitors or sacubitril/valsartan
• Steroid medicines for inflammation such as prednisolone
• Allopurinol
• Procainamide
• Temsirolimus
• Sirolimus, everolimus
• Vildagliptin
• Racecadotril
• ARB blockers or aliskiren
• Medicines for diabetes
• Lithium

How to cope with Ramipril side effects

The most common side effect of Ramipril is dizziness, and your doctor will start by prescribing a low dose so that your body can adjust to the treatment. If you feel dizzy, or experience blurred vision, stop what you are doing and find somewhere to lie down until it has passed. Do not try to drive, ride a bike, or operate heavy machinery. Some people may experience headaches while taking Ramipril, which can be managed by drinking plenty of fluids and taking painkillers if necessary. However, if headaches persist for longer than a week, speak to your doctor for advice.

Ramipril and pregnancy

Tell your doctor if you are pregnant or are planning to become pregnant. Ramipril should not be taken in the first 12 weeks of pregnancy or at all from the 13th week, as it can be harmful to your baby. If you become pregnant while taking Ramipril, consult your doctor immediately.

Ramipril should not be taken while breastfeeding.  

Ramipril and alcohol

Alcohol can increase the blood pressure-lowering effect of Ramipril and cause you to feel dizzy or lightheaded. You should avoid alcohol altogether when you first start taking Ramipril, of if you continue to experience dizziness during treatment.

Ramipril and driving

If you experience dizziness or blurred vision while taking Ramipril, do not drive or ride a bike.

Alternatives to Ramipril

There are a few different options available for treating high blood pressure. Patients who are over the age of 55 or of Afro-Caribbean descent may be better suited to an alternative treatment, as ACE inhibitors are thought to be less effective for these groups. Diuretics are prescribed to help lower blood pressure because they relax the walls of blood vessels and allow blood to flow more easily, and are sometimes taken in combination with the ACE inhibitor Enalapril. Alternatively, Beta-blockers work by slowing your heart rate and blocking angiotensin II, a hormone which causes vasoconstriction (narrowing of the arteries). A similar function is carried out by Angiotensin receptor blockers (ARBs) such as Losartan, Irbesartan, Candesartan and Valsartan. Calcium-channel blockers such as Amlodipine, Felodipine and Lercanidipine are another alternative, and work by blocking calcium from causing blood vessels to constrict.

Speak to a doctor to find out which type of blood pressure medication is best for you.  

Lifestyle changes to make when taking Ramipril

Alongside treatment, it is important to make a few lifestyle changes to boost the health of your heart. Eating too much salt is the main cause of high blood pressure, so try not to eat more than 6g of salt per day. Try aso to cut back on fatty foods, and include plenty of fruit and vegetables, wholegrains and lean protein. Exercising regularly helps to keep your heart and blood vessels in good condition and also help you deal with stress. Stress can cause your blood pressure to rise so try to find ways to avoid it, such as spending time with friends and family, going for walks and giving yourself time to relax where possible. If you haven’t already done so, quit smoking, and try and reduce the amount of alcohol you drink.

Ramipril vs Lisinopril

Ramipril and Lisinopril are both ACE inhibitors that work in the same way with similar risk of side effects. The active ingredient in Ramipril is ramipril, and the active ingredient in Lisinopril is lisinopril dihydrate. Lisinopril is more suitable for patients with kidney problems, as it is the only ACE inhibitor that is excreted passively by the kidneys.

What will happen if I stop taking Ramipril?

Never stop taking Ramipril without first consulting a doctor, as this can cause a dangerous rise in blood pressure and increase your risk of experiencing a heart attack or stroke.

Can I stop taking Ramipril when my blood pressure is reduced?

Even if your blood pressure is reduced, it is recommended that you continue to take Ramipril. This medication is usually taken for life, as coming off it can cause your blood pressure to rise and lead to a heart attack or stroke.

Can I take Ramipril before surgery?

If you are scheduled to undergo surgery that requires a general anaesthetic, let your doctor know if you are taking Ramipril. They may advise you to stop taking it 24 hours before you undergo surgery. 

Will I need to take Ramipril forever?

Ramipril is intended for long-term use and is usually taken for the rest of your life.

Is Ramipril a statin?

Ramipril is not a statin, which are used in the treatment of high cholesterol. 

Is Ramipril a beta blocker?

Ramipril is not a beta blocker, it is an ACE inhibitor.

What should I do if Ramipril isn’t working for me?

It can take several weeks before you get the full benefits of taking Ramipril. If your condition does not improve or worsens, speak to your doctor for advice.

Sources

• Patient Information Leaflet
• NHS > Ramipril
• NHS > High Blood Pressure
• WebMD > ACE Inhibitors